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A    MANUAL    OF    SURGERY 
yoc  StuDents  an&  SJracttttonecs 


Digitized  by  the  Internet  Areiiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/rosecarlesssmanu1912rose 


ROSE  AND  CARLESS'S 

MANUAL   OF  SURGERY 

jTor  Students  anb  practitioners 

EIGHTH   EDITION 


REVISED  BY 

ALBERT    CARLESS,    M.B.,  M.S.   Lond.,  F.R.C.S. 

Professor  of  Surgery    in,   and  Surgeon   to,    King's  College    Hospital,    London  ; 

Examiner   in   Surgery   to   the   University    of   London   and   formerly   to 

THE  Universities  of  Glasgow,  Manchester,  Liverpool,  and  Leeds  ; 

Consulting  Surgeon  to  the  King  Edward's  Memorial  Hospital, 

Ealing;  to  the  St. John's  Hospital,  Twickenham,  etc. 


NEW    YORK 
WILLIAM    WOOD    &    COMPANY 

MDCCCCXII 


n~  /U^^ 


TO 

LORD    LISTER,  ll.d,  f.r.s., 

President  of  the  Royal  Society, 

THE    FATHER    OF    ANTISEPTIC    SURGERY, 

THIS   WORK   IS,   WITH   PERMISSION, 

pBbirateb  bg  the  ^xd\xaxQ, 

IN    GRATEFUL   ACKNOWLEDGMENT    OF   THE    MANY    ADVANTAGES 
THEY   HAVE   DERIVED 
WHILST   ASSOCIATED   WITH   HIM    IN    HIS   WORK 
~  AT   king's  COLLEGE   HOSPITAL. 


PREFACE   TO  THE    EIGHTH    EDITION, 

Since  the  issue  of  the  last  edition  my  old  friend  and  colleague 
Professor  William  Rose,  has  passed  away,  after  a  long  and  painful 
illness.  For  a  time  he  seemed  to  be  on  the  highway  to  recovery 
from  his  earlier  nervous  breakdown,  but  malignant  disease  super- 
vened, and  gradually  ran  its  wearisome  and  painful  course.  This  is 
not  the  place  to  write  an  obituary  notice,  which  has  been  done 
elsewhere,  but  the  opportunity  cannot  be  denied  of  placing  on  record 
my  feeling  of  gratitude  for  many  a  kindly  act  and  much  timely  help 
and  counsel,  and  my  appreciation  of  his  professional  work.  It 
must  not  be  forgotten  that  he  was  the  first  surgeon  deliberately 
to  open  the  skull  for  the  removal  of  the  Gasserian  ganglion,  and 
although  his  method  of  approach  has  been  set  aside  in  favour  of 
something  better,  yet  he  was  the  pioneer  in  this  field  of  operative 
activity.  A-^skilful  and  brilliant  operator  and  a  master  of  technique, 
it  was  ever  a  pleasure  and  a  lesson  to  see  him  undertake  operations  such 
as  excisions  or  osteotomies,  where  his  great  mechanical  aptitude  could 
have  full  play,  or  those  for  hare-lip  or  cleft  palate,  where  he  was  so 
brilliantly  successful.  As  regards  this  work,  he  did  not  take  much 
share  in  the  issue  of  the  later  editions,  so  that  its  character  and  scope 
will  not  be  altered  by  his  death. 

In  the  present  edition  I  have  endeavoured  to  bring  things  up 
,  to  date,  and  to  incorporate  as  much  of  the  newer  work  as  seems 
desirable  for  the  help  of  students  and  practitioners  alike.  It  was 
impossible  to  attain  this  without  some  increase  in  size,  but  this  has 
been  kept  down  as  much  as  possible.  Several  sections  have  needed 
to  be  rewritten — e.g.,  those  dealing  with  diseases  of  the  gall-bladder 
and  with  the  treatment  of  malignant  disease  of  the  rectum ;  others 
have  needed  to  be  remodelled  and  rearranged  so  as  to  present  them 

vii 


viii  PREFACE  TO  THE  EIGHTH  EDITION 

in  a  more  orderly  fashion.  Short  introductions  to  several  sections 
have  been  added,  dealing  with  surgical  anatomy  and  methods  of 
examination ;  typical  blood  -  counts  and  results  of  test  -  meals  in 
various  conditions  have  been  introduced,  and  I  hope  that  in  this 
way  the  work  will  prove  more  generally  useful.  Careful  revision 
of  the  illustrations  has  resulted  in  the  removal  of  some  of  the  older 
blocks  and  their  replacement  by  others,  whilst  a  certain  number  of 
coloured  plates  have  been  added. 

My  best  thanks  are  due  to  Dr.  D'Este  Emery  for  help  in  the 
pathological  side  of  the  work,  and  for  preparing  coloured  plates  of 
bacteria ;  to  Mr.  A.  D.  Reid  for  assistance  with  the  radiographic  and 
radiotherapeutic  sections,  and  for  providing  a  number  of  new  X-ray 
pictures ;  to  Dr.  Dupuy  for  his  skill  in  preparing  new  illustrations 
and  in  retouching  and  improving  some  of  the  older ;  to  Mr.  Eric  G. 
Gauntlett,  M.B.,  F.R.C.S.,  who  has  worked  up  the  literature  for  me 
and  sketched  out  much  of  the  new  work,  and  in  addition  has  under- 
taken the  laborious  and  irksome  task  of  revising  the  index ;  and 
to  several  friends,  such  as  Mr.  Burghard,  Mr.  James  Berry,  and 
Dr.  Parkes  Weber,  who  have  kindly  placed  photographs  at  my 
disposal.  Hearty  thanks  must  also  be  accorded  to  the  publishers, 
who,  as  ever,  are  ready  and  helpful  with  suggestions,  and  gladly  fall 
in  with  reasonable  proposals.  In  conclusion,  I  must  thank  those 
known  and  imknown  correspondents  from  all  corners  of  the  earth 
who  have  sent  me  corrections,  suggestions,  and  criticisms ;  it  is 
impossible  for  one  living  in  London  to  keep  au  courant  with  all 
modern  progress  or  with  the  varieties  of  disease  or  local  peculiarities 
which  are  observable  by  those  whose  work  lies  farther  afield.  All 
such  communications  are  gladly  welcomed,  and  I  heartily  appreciate 
the  kindly  thought  which  leads  to  the  helpful  letter.  I  can  only  once 
again  express  the  hope  that  this  work,  in  so  far  as  it  represents 
modem  surgery,  may  prove  in  the  future,  as  in  the  past,  to  be  a 
helpful  guide  to  those  who  are  seeking  to  relieve  suffering  and  to 

restore  health. 

ALBERT  CARLESS. 

6,  Upper  Wimpole  Street,  W., 
September,  191 1. 


PREFACE  TO  FIRST  EDITION 

In  preparing  this  Manual  of  Surgery  for  the  profession,  we  have 
endeavoured  to  meet  what  we  think  is  at  the  present  time  a  genuine 
need.  The  many  large  and  valuable  text-books  and  works  of 
reference  already  in  existence  are  almost  more  than  the  ordinary 
student  can  master  during  the  time  at  his  disposal.  It  has  therefore 
been  our  aim  to  present  the  facts  of  surgical  science  in  a  concise 
and  succinct  form,  so  as  to  satisfy  the  needs  of  the  student,  even  of 
those  who  are  preparing  for  the  higher  examinations.  At  the  same 
timC)  the  requirements  of  the  general  practitioner  have  not  been 
overlooked,  for  we  have  taken  care  to  discuss  in  detail  those  con- 
ditions which  are  most  likely  to  be  met  with  in  ordinary  practice. 
The  main  difficulty  has  been  to  compress  into  a  small  space  the 
ever-increasing  amount  of  material  available,  so  that  we  have  only 
been  able  to^ketch  in  outline  much  that  could  have  been  elaborately 
described  did  the  size  of  the  book  permit.  For  the  same  reason, 
historical  and  bibliographical  references  have  to  a  large  extent  been 
omitted,  whilst  diseases  of  special  regions — such  as  the  eye,  ear, 
and  female  genital  organs — are  also  practically  excluded,  except  in 
so  far  as  they  encroach  on  the  domains  of  general  surgery.  The 
progress  of  bacteriology  and  the  influence  of  antisepsis  have  so 
transformed  the  characters  and  extended  the  scope  of  surgical  work, 
that  many  of  the  traditions  and  theories  of  the  past  have  had  to  be 
discarded,  although  at  the  same  time  we  have  endeavoured  to 
preserve  and  respect  that  which  has  been  shown  to  be  good  and 
useful  in  the  laborious  researches  and  accumulated  experiences  of 
bygone  generations. 

In  conclusion,  our  best  thanks  are  due  to  Dr.  St.  Clair  Thomson, 
who  has  kindly  looked  through  the  proofs  of  the  sections  devoted  to 


X  PREFACE  TO  FIRST  EDITION 

the  nose  and  ear  ;  to  Dr.  Silk,  who  has  fulfilled  a  similar  offict-  in 
reference  to  the  chapter  on  anaesthetics  ;  to  Mr.  William  Turner  for 
preparing  the  Index  ;  and  to  Dr.  Arthur  Griffiths,  late  of  the  Bristol 
General  Hospital,  who  has  drawn  several  of  the  pictures,  and  given 
other  valuable  assistance. 

Many  of  the  illustrations  have  been  specially  prepared  for  this 
work,  but  we  have  also  to  acknowledge  the  loan  of  blocks  from 
Messrs.  Veit  and  Co.,  of  Leipzig  ;  from  Messrs.  Cassell  and  Co., 
J.  and  A.  Churchill,  Longmans  and  Co.  ;  and  from  the  editors  of 
the  Lancet  for  the  loan  of  Fig,  287.  The  various  sources  from 
which  these  are  derived  are  acknowledged  throughout  the  book. 
Illustrations  of  instruments  are  mainly  derived  from  Messrs.  Dowb 
Brothers,  who  have  kindly  placed  them  at  our  disposal. 

W.  ROSE, 

17,  Harley  Street,  W. 

A.  CARLESS, 

10.  Welbeck  Street.  W. 

London, 

May  I,  iSg.-? 


CONTENTS 


CHAPTER  I'Aca 

I.    SURGICAL    BACTERIOLOGY INFECTION IMMUNITY       (bY 

DR.    W.    d'eSTE    emery)  -  -  -  -  I 

ii.  inflammation       -  -  -  -  -  "3° 

iii.  examination  of  the  blood  in  health   and    disease. 

(by  dr.  w.  d'este  emery)      -  -  -  "49 

iv.  non-specific  pyogenic  infections         -  -  "59 

v.  ulceration  -  -  -  -  -  "91 

vi.  gangrene  ■  -  -  -  -  "99 

vii.  specific  infective  diseases      .  -  -  -    120 

viii.  tumours  and  cysts        -  -  -  -  =    184 

ix.  wounds    -------    230 

x.  the  general  technique  of  operative  surgery    -  26 s 

•  i 

XI.    HEMORRHAGE            -                   -                   -                   -                  -                   -  276 

XII.    INJURIES    AND    DISEASES    OF    ARTERIES ANEURISM LIGA- 
TURE   OF    ARTERIES          -----  298 

XIII.    SURGERY    OF    THE    VEINS    -----  j  ]  j 

XIV.    DISEASES    OF    THE    LYMPHATICS       -                   -                   -                   -  338 

XV.    AFFECTIONS    OF    NERVES     -  -  -  -  "373 

XVI.    SURGICAL    DISEASES  OF  THE  SKIN  AND  OF  THE  CUTANEOUS 

APPENDAGES       ------  ^97 

XVII.    AFFECTIONS    OF    MUSCLES,    TENDONS,    AND    BURS.E                   -  4II 

XVIII.    DEFORMITIES             ------  j_26 

XIX.    INJURIES    OF    BONES FRACTURES  -                   -                  -                  -  463 

XX.    DISEASES    OF    BONE                  ....                  -  -02 

XXI.    INJURIES    OF    JOINTS DISLOCATIONS             -                   -                   -  6 ID 

XXII.    DISEASES    OF    JOINTS              ...                  -                   -  639 

XXIII.    INJURIES    OF    THE    SPINE    -----  693 


xii  CONTENTS 

CHAPTER  PAGE 

XXIV.    DISEASES    OF    THE    SPINE                 ....  713 

XXV.    AFFECTIONS    OF    THE    SCALP    AND    CRANIUM             -                   -  735 

XXVI.    AFFECTIONS    OF    THE    BRAIN    AND    ITS    MEMBRANES             -  757 

XXVII.    AFFECTIONS    OF    THE    LIPS    AND    JAWS      -                   -                   -  794 

XXVIII.    AFFECTIONS    OF    THE    NOSE    AND    NASO-PHARYNX                    -  825 

XXIX.    AFFECTIONS    OF    THE    MOUTH,  THROAT,  AND    CESOPHAGUS  844 

XXX.    AFFECTIONS    OF    THE    EAR                 -                   -                   -                   -  885 

XXXI.    SURGERY    OF    THE    NECK                    .....  897 

XXXII.    SURGERY    OF    THE    AIR-PASSAGES,    LUNGS,    AND    CHEST     -  912 

XXXIII.    DISEASES    OF    THE    BREAST             ■*                  -             ■      -                   -  944 

XXXIV.    ABDOMINAL    SURGERY  *  -                   -                   -                   -                   -  969 

XXXV.    HERNIA  f                 -                  -                   ....  1087 

XXXVI.    INTESTINAL    OBSTRUCTION    *         -                   -                   -                   -  II27 

XXXVII.    AFFECTIONS    OF    THE    RECTUM    AND    ANUS  '            -                   -  II46 

XXXVIII.    SURGICAL    AFFECTIONS    OF    THE    KIDNEYS    ^           -                   -  1X77 

XXXIX.    SURGERY    OF    THE    BLADDER    AND    PROSTATE*      -                   -  I2IO 

XL.    AFFECTIONS    OF    THE    URETHRA    AND    PENIS            -                   -  1257 

XLI.    AFFECTIONS     OF     THE      TESTIS,      CORD,      SCROTUM,      AND 

SEMINAL    VESICLES  -                   .                   -                   .                   .  I279 

XLII.    SURGERY    OF    THE    FEMALE    GENITAL    ORGANS       -                   -  I3O3 

XLIII.    AMPUTATIONS      --.--•  I328 

XLIV.    ANAESTHESIA        -                   -                   -                   -                   -           *     •  1346 


INDEX 


^357 


PLATE    I. 


Fig.  I. — Staphylococci  in  pus.  Staining — Gram  and  dilute  carbol-fuchsin. 
Fig.  2. — Streptococci  in  pus.  Staining — methylene  blue.  Fig.  3. — Gonococci  in 
pus.  Gram  and  carbol-fuchsin,  only  the  latter  of  which  has  stained.  Fig.  4. — Pneu- 
mococci  in  sputum.  Methylene  blue.  Fig.  5.  —  Sarcinae,  from  a  culture.  Gram's 
stain.     Fig.  6.— Spirilla  (with  a  few  bacilli)  from  Vincent's  angina.     Carbol-fuchsin. 

\To  face  page  i. 


A    MANUAL   OF   SURGERY 

CHAPTER  I. 
BACTERIOLOGY— INFECTION— IMMUNITY. 

The  importance  to  the  surgeon  of  a  study  of  bacteriology  is  twofold. 
In  the  first  place,  many  surgical  diseases  (especially  those  of  an 
inflammatory  nature)  are  due  to  the  action  of  bacteria ;  secondly, 
these  organisms  are  practically  ubiquitous,  and  in  the  absence  of 
suitable  precautions  will  infallibly  enter  any  external  wound,  whether 
accidental  or  intentional,  and  by  their  development  delay  the  process 
of  healing,  or  even  give  rise  to  fatal  results.  Thus  it  becomes 
necessary  for  every  surgeon  to  have  a  general  knowledge  of  the 
habits  and  distribution  of  the  more  important  species  of  bacteria, 
their  mode  of  life,  and  the  mechanism  by  which  they  give  rise  to 
morbid  processes  in  the  human  body,  as  well  as  of  the  methods  used 
in  their  investigation.  It  was  only  by  means  of  such  knowledge  that 
the  foundations  of  the  present  methods  of  treating  wounds  were 
laid,  and  without  it  it  is  difficult  to  apply  these  methods  intelli- 
gently in  actual  practice.  In  addition,  the  diagnosis  of  disease  is  often 
much  assisted  by  the  bacteriological  examination  of  morbid  products, 
and  although  the  methods  employed  are  in  many  cases  extremely 
simple,  yet  they  frequently  lead  to  information  of  the  highest 
importance  in  diagnosis  and  prognosis. 

Bacteria  (schizomycetes,  or  fission  fungi)  form  a  very  important 
group  of  the  lower  plants.  Although  several  thousand  species  have 
been  described,  comparatively  few  are  of  importance  in  medicine  or 
surgery.  They  may  be  defined  as  very  minute  unicellular  plants, 
which  reproduce  themselves  by  simple  fission,  or  in  some  forms  by 
endogenous  spore-formation,  not  more  than  one  spore  being  formed 
in  each  cell.  They  are  devoid  of  organs  except  flagella,  and  they 
contain  no  chlorophyll.  Their  structure  is  extremely  simple.  They 
consist  of  a  delicate  cell-wall  (composed  of  cellulose  or  an  allied  sub- 
stance), which  encloses  a  mass  of  protoplasm,  in  which  there  may 
be  one  or  more  vacuoles  and  a  few  granules  of  unknown  nature. 
External  to  the  cell-wall  there  is  sometimes  a  gelatinous  capsule, 


2  A  MANUAL  OF  SURGERY 

which  may  serve  to  unite  the  bacterial  cell  loosely  with  its  neigh- 
bours. When  such  capsules  become  very  prominent,  large  numbers 
of  bacteria  may  become  embedded  in  a  gelatinous  mass,  known 
as  a  zooglcea.  Capsule-formation  is  of  some  importance  in  diagnosis ; 
the  pneumococcus,  for  example,  possesses  a  well-marked  capsule 
when  it  occurs  in  blood  or  morbid  exudates,  and  may  thereby  be 
distinguished  from  many  organisms  otherwise  resembling  it. 

The  Methods  of  Reproduction  which  occur  among  the  bacteria  are 
extremely  simple,  nothing  akin  to  sexual  processes  having  been 
observed.  In  simple  fission  the  cell  becomes  divided  into  two  by  a  thin 
membrane,  and  these  two  portions  develop  into  mature  organisms. 
In  many  cases  the  two  bacteria  thus  produced  become  entirely 
separated  from  one  another ;  but  in  some  species  they  remain  more 
or  less  connected  by  means  of  the  capsules  described  above,  and  in 
this  way  the  individual  bacteria  become  united  into  groups,  which 
are  more  or  less  characteristic  of  the  species.  This  process  of  division 
may  take  place  with  great  rapidity,  so  that  a  suitable  material  which 
has  become  infected  with  one  or  two  bacteria  may  contain  vast 
numbers  in  the  course  of  a  few  hours. 

Spore-formation  is  a  more  complicated  process,  and  is  found  only  in 
certain  of  the  rod-shaped  bacteria  or  bacilli.  Bacterial  spores  are 
round  or  oval  in  shape,  and  are  formed  within  the  bacterial  cell 
(endospores).  They  consist  of  a  thick  cell-wall  filled  with  proto- 
plasm, which  contains  less  water  than  the  mature  bacterium,  and  has, 
therefore,  a  highly  refractile  appearance  when  seen  under  the  micro- 
scope. The  shape  and  size  of  the  spores  have  much  diagnostic 
value ;  thus,  the  bacillus  of  tetanus  has  an  almost  spherical  spore, 
which  is  distinctly  larger  than  the  diameter  of  the  rod  in  which  it  is 
formed,  whilst  the  spore  of  the  anthrax  bacillus  is  oval,  and  little  or 
no  broader  than  the  rod  itself.  The  position  of  the  spore  is  also  of 
importance.  The  spores  of  the  tetanus  bacillus  are  at  the  extreme 
end  of  the  bacillus,  giving  it  the  appearance  of  a  drumstick,  whilst 
those  of  anthrax  are  central.  Spores  are  to  be  regarded  as  resting 
forms  adapted  to  maintain  the  life  of  the  species  under  adverse  con- 
ditions, and  in  this  respect  are  analogous  to  the  seeds  of  the  higher 
plants.  They  resist  drying  to  a  far  greater  extent  than  do  the 
bacteria  themselves.  Anthrax  spores  have  been  preserved  in  the 
laboratory  for  twenty  years  without  loss  of  viability  or  virulence, 
whilst  asporogenous  anthrax  dies  in  a  few  weeks  when  dried.  They 
are  also  very  resistant  to  heat.  Most  bacteria  (when  moist)  are 
killed  when  exposed  to  a  temperature  of  60°  C.  for  half  an  hour, 
whereas  many  spores  are  not  killed  by  prolonged  boiling.  Lastly, 
they  are  very  difficult  to  kill  by  means  of  antiseptics.  Anthrax  spores 
can  be  killed  by  immersion  in  i  in  20  carbolic  lotion,  but  only  after 
several  days.  Of  the  bacilli  of  chief  interest  to  the  surgeon  the 
B.  tetani,  B.  anthracis,  B.  oedematis  maligni  form  spores,  and  of  those 
only  the  B.  tetani  in  the  body,  whilst  those  of  glanders,  tubercle, 
diphtheria,  typhoid  fever,  leprosy,  influenza,  and  soft  sore  are 
asporogenous. 

Flagella  are   delicate  filamentous    extensions  of   the  protoplasm. 


BA  CTERIOLOG  Y— INFECTION— IMM  UNIT  Y  3 

which  occur  in  those  bacteria  which  are  possessed  of  spontaneous 
mobility.  They  are  sometimes  of  great  length,  but  are  always 
extremely  thin,  and  are  only  visible  after  the  use  of  complicated 
staining  processes.  Their  number  is  of  importance  in  diagnosis. 
The  typhoid  bacillus,  for  example,  has  usually  from  twelve  to  twenty 
flagella  (Plate  II.,  Fig.  21),  whilst  the  closely-allied  B.  coli  has  from 
three  to  six.  It  should  be  remembered  that  bacteria  which  are 
devoid  of  flagella  often  exhibit  very  marked  Brownian  movement, 
which  the  uninitiated  might  mistake  for  spontaneous  motility. 

The  Classification  of  the  bacteria  is  based,  in  the  first  instance,  on 
their  morphology,  but  owing  to  the  simplicity  of  the  shape  of  the 
organisms,  morphological  characteristics  have  to  be  supplemented 
by  physiological  and  cultural  properties  in  the  definition  of  the 
separate  species.  There  are  three  great  groups — the  cocci,  bacilli, 
and  spirilla. 

I.  Cocci  are  organisms  which  are  spherical,  or  nearly  spherical. 
They  constitute  the  simplest  forms  of  bacteria,  since  but  few  species 
possess  flagella,  and  spore-formation  is  unknown.  They  are  sub- 
divided according  to  the  methods  in  which  the  individual  cocci  are 
arranged,  [a)  Micrococci  are  those  forms  in  which  there  is  no  definite 
arrangement  into  groups.  The  term  'staphylococcus' — more  properly 
the  name  of  a  species,  the  Staphylococctis  pyogenes — is  applied  to  cocci 
in  which  the  individual  elements  are  arranged  in  clusters  resembling 
bunches  of  grapes  (Plate  I.,  Fig.  i).  {b)  Diplococci  (Plate  I.,  Fig.  4) 
are  forms  in  which  the  two  elements  arising  from  the  division  of  a 
single  coccus  remain  in  more  or  less  close  apposition,  so  that  they 
are  arranged  in  pairs,  (c)  Streptococci  (Plate  I.,  Fig.  2)  are  arranged 
in  longer  or  shorter  chains,  like  a  necklace.  This  formation  is  due 
to  the  fact  that  the  successive  planes  of  division  by  which  the  cocci 
are  divided  lie  parallel  to  one  another,  [d)  In  a  few  cases  a  coccus 
divides  into  two,  which  are  again  divided  by  a  plane  at  right  angles 
to  the  first,  so  that  the  four  cocci  which  result  lie  at  the  corners  of 
a  square  ;  these  are  called  Tetracocci.     Lastly,  {e)  Sarcincs  are  formed 

■  by  three  consecutive  divisions  in  the  three  planes  of  space,  so  that 
the  eight  cocci  which  are  formed  lie  at  the  corners  of  a  sphere 
(Plate  I.,  Fig.  5).  In  these  forms  the  separation  of  the  individual 
cocci  is  rarely  complete,  so  that  the  mass  resembles  a  bale  of  wool 
tightly  tied  in  three  directions.  These  cocci  often  divide  again,  and 
lead  to  the  formation  of  composite  masses. 

II.  Bacilli  (Plate  II.,  p.  59)  are  bacteria  which  have  the  form  of 
rods,  the  long  diameter  of  the  cell  being  greatly  larger  than  the  short 
diameter.  They  are  usually  straight ;  but,  if  curved,  the  curve  is 
only  in  one  plane,  so  that  the  rod  would  lie  flat  on  a  plane  surface. 
Spore-formation  is  common  in  this  group,  and  many  of  its  members 
possess  flagella.  The  group  is  not  subdivided,  but  the  terms  stvepto- 
hacillus  for  those  which  remain  adherent  in  chains,  and  leptothrix  for 
forms  which  produce  long  threads  before  breaking  up  into  short  rods, 
are  convenient. 

III.  Spirilla  are  rods  which  are  uniformly  curved  in  the  three 


4  A  MANUAL  OF  SURGERY 

planes  of  space,  so  that  when  sufficiently  long  they  form  corkscrew- 
like spirals.  Short  forms  also  occur,  and  these  are  sometimes 
designated  vibrios,  the  term  '  spirilla '  being  then  reserved  for  the 
long  spiral  forms.  The  spirilla  are  not  of  much  surgical  importance, 
the  only  well-known  pathogenic  varieties  being  the  V.  cholevce  Asiaticcn 
and  the  spirillum  of  relapsing  fever  (Plate  I.,  Fig.  6),  which  latter, 
however,  is  now  thought  to  be  of  animal  nature. 

In  regard  to  their  physiology,  bacteria  resemble  the  other  plants 
devoid  of  chlorophyll  in  being  unable  to  form  proteid  from  simple 
materials  in  presence  of  sunlight,  and  have  to  be  supplied  with 
ready-formed  organic  nitrogen  from  animal  or  vegetable  sources. 
Regarded  from  this  standpoint,  they  may  be  divided  into  two  classes 
— the  parasites,  which  can  obtain  their  pabulum  only  from  the  living 
animal  (or  plant),  and  the  saprophytes,  which  are  unable  to  do  so,  and 
flourish  only  in  dead  materials.  The  leprosy  bacillus  may  be  taken 
as  an  example  of  a  strict  parasite,  since,  as  far  as  is  known  at  present, 
it  grows  only  in  the  living  tissues,  and  cannot  be  cultivated  outside 
the  body.  The  term  facultative  saprophyte  is  applied  to  those  organisms 
which  prefer  a  parasitic  existence,  but  which  will  grow  under  suit- 
able conditions  in  dead  materials.  The  gonococcus  is  a  good  example; 
it  multiplies  readily  enough  in  the  living  mucous  membrane,  but 
grows  only  feebly  on  dead  culture  media.  Facultative  parasites,  on  the 
other  hand,  are  organisms  which  grow  best  in  dead  materials,  but 
which  have  the  power  of  adapting  themselves  to  a  parasitic  existence. 
It  must  be  understood  that  the  terms  '  parasitic  '  and  '  pathogenic ' 
are  not  quite  synonymous.  A  pathogenic  organism  is  one  that  has  the 
power  of  producing  disease,  and  it  may  do  so  without  entering  the 
living  tissues  at  all,  as  when  putrefactive  organisms  gain  access  to 
a  blood-clot  in  the  uterus  and  cause  saprasmia.  A  parasitic  organism 
is  not  necessarily  pathogenic,  especially  in  the  lower  animals,  since 
these  frequently  harbour  blood-parasites  without  appearing  to  suffer 
therefrom  in  any  way. 

In  addition  to  combined  nitrogen,  all  bacteria  require  water,  certain 
salts,  and  a  suitable  temperature  for  their  growth.  The  necessity 
for  water  must  be  borne  in  mind  in  surgical  practice,  and  every 
attempt  must  be  made  (by  accurate  co-aptation  of  parts,  drainage, 
etc.)  to  prevent  the  accumulation  of  putrescible  material  in  wounds 
or  body-cavities.  This  is  well  seen  in  dealing  with  the  peritoneum, 
the  absorptive  power  of  which  is  one  of  the  chief  natural  defences 
against  peritonitis.  In  laboratory  experiments  we  find  that  large 
amounts  of  fluid  cultures  of  pathogenic  bacteria  can  be  injected  into 
the  peritoneal  cavity  of  animals  without  injury  ;  the  fluid  is  rapidly 
absorbed  and  bacterial  growth  ceases.  If,  however,  the  peritoneum 
is  injured  so  that  absorption  is  checked,  the  bacteria  continue  to 
grow,  and  fatal  peritonitis  results. 

The  requirements  of  different  bacteria  as  to  temperature  vary 
enormously.  The  majority  of  those  of  importance  in  human  patho- 
logy grow  best  at  or  about  the  body  temperature  (37°  C),  but  many 
forms,  especially  those  which  are  commonly  met  with  as  saprophytes 
outside  the  body  (such  as  Staphylococcus  pyogenes  and  B.  coli),  grow 


BA  CTERIOLOG  Y— INFECTION— IMM  UNITY  5 

well  at  18°  C,  or  even  lower.  Other  forms  flourish  best  at  lower  or 
higher  temperatures  than  these,  but  they  are  not  of  pathological  im- 
portance. Lower  temperatures  inhibit  growth,  but  do  not  kill  the 
bacteria  unless  applied  for  long  periods.  The  destruction  of  bacteria 
and  spores  by  heat  has  been  already  mentioned. 

Light  is  injurious  to  almost  all  bacteria.  This  is  especially  the  case 
with  B.  tuberculosis,  which  in  vitro  is  killed  after  a  very  short  expo- 
sure to  sunlight  and  more  slowly  by  diffused  daylight.  The  action 
seems  to  depend  on  the  formation  of  peroxide  of  hydrogen  in  the 
culture  medium. 

Many  pathogenic  organisms  require  free  oxygen  for  their  develop  - 
ment,  and  are  spoken  of  as  aerobes.  A  few,  such  as  the  tetanus 
bacillus,  will  grow  only  in  the  complete  absence  of  oxygen,  ceasing  to 
develop,  though  still  remaining  alive,  when  that  gas  is  admitted  ;  such 
organisms  are  called  anaerobes.  Bacteria  which  grow  best  in  air,  but 
which  will  also  grow  in  its  absence,  are  called  facultative  anaerobes, 
and  those  which  grow  best  under  anaerobic  conditions,  but  are  capable 
of  some  growth  in  presence  of  oxygen,  are  called  facultative  aerobes. 
It  must  be  pointed  out  that  the  conditions  in  the  living  body  are 
peculiar,  in  that  both  strict  aerobes  and  strict  anaerobes  are  capable 
of  growth.  Further,  a  strict  anaerobe  may  grow  in  a  fluid  freely 
exposed  to  air  in  the  presence  of  other  organisms  which  have  a  great 
affinity  for  oxygen  and  rapidly  absorb  it.  In  this  way  tetanus  bacilli 
may  flourish  in  superficial  wounds  freely  open  to  the  air  if  other 
bacteria  are  present. 

In  their  growth  bacteria  give  off  metabolic  products  which  are  often 
of  great  importance.  The  chief  of  these  are  (i)  acids,  such  as  lactic, 
acetic,  butyric,  etc.  ;  (2)  alkalies ;  (3)  gases,  such  as  sulphuretted 
hydrogen,  marsh  gas,  etc. ;  (4)  pigments,  such  as  the  green  colouring 
matter  produced  by  B.  pyocyaneus  and  seen  in  the  so-called  blue  pus ; 
(5)  aromatic  substances,  such  as  indol,  phenol,  and  tyrosin  ;  (6)  alcohol 
and  other  similar  bodies ;  (7)  ferments — e.g.,  diastase,  invertase,  and 
a  ferment  allied  to  rennin.  A  more  important  enzyme  is  one 
resembhng  trypsin  and  having  the  power  of  peptonizing  proteid 
material.  This  is  produced  by  one  of  the  commonest  pus-producing 
organisms  {Staphylococcus  pyogenes),  and  plays  some  part  in  the  destruc- 
tion of  the  tissues  in  suppuration.  The  presence  or  absence  of  this 
ferment  is  usually  ascertained  by  cultivating  the  organism  in  ques- 
tion on  gelatin  or  coagulated  blood-serum,  either  of  which  is  digested 
or  '  liquefied  '  if  the  enzyme  is  produced.  (8)  Certain  crystaUizable 
organic  substances  of  definite  chemical  composition,  allied  to  the 
vegetable  alkaloids,  and  spoken  of  as  ptoniains.  They  have  some 
poisonous  properties,  and  were  once  thought  to  be  of  great  impor- 
tance in  the  production  of  disease.  (9)  The  true  toxins  have  never 
been  isolated  in  a  state  of  purity,  but  appear  to  be  allied  in  chemical 
composition  to  the  albumoses,  and  have  some  features  in  common 
with  the  enzymes.  They  are  intensely  poisonous  when  injected  into 
the  blood  or  tissues,  though  innocuous  (in  most  cases)  when  taken 
by  the  mouth.     They  are  very  unstable  substances,  being  readily 


6  A  MANUAL  OF  SURGERY 

destroyed  by  heat,  peptic  digestion,  etc.,  and  when  kept  in  a  state 
of  solution  gradually  become  inert. 

Toxins  are  divided  into  two  distinct  classes  :  (a)  Certain  organisms, 
of  which  the  most  important  are  the  bacilli  of  tetanus  and  diphtheria, 
produce  soluble  extracellular  toxins  which  accumulate  in  the  fluid  in 
which  they  are  grown,  (h)  In  the  case  of  many  other  organisms,  all 
attempts  to  produce  a  powerful  soluble  toxin  have  failed,  and  the 
specific  poison  appears  to  remain  locked  up  in  the  bodies  of  the 
bacteria,  and  is  only  given  off  under  conditions  which  we  are  unable 
to  reproduce  experimentally.  These  are  known  as  intracellular  toxins. 
For  example,  the  soluble  products  secreted  by  the  tubercle  bacillus 
have  but  little  toxic  action,  whereas  the  washed  bodies  of  the  bacilli 
themselves  are  extremely  poisonous. 

The  pathological  effects  of  these  toxins  are  highly  diverse,  but  in 
nearly  all  cases  they  include  the  production  of  fever.  Some  are 
selective  in  their  action,  affecting  only  a  certain  class  of  cell — e.g.,  the 
cells  of  the  central  nervous  system  in  the  case  of  tetanus.  Others, 
such  as  those  of  the  pyogenic  bacteria,  affect  any  tissues  they  may 
happen  to  reach.  Under  natural  conditions  the  results  of  their 
presence  in  the  body  vary  according  to  the  amount  of  toxin  pro- 
duced, and  to  the  susceptibility  of  the  animal  and  of  the  tissues  in 
question.  Thus  a  very  powerful  toxin  may  immediately  destroy 
the  vitality  of  a  part,  leading  to  gangrene,  whilst  one  that  is  some- 
what less  intense  in  its  action  may  kill  the  tissues  en  masse,  but  only 
after,  leading  to  an  acute  inflammation,  thereby  inducing  one  form 
of  coagulation-necrosis.  A  similar  but  still  slower  process  leads  to 
caseation  ;  in  this  fatty  degeneration  has  time  to  supervene  in  the 
affected  tissues  before  their  death.  In  another  group  of  cases  the 
acute  inflammation  may  terminate  in  a  slower  but  progressive  mole- 
cular death  of  the  tissues,  a  cell  at  a  time,  leading  to  suppuration. 
Finally,  if  a  very  feeble  toxin  acts  for  prolonged  periods  it  may  serve 
as  a  stimulant  to  growth  and  lead  to  proliferation  of  the  fibrous 
tissues,  etc.,  without  the  development  of  any  external  signs  of 
inflammation. 

Distribution. — Bacteria  are  very  widely  distributed  in  nature. 
Their  presence  in  the  air  varies  greatly  with  circumstances.  They 
are  absent  from  the  pure  air  of  mountain-tops  or  the  mid-ocean,  and 
present  in  vast  numbers  in  cities,  especially  in  houses.  They  are  not 
given  off  from  the  surface  of  liquids  containing  them,  and  only  remain 
in  suspension  in  the  atmosphere  when  adherent  to  particles  of  dust 
or  moisture.  They  are  more  plentiful  in  dry  weather  than  in  wet, 
and  more  abundant  in  occupied  houses  than  in  the  open  air.  When 
the  atmosphere  of  an  enclosed  space  is  kept  at  rest,  the  dust  gradually 
sinks  to  the  bottom  and  the  air  becomes  absolutely  sterile.  It  has 
been  found  that  the  air  of  schoolrooms  contains  far  fewer  bacteria 
when  the  scholars  are  sitting  quietly  than  when  they  are  allowed  to 
move  about — a  fact  which  should  be  borne  in  mind  by  the  spectators 
at  a  surgical  operation.  Expired  air  is  sterile,  but  in  speaking  and 
coughing  vast  numbers  of  minute  particles  of  fluid  are  ejected,  and 


BACTERIOLOGY— INFECTION— IMMUNITY  7 

these  are  charged  with  bacteria,  and  may  remain  suspended  in  the  air 
for  long  periods.  This  is  of  special  importance  in  surgery,  since  the 
bacteria  thus  given  oflf  from  the  mouth  are  frequently  pathogenic, 
and  may  constitute  a  source  of  danger  in  operations.  The  bacterial 
contents  of  water  also  vary  greatly.  That  suitable  for  a  pubHc 
water-supply  should  contain  but  few  bacteria,  and  pathogenic  forms 
should  be  absent.  Where  this  is  known  to  be  the  case,  the  water  may 
be  used  in  an  emergency  to  cleanse  wounds,  though  even  then  it  is 
desirable  to  sterilize  it  by  heat  or  filtration  ;  but  in  the  great  majority 
of  samples  of  water  from  natural  sources  the  probability  of  the 
presence  of  injurious  bacteria  is  so  great  that  a  preliminary  steriliza- 
tion is  absolutely  necessary  before  their  use  for  surgical  purposes. 
Earth  contains  vast  numbers  of  bacteria,  and  pathogenic  varieties 
are  frequently  present. 

The  human  skin  teems  with  bacteria,  like  anything  else  which  is 
exposed  to  dust  and  dirt.  The  majority  of  these  organisms  are  present 
simply  by  accident,  and  are  readily  removed  by  washing.  A  few, 
however,  are  normal  inhabitants  of  the  skin,  and  are  very  difficult  to 
destroy,  as  they  penetrate  deeply.  Bacteria  are  also  present  in  the 
alimentary  canal  from  the  mouth  to  the  anus,  the  external  auditory 
meatus,  the  inferior  meatus  of  the  nose,  the  conjunctiva,  the  anterior 
portion  of  the  male  urethra,  and  the  vulva.  The  superior  meatus  ot 
the  nose,  the  deeper  portions  of  the  urethra,  and  the  upper  part  of 
the  vagina  in  a  virgin  are  in  general  sterile,  as  are  also  the  gall- 
bladder, together  with  the  bihary  and  pancreatic  ducts.  The  blood 
and  deeper  tissues  of  a  healthy  animal  are  usually  free  from  germs, 
but  careful  observations  have  shown  that  the  escape  of  small  numbers 
of  bacteria  from  the  alimentary  canal  into  the  blood  and  lymph  is  a 
common,  perhaps  constant,  occurrence.  Under  conditions  of  health 
these  bacteria  do  not  find  suitable  conditions  for  continued  growth 
in  the  body,  and  are  soon  destroyed  by  phagocytosis  or  the  bactericidal 
powers  of  the  blood ;  but  when  the  general  vitahty  of  the  body  is 
lowered,  or  when  a  lesion  is  present,  these  bacteria  may  find  a  suit- 
able foothold  in  an  area  of  low  vitality  (such  as  a  blood  clot),  continue 
to  grow,  and  give  rise  to  pathological  effects.  This  is  probably  the 
explanation  of  the  suppuration  that  sometimes  occurs  in«deep  lesions, 
such  as  the  subcutaneous  rupture  of  a  muscle  or  ligament,  and  it  is 
termed  auto-infection.  It  is  probable  that  organisms  can  exist  for  a 
longer  time  in  the  blood  of  a  patient  of  lowered  vitality,  so  that  these 
patients  are  more  likely  to  develop  suppurative  lesions  in  this  way. 

Methods  of  Observation. — (i)  Microscopical  Examination. — This  may 
be  carried  out  on  morbid  material  taken  direct  from  the  body,  or 
on  cultures  of  organisms  derived  therefrom.  A  high  magnifying 
power  and  a  suitable  substage  condenser  are  necessary.  The  material 
may  be  stained  or  unstained.  Unstained  specimens  are  usually 
examined  in  a  '  hanging-drop '  preparation,  and  this  enables  the 
observer  to  recognise  the  shape,  size,  and  arrangement  of  the 
bacteria  present,  the  presence  or  absence  of  spores,  and  also  whether 
the  organism  is  motile.    This  method  of  examination  is  of  the  highest 


8  A  MANUAL  OF  SURGERY 

importance  in  dealing  with  cultures,  and  should  never  be  omitted. 
For  morbid  exudates,  pus,  etc.,  it  is  often  unnecessary,  and  chief 
reliance  is  placed  on  stained  specimens.  To  this  end  a  thin  film 
of  the  material  is  spread  on  a  clean  slide  or  cover-glass,  allowed 
to  dry,  and  fixed  by  being  passed  two  or  three  times  through  the 
flame.  This  film  is  then  submitted  to  the  staining  process,  of  which 
there  are  three  chief  varieties  : 

(a)  Simple  stains,  such  as  carbol-fuchsin,  carbol-thionin,  methylene 
blue,  etc.,  affect  all  bacteria,  as  well  as  the  cells,  nuclei,  etc.,  of  the 
morbid  material.  They  enable  the  presence  of  the  bacteria  to  be 
recognised,  and  their  shape,  size,  etc.,  to  be  determined.  The  other 
two  methods  are  differential  stains,  and  of  great  importance  in  the 
recognition  of  the  species  of  bacteria  present. 

(b)  Gram's  Method. — The  film  is  immersed  for  three  to  five  minutes 
in  a  stain  consisting  of  lo  parts  of  a  saturated  alcoholic  solution  of 
gentian  violet  diluted  with  90  parts  of  i  in  20  carbolic  acid  in  water. 
It  is  then  trea  ted  for  two  or  three  minutes  with  a  watery  solution  of 
iodine  in  iodide  of  potassium  (iodine  i,  KI  2,  water  300),  and  finally 
washed  in  alcohol  until  no  more  colour  is  dissolved  out.  Some 
bacteria  remain  stained  when  treated  in  this  way,  whilst  others  are 
completely  decolorized. 

The  following  are  stained  :  Staphylococci,  Streptococcus  pyogenes,  the 
pneumococcus,  the  Micrococcus  tetragenes,  the  bacilli  of  tetanus,  anthrax, 
tubercle,  leprosy,  diphtheria,  and  the  streptothrices  causing  actino- 
mycosis. 

The  following  are  unstained  :  The  gonococcus,  the  meningococcus, 
the  Micrococcus  Melitensis,  the  B.  coli,  the  bacilli  of  glanders,  typhoid 
fever,  influenza,  and  soft  sore,  the  B.  pyocyaneus,  the  vibrio  of  cholera, 
the  spirillum  of  relapsing  fever,  and  the  spirochsete  of  syphilis. 

(c)  The  Ziehl-Nielsen  Method. — The  film  is  stained  by  means  of  a 
powerful  stain,  usually  carbol-fuchsin,  which  is  either  heated  or 
allowed  to  act  for  several  hours.  It  is  then  immersed  in  20  to 
25  per  cent,  sulphuric  acid  for  five  or  ten  minutes.  This  removes 
the  stain  from  all  cells,  etc.,  and  from  the  majority  of  bacteria.  A 
few,  however,  retain  it,  and  these  are  called  acid-fast.  Films  may 
also  be  stained  in  the  same  way  and  subsequently  decolorized  in 
alcohol,  and  organisms  which  reiain  the  stain  are  called  alcohol-fast. 
Of  the  organisms  which  are  of  importance  in  human  pathology, 
the  bacilli  of  tubercle  and  leprosy  and  a  bacillus  frequently  found  in 
smegma  are  acid-fast,  and  the  two  former  are  also  alcohol-fast. 
Certain  streptothrices  are  also  acid-fast. 

(2)  It  is  usually  necessary  to  supplement  microscopical  examina- 
tion by  cultural  methods  in  which  a  suitable  culture  medium  is 
inoculated  with  the  material  to  be  examined  and  kept  at  a  proper 
heat  for  the  development  of  the  bacteria  suspected  to  be  present. 
These  culture  media  are  very  numerous,  but  broth,  gelatin,  solidified 
blood-serum,  and  agar-agar  suffice  for  most  purposes.  Broth  con- 
sists of  a  solution  of  the  extractives  of  meat,  peptone,  and  salt.  It 
is   chiefly  used   for   making  cultures   for  animal    inoculations,  and 


BACTERIOLOGY— INFECTION— IMMUNITY  9 

for  observations  on  the  chemical  products  of  bacteria.  Solid  culture 
media  are  more  useful,  since  many  organisms  form  characteristic 
growths  or  colonies  on  the  surface  or  in  the  depth  of  the  medium. 
Nutrient  gelatin  is  simply  broth  solidified  by  the  addition  of  10  to 
15  per  cent,  of  gelatin,  and  is  especially  valuable,  since  it  is  liquefied 
by  some  bacteria,  whilst  others  have  no  such  action.  A  disadvantage 
is  that  it  melts  at  the  temperature  necessary  for  the  growth  of 
many  pathogenic  bacteria,  and  when  this  is  the  case  observations  on 
the  formation  of  a  peptonizing  ferment  have  to  be  carried  out  by 
cultures  on  blood- serum  coagulated  by  heat.  Agar-agar  is  broth 
solidified  by  the  addition  of  a  substance  prepared  from  a  seaweed. 
It  is  not  melted  at  the  temperature  of  the  body,  and  is  not  liquefied 
by  any  organism.  It  is  the  most  generally  useful  of  all  media  for 
pathological  work. 

For  the  methods  used  in  obtaining  pure  cultures  of  organisms 
from  material  containing  a  mixture  of  several  varieties  (often  a 
matter  of  great  difficulty)  a  work  on  bacteriology  must  be  consulted. 

(3)  The  inoculation  of  living  animals  is  also  frequently  necessary. 
This  method  of  investigation  is,  perhaps,  most  useful  in  the  examina- 
tion of  morbid  materials  (urine,  pus,  etc.)  for  the  tubercle  bacillus, 
which  is  often  present  in  such  scanty  numbers  that  it  eludes  a 
careful  search,  and  cultural  methods  are  hardly  applicable  in  practice. 
The  subcutaneous  or  intraperitoneal  inoculation  of  a  guinea-pig  is 
an  extremely  delicate  test,  and  will  infallibly  lead  to  the  development 
of  tuberculosis  if  living  bacilli  are  present.  The  chief  drawback  is 
the  fact  that  it  takes  two  or  three  weeks  for  the  disease  to  develop. 
Inoculations  of  pure  cultures  are  often  resorted  to  where  the  organism 
.present  has  so  close  a  resemblance  to  a  non -pathogenic  form  that 
its  recognition  is  a  matter  of  uncertainty.  Thus,  several  harmless 
organisms  have  a  close  resemblance  to  the  anthrax  bacillus,  and 
the  latter  can  only  be  distinguished  by  causing  anthrax  when  injected 
into  the  lower  animals.  A  refinement  on  this  method,  which  is 
applicable  in  some  cases,  consists  in  injecting  a  normal  animal  and 
also  an  animal  immunized  against  the  organism  suspected  to  be 
present  in  the  culture.  As  an  example,  we  may  take  the  recognition 
of  the  tetanus  bacillus  in  pus,  where  it  is  usually  mixed  with  many 
other  bacteria,  so  that  it  is  excessively  difficult  to  isolate.  A  broth 
culture  is  inoculated  with  the  pus  in  question,  and  incubated  in  the 
absence  of  air,  since  the  tetanus  bacillus  is  an  anaerobe.  It  is  then 
divided  into  two  parts,  of  which  one  is  injected  into  a  normal 
animal  and  the  other  into  one  which  has  received  a  dose  of  antitetanic 
serum.  If  the  former  dies  and  the  latter  remains  alive,  the  presence 
of  the  tetanus  bacillus  in  the  culture  is  certain. 

Injections  are  also  necessary  in  order  to  prove  that  an  organism 
which  has  been  isolated  in  cases  of  a  given  disease  is  actually  the 
cause  of  that  disease.  In  the  early  days  of  bacteriology,  when  the 
bacterial  origin  of  disease  was  hotly  contested,  Koch  formulated 
the  following  postulates,  and  when  these  are  fulfilled,  we  may 
consider  the  cause  of  the  disease  as  proved  to  demonstration : 


lo  A  MANUAL  OF  SURGERY 

(a)  The  organism  (which  must  be  one  that  can  be  definitely 
recognised  from  all  others)  must  be  present  in  the  body  in  every 
case  of  the  disease. 

(b)  It  must  be  possible  to  cultivate  it  for  many  generations  apart 
from  the  body.  This  is  to  get  rid  of  every  trace  of  the  substance 
taken  from  the  first  case  of  the  disease  in  making  the  original 
culture. 

(c)  The  inoculation  of  a  suitable  animal  must  be  followed  by  the 
appearance  of  the  specific  disease. 

{d)  The  organism  must  be  found  in  the  animal  thus  infected. 

We  do  not  now  demand  so  rigid  a  proof  of  the  pathogenic  effects 
of  bacteria.  Thus,  although  the  B.  lepra  is  universally  admitted  to 
be  the  cause  of  leprosy,  yet  it  has  never  been  cultivated,  so  that  with 
it  only  the  first  of  Koch's  postulates  holds.  Other  tests,  such  as  the 
presence  of  specific  agglutinins  in  the  blood  of  cases  of  the  disease, 
are  now  applicable. 

A  few  other  micro-organisms  other  than  bacteria  require  brief 
mention,  but  they  are  of  little  surgical  importance. 

1.  The  yeasts  or  hlastoniycetes  are  devoid  of  chlorophyll,  and  multiply 
by  budding,  or  endogenous  spore-formation,  in  which  several  spores 
are  formed  in  each  cell.  They  cause  many  forms  of  fermentation — 
e.g.,  the  alcoholic  fermentation  in  solutions  of  grape-sugar;  they 
occasionally  gain  access  to  the  urinary  bladder  in  diabetes,  and,  by 
leading  to  the  production  of  irritative  products  of  fermentation,  give 
rise  to  cystitis.  The  only  important  disease  now  attributed  to  the 
yeast-fungi  is  blastomycetic  dermatitis^  which  is  characterized  by  multiple 
chronic  lesions,  resembling  verrucous  tuberculides. 

2.  The  hyphomycetes,  or  filamentous  fungi,  are  characterized  by  the 
presence  of  a  mycelial  network  of  long  fibres,  and  have  a  method  of 
sporulation  which  is  more  complicated  than  that  seen  in  the  bacteria 
or  yeasts.  The  following  are  the  more  important  of  their  pathological 
effects  : 

Thrush,  due  to  Oidium  albicans,  an  organism  sometimes  included  in 
the  blastomycetes,  and  called  Saccharomyces  or  Monilia  albicans. 

Ringworm,  which  may  be  caused  by  Microsporon  A  udouini  (the  small- 
spored  fungus),  or  the  Trichophyton  or  large-spored  fungus,  of  which 
there  are  several  varieties.  Of  these  the  former  is  more  common  in 
London  and  Paris,  but  is  rare  in  most  parts  of  the  Continent. 

Favus,  caused  by  the  Achorion  Schonleinii. 

Pityriasis  rubra,  due  to  the  Microsporon  furfur. 

Keratomycosis,  or  parasitic  ulcer  of  the  cornea,  is  due  to  fungi  of  the 
aspergillus  type,  and  similar  organisms  may  also  affect  the  lungs 
(pneumomycosis)  or  the  external  auditory  meatus  (otomycosis). 

The  group  streptothrix  may  be  regarded  as  the  lowest  of  the 
hyphomycetes,  and  its  members  possess  many  similarities  to  the 
bacteria.  They  are  of  importance,  since  their  pathogenic  members 
give  rise  to  the  group  of  diseases  known  as  '  actinomycosis.'  The 
streptothrices  form  long  filamentous   hyphae,  which   are  narrower 


BA  CTERIOLOG  Y— INFECTION— IMM  UNITY  1 1 

than  those  of  the  higher  fungi,  and  which  differ  from  the  leptothrical 
filaments  sometimes  exhibited  by  some  bacilli  in  that  they  exhibit 
true  branching.  They  form  chain-spores,  the  protoplasm  of  the 
mycelial  threads  collecting  in  small  masses  separated  by  spaces  in 
which  the  sheath  is  empty.  These  appear  to  be  true  spores,  since 
they  resist  a  temperature  higher  than  that  which  kills  the  mycelium 
itself.  The  streptothrices  are  widely  distributed,  and  many  forms 
are  known,  of  which  but  a  few  are  pathogenic. 

It  is  worthy  of  notice  that  the  tubercle  bacillus  (as  well  as  other 
organisms  usually  classified  as  bacteria)  sometimes  grows  into  long 
branching  filaments.  Hence  some  regard  it  as  belonging  to  the 
streptothrices,  and  term  it  tuberculomyces. 

3.  The  protozoa,  or  unicellular  animals,  are  a  group  of  considerable 
importance,  since  syphilis  and  not  a  few  tropical  affections  are  due  to 
members  of  this  family.  The  life-history  of  many  of  them  is  not 
known  in  its  entirety,  but  it  has  been  traced  out  in  some.  Malaria 
and  the  amoebic  form  of  dysentery,  together  with  the  tropical  abscess 
of  the  liver  associated  therewith,  are  protozoal  in  origin.  Tvypano- 
somes  are  also  of  animal  nature,  and  by  their  development  in  the  body 
give  rise  to  sleeping  sickness  and  numerous  other  tropical  diseases  in 
man  and  lower  animals.  The  psorosperms  which  belong  to  this  group 
cause  disease  in  the  lower  animals,  and  are  of  interest  in  human 
pathology,  since  the  peculiar  bodies  seen  in  Paget's  disease,  and  in 
molluscum  contagiosum  were  once  thought  to  be  of  this  nature,  but 
are  now  known  to  be  merely  forms  of  cell  degeneration. 

Infection. 
Infection  may  be  defined  as  the  access  of  living,  virulent,  patho- 
genic bacteria  to  a  region  whence  their  toxins  may  act  on  the 
tissues  of  the  body.  Certain  points  in  this  definition  require  explana- 
tion :  (i)  It  is  interesting  to  notice  that  dead  bacteria,  especially 
dead  tubercle  bacilli,  may  cause  pathogenic  effects  quite  similar 
to  those  of  the  living  ones.  This,  however,  would  scarcely  be  spoken 
of  as  infection,  since  one  of  our  fundamental  ideas  of  that  process 
is  that  it  can  be  transmitted  from  one  sufferer  to  another  indefinitely. 
(2)  The  question  of  virulence  is  one  of  the  greatest  importance.  Many 
organisms  vary  enormously  in  this  respect.  For  instance,  the  Strepto- 
coccus pyogenes  is  often  quite  devoid  of  virulence  to  rabbits,  the 
injection  of  large  amounts  of  pure  culture  being  followed  by  no  bad 
results  of  any  sort ;  and  yet  it  is  possible  to  exalt  the  virulence  of 
the  same  culture  enormously,  so  that  an  extremely  small  dose  (possibly 
a  single  coccus)  may  cause  death.  This  exaltation  of  virulence  is 
usually  accomplished  by  '  passage  '  through  animals,  an  animal  being 
inoculated  with  large  doses  of  the  organism,  and  cultures  from  this 
animal  being  taken  to  inoculate  the  next,  and  so  on,  until  many 
animals  have  been  inoculated  in  series.  Probably  something  of  the 
sort  occurs  under  natural  conditions,  for  an  organism  taken  directly 
from  a  patient  is  usually  much  more  virulent  than  one  that  has 
been  cultivated  in  the  laboratory.  Thus,  a  slight  post-mortem 
wound  infected  from  a  case  of  streptococcic  peritonitis  is  usually 


12  A  MANUAL  OF  SURGERY 

very  severe,  indicating  a  very  high  degree  of  virulence  in  the 
organism.  In  general,  we  know  little  or  nothing  of  the  causes 
which  lead  to  increase  of  virulence  under  natural  conditions.  The 
outbreak  of  an  epidemic  of  small-pox,  for  instance,  must  be  due  to  a 
sudden  increase  in  virulence  of  the  specific  organism,  but  the  causes 
which  lead  to  this  are  quite  obscure. 

Cultures  of  an  organism  of  diminished  virulence  are  said  to  be 
attenuated;  thus  vaccine  is  a  culture  of  the  unknown  small-pox 
organism  in  an  attenuated  state.  The  artificial  attenuation  of  patho- 
genic bacteria  is  a  subject  of  great  importance  in  connection  with  the 
production  of  immunity,  and  it  may  be  laid  down  as  a  general  rule  that 
the  cultivation  of  an  organism  under  slightly  disadvantageous  con- 
ditions tends  to  diminish  its  virulence,  and  vice-vevsd.  For  example, 
the  anthrax  bacillus  grows  best  at  37°  C,  or  thereabouts,  and  retains 
its  virulence  for  long  periods  at  this  temperature,  but  if  it  is  culti- 
vated at  42°  C.  it  becomes  attenuated.  Cultures  thus  treated  con- 
stitute Pasteur's  vaccine  against  anthrax  ;  when  injected  into  animals 
they  cause  transient  ill-effects,  but  the  animal  becomes  immune  to 
the  disease. 

(3)  The  organism  must  be  pathogenic,  if  infection  is  to  occur,  and 
by  this  we  mean  capable  of  producing  disease  in  the  animal  in 
question.  Thus,  the  inoculation  of  the  gonococcus  into  the  urethra 
of  animals  leads  to  no  results,  and  infection  does  not  take  place. 
Hence  two  factors  must  be  present :  the  organism  must  be  virulent, 
and  the  host  susceptible. 

(4)  Lastly,  an  essential  feature  of  infection  is  that  the  toxins  of 
the  organism  must  act  on  the  tissues  of  the  host.  Thus,  it  is  quite 
possible,  and  not  uncommon,  for  streptococci  to  be  present  in  the 
outer  layers  of  the  skin,  and  the  B.  diphtherias  in  the  mouth,  etc.,  and 
yet  for  no  harmful  effects  to  arise,  since  either  the  organisms  do 
not  form  toxins,  or  else  these  toxins  do  not  reach  the  tissues.  This 
is  not  infection,  although  in  such  cases  any  slight  lesion  or  any 
condition  leading  to  local  or  general  lowering  of  resistance  may 
bring  it  about. 

The  terms  specific  and  non-specific  as  applied  to  infectious  diseases 
also  require  explanation.  A  specific  disease  is  defined  as  one  which 
is  produced  by  a  single  cause — i.e.,  a  particular  species  of  micro- 
organism, and  by  no  other.  Thus,  tetanus  is  a  well-marked  patho- 
logical entity,  always  due  to  the  B.  tetani,  and  may  be  taken  as  the 
type  of  a  specific  infection.  Suppuration,  on  the  other  hand,  may  be 
caused  by  a  large  number  of  species  of  bacteria,  or  even  by  chemical 
irritants,  and  is  therefore  termed  non-specific.  The  boundaries  of 
these  divisions  are  constantly  changing  with  the  advancement  of 
pathological  research.  The  common  process  is  for  diseases  which 
are  apparently  homogeneous  to  be  split  up  into  groups  of  specific 
diseases,  each  due  to  its  own  organism.  Thus,  ringworm  is  now 
known  to  be  due  to  several  different  forms  of  fungus,  and  combined 
clinical  and  pathological  research  have  shown  that  the  diseases  due 
to  one  variety  differ  in  minute  points  from  those  due  to  another. 


BACTERIOLOG  Y— INFECTION— IMMUNITY  13 

Again,  actinomycosis  was  formerly  thought  to  be  a  specific  disease 
due  to  a  single  micro-organism,  but  it  has  been  found  recently  that 
many  organisms  may  produce  it.  The  reverse  process  is  sometimes 
seen,  several  apparently  different  diseases  being  united  together  on 
the  discovery  of  their  cause.  For  example,  malignant  pustule  and 
wool-sorter's  disease  are  apparently  quite  distinct  maladies  ;  yet  since 
it  has  been  found  that  they  are  both  caused  by  the  B.  anthracis  they 
can  now  be  included  as  manifestations  of  one  specific  disease. 

Local  Infective  Processes  are  those  caused  at  the  site  of  inoculation 
by  the  growth  and  development  of  the  microbes.  After  a  period 
of  incubation — which  varies  with  different  organisms,  and  during 
which  we  may  imagine  that  they  are  struggling  with  the  germicidal 
action  of  the  tissues,  and  establishing  their  foothold  in  the  body — the 
bacteria  begin  to  grow  and  multiply,  and  by  the  deleterious  products 
of  their  activity  cause  irritation  of  the  tissues  and  various  degrees  ol 
inflammation. 

These  inflammatory  foci  may  remain  limited,  or  diffusion  may 
occur  by  the  bacteria  spreading  with  more  or  less  rapidity  by  con- 
tinuity of  tissue  or  along  lymph  channels  ;  or  the  organisms  may  be 
widely  disseminated  through  the  body  by  the  bloodvessels  in  the 
shape  of  emboli.  A  certain  amount  of  constitutional  disturbance 
may  accompany  these  manifestations,  due  to  the  absorption  of  the 
toxins  produced  locally,  whilst  in  some  diseases  the  general  toxic 
symptoms  (or  toxaemia)  associated  with  some  local  mischief  may  be 
extremely  severe,  as  in  tetanus  and  diphtheria.  Hence  local  infective 
processes  may  be  classed  in  two  divisions :  (a)  those  in  which  there 
is  but  little  or  no  general  toxaemia,  such  as  a  soft  chancre,  a  tuber- 
culous abscess,  or  a  mild  attack  of  gonorrhoea ;  and  (b)  those  in 
which  the  toxaemic  condition  is  well  marked,  as  in  erysipelas, 
tetanus,  diphtheria,  etc.,  the  character  of  the  symptoms  varying 
necessarily  with  the  different  toxins. 

Many  of  the  organisms  which  are  the  causes  of  local  infection 
may  also  develop  generally  in  the  system,  and  produce  grave  con- 
stitutional affections. 

General  Infective  Processes  are  those  in  which  the  organisms 
develop  and  multiply  in  the  blood-stream,  so  that  inoculation  of  a 
sound  person  with  the  blood  would  almost  certainly  transmit  the 
disease  if  a  sufficient  dose  were  introduced.  Many  of  the  bacteria 
producing  local  infection  ■  give  rise  to  the  se  general  diseases,  and, 
indeed,  in  surgery  we  rarely  see  the  latter  without  some  local 
condition  being  present  to  explain  its  origin.  Septicaemia,  pyaemia, 
acute  tuberculosis,  the  second  stage  of  syphilis,  anthracaemia,  and 
probably  the  exanthemata,  are  illustrations  of  general  infection  (see 
Chapters  IV.  and  VII.). 

Immunity. 

Under  ordinary  circumstances  every  living  animal  is  constantly 
exposed  to  possible  sources  of  infection.     Bacteria  are  present  in  the 


14  A  MANUAL  OF  SURGERY 

air  we  breathe,  in  our  food,  drink,  etc.,  as  well  as  on  our  skins  and  in 
our  alimentary  canals.  It  is  obvious,  therefore,  that  there  is  some 
potent  natural  means  of  resisting  the  attack  of  these  organisms, 
and  that  it  is  only  when  these  means  break  down  or  are  insufficient 
that  infection  occurs.  This  power  of  resisting  the  invasion  of  micro- 
organisms is  termed  immunity,  and  it  is  the  exact  opposite  of  suscepti- 
bility. Further,  the  process  of  natural  cure  of  any  infective  disease 
is  brought  about  by  the  production  of  such  a  degree  of  immunity 
(whether  local  or  general)  as  shall  suffice  to  destroy  the  causative 
bacteria.  It  is  therefore  obvious  that  the  study  of  immunity  is  of 
the  greatest  importance  in  connection  with  the  prevention  and  cure 
of  disease,  and  the  more  so  since  the  most  potent  artificial  methods 
of  accomplishing  these  ends  are  those  which  imitate,  or  stimulate, 
or  give  free  play  to,  these  natural  processes.  A  brilliant  example 
of  this  is  seen  in  the  modern  treatment  of  diphtheria  by  means 
of  antitoxin,  in  which  the  natural  cure  of  the  disease  is  imitated 
exactly  by  artificial  means.  Unfortunately,  however,  the  forces 
concerned  in  immunity  are  still  very  imperfectly  understood,  although 
an  enormous  am.ount  of  work  has  been  devoted  to  their  elucidation, 
and  it  is  in  but  few  cases  that  the  practical  application  of  our 
scientific  knowledge  has  been  followed  by  such  happy  results. 

Natural  Immunity  is  that  which  is  inherent  in  the  constitution  of 
the  animal  when  born,  and  not  due  to  any  event  taking  place  in  its 
life  history.  Thus  the  lower  animals  are  all  naturally  immune  to 
gonorrhoea  and  many  other  diseases  which  affect  man,  whereas  man 
is  naturally  immune  to  many  of  the  diseases  of  the  lower  animals. 
In  most  cases  natural  immunity  is  general  throughout  all  the  members 
of  the  species,  but  this  is  not  always  the  case.  For  example,  some 
children  are  absolutely  immune  to  vaccinia,  though  the  vast  majority 
are  susceptible.  Hence  racial  immunity  is  not  quite  identical  with 
natural  immunity. 

It  must  be  clearly  understood  that  there  is  no  absolute  standard 
of  immunity,  since  the  reaction  of  the  tissues  varies  between  the 
highest  degree  of  susceptibility  and  the  highest  degree  of  immunity. 
Thus,  if  several  animals  are  inoculated  with  equal  doses  of  the  same 
bacterial  culture,  one  may  show  no  ill  effects  ;  another  may  exhibit  a 
slight  amount  of  inflammation  at  the  site  of  inoculation  ;  a  third 
may  acquire  a  spreading  inflammation,  which  may  progress  to  sup- 
puration or  gangrene ;  whilst  a  fourth  may  develop  a  fatal  general 
infection.  Further,  an  animal  may  be  highly  immune  to  an  organism 
of  ordinary  virulence,  and  at  the  same  time  highly  susceptible  to 
the  same  organism  when  its  virulence  is  exalted. 

Again,  it  is  of  the  utmost  importance  to  reaHze  that  the  immunity 
or  susceptibility  of  any  animal  to  a  given  bacterium  is  not  a  definite 
fixed  amount,  but  that  it  varies  from  time  to  time,  and  is  greatly 
influenced  by  external  and  internal  conditions.  A  study  of  these  conditions 
is  of  fundamental  importance  in  the  prevention  of  disease.  It  may 
be  regarded  as  certain  that  man  possesses  a  very  considerable  degree 
of  immunity  to   nearly  all    bacteria   (including   even  the   tube'rcle 


BACTERIOLOGY— INFECTION— IMMUNITY  15 

bacillus),  and  it  is  only  when  this  immunity  becomes  lowered  by 
causes  which  depreciate  the  general  or  local  vitality  that  infection 
occurs.  These  causes  may  be  divided  into  two  groups,  local  and 
general. 

Of  the  general  causes,  cold  and  wet,  especially  if  combined,  are 
perhaps  the  most  potent,  but'  the  method  in  which  they  act  is  still 
uncertain.  Starvation  and  malnutrition  are  also  important,  and  even 
in  slight  degrees  have  a  very  decided  efifect  on  immunity.  Thus  it 
has  long  been  recognised  that  post-mortem  wounds  received  when 
fasting  are  more  dangerous  than  those  received  when  digestion  is 
in  progress.  In  this  case  the  immunity  may  perhaps  be  correlated 
with  the  increased  number  of  leucocytes  in  the  blood  during  digestion, 
but  it  does  not  appear  to  be  a  constant  fact  that  a  large  number  of 
leucocytes  always  implies  a  high  grade  of  resistance,  and  vice-vend. 
Age  is  an  important  factor,  children  being,  as  a  rule,  much  more 
susceptible  than  adults.  Immunity  is  also  greatly  reduced  by  hemor- 
rhage, and  by  certain  poisons,  particularly  alcohol.  Prolonged  exposure 
to  a  vitiated  atmosphere  is  also  a  very  potent  factor,  especially  in  the 
production  of  susceptibility  to  the  tubercle  bacillus.  Prolonged  anes- 
thesia also  lowers  the  general  resistance  of  the  body,  as  also  certain 
diseases,  notably  Bright's  disease  and  diabetes. 

The  local  causes  include  injury,  especially  bruises,  contusions,  burns, 
and  the  irritation  due  to  chemical  substances.  This  latter  condition 
is  often  used  in  the  laboratory  to  exalt  the  virulence  of  certain 
bacteria.  Thus,  pyogenic  cocci  are  often  without  action  on  rabbits, 
even  in  tolerably  large  doses  ;  but  if  injected  together  with  some 
dilute  lactic  acid,  the  toxins  of  other  bacteria  (such  as  B .  prodigiosus), 
or  other  soluble  irritant,  they  are  frequently  enabled  to  develop 
and  produce  pathological  effects.  Considerable  surgical  importance 
is  attached  to  this  observation,  since  it  must  not  be  forgotten  that 
nearly  all  antiseptics  are  irritant,  and  if  applied  in  too  concentrated 
a  state  or  for  too  long  may  lower  the  local  resistance,  and  render  the 
wound  more  liable  to  be  infected  by  any  organism  that  may  at  the 
time  or  subsequently  gain  accidental  entrance.  The  local  applica- 
tion of  cold  or  hot  liquids  has  a  similar  action,  and  hence  all  fluids 
used  to  wash  out  wounds  or  body  cavities  should  be  used  exactly 
at  blood  heat,  unless  the  direct  effect  of  the  heat  or  cold  is  required. 
Lastly,  a  local  deficiency  in  the  blood-supply,  due  to  disease  in  the  blood- 
vessels or  elsewhere,  or  to  tight  bandaging,  pressure,  etc.,  also  renders 
a  part  less  resistant  to  infection. 

Acquired  Immunity  is  of  two  kinds — active  and  passive. 
Active  immunity  results  from  a  previous  attack  of  the  disease,  either 
natural  or  due  to  artificial  inoculation,  so  that  the  individual  is  freed 
from  the  risk  of  contracting  it  again.  Syphilis  and  the  exanthemata 
are  good  illustrations  of  diseases  conferring  an  active  immunity, 
which,  however,  is  not  always  absolute,  since  well-confirmed  examples 
of  second  attacks,  even  of  syphilis,  have  been  recorded.  On  the 
other  hand,  it  is  doubtful  whether  tuberculosis  and  the  pyogenic 
diseases  are  capable  of  producing  immunity. 


'6  A  MANUAL  OF  SURGERY 


_    The  following  are  the  most  important  artificial  methods  of  bestow- 
ing active  immumty  :  (i)  Inoculation  of  the  disease  as  it  occurs  in 
nature.     This  is  of  course  a  dangerous  method,  since  the  attack  is 
almost  as  severe  as  one  acquired  in  the  normal  way.     It  was  formerly 
practised  as  a  preventive  of  small-pox  before  the  introduction  of 
vaccination.      (2)   Inoculation  with  the  virus  of  the  disease  or  its 
causal  micro-organism  m  a  mitigated  state.     Vaccination  is  the  best 
example  of  this  process  ;  the  lymph  employed  is  a  culture  of  the 
small-pox   organism  (the  exact  nature  of  which  is  at  present  not 
definitely  known)  m  a  state  of  diminished  virulence.     Pasteur  also 
applied  the  same  method  in  the  prevention  of  hydrophobia  (p.  i^ii) 
and  of  anthrax  m  cattle,  the  '  vaccine  '  in  the  latter  case  being  a  living 
culture  of  anthrax  bacilli  mitigated  by  being  cultivated  at  a  hiag 
temperature.    _  (3)    Injection  of  dead  cultures  of  bacteria  is  used 
m  the  preventive  moculation  against  plague  (Hafifkine)  and  a"-ainsL 
typhoid  fever  (Wright).     The  cultures  are  killed  by  heat,  andfmal 
doses  mjected  subcutaneously.     The  result  is  a  local  inflammatory 
reaction  of  varying  severity,  together  with  general  symptoms  such 
as  fever  and  malaise.     When  these  have  palsed  off,  t^he^padent  has 
acquired  some  immumty  to  the  disease,  so  that  he  is  now  able  to 
withstand  the  injection  of  a  larger  dose  or  even  of  a  livinJ  culture 

tubercuhn  (TR)  is  of  a  similar  nature;  it  consists  of  an  emulsion  of 
finely  comminuted  tubercle  bacilli  which  have  been  killed  by  a 
process  of  grinding  Repeated  injections  are  necessary,  and  the  dose 
must  be  gradually  mcreased  as  toleration  is  acquired.^  This  method 
has  now  been  extended  to  the  cure  of  many  infective  conditons 
(4)  Injection  of  the  extracellular  toxins  of  the  causative  organism  S 
not  used  m  man,  but  it  is  of  the  utmost  value  in  immun  W 
the  lower  animals  for  the  preparation  of  curative  sera  eTDecianf 
antidiphtheritic_  and  antitetanic.  The  horse  ilchos^n  for  th^ 
purpose  since  It  is  easy  to  handle,  and  yields  a  large  amount  of 
serum  at  each  bleeding.  The  principle  of  the  method  is  simX  A 
small  quantity  of  the  toxin  (which  has  been  filtered  to  r  mo"e  li'vint 
bacteria)  IS  injected  subcutaneously.     It  causes  local  inflan^mation'' 

liX'l^f  '^'^^''''  ^"'r^^  *^^^^  h^^^  q^ite  subsided,  anXr  and 
slightly  larger  amount  of  toxin  can  be  tolerated.  In  his  way  the 
dose  IS  gradually  increased,  until  the  animal  is  so  resistant  thaf  th! 

Zhr°^°?^°™°^'-?°^^^  °^  ^°^^  P°^^^^f^l  toxin  wil  produce  but 
slight  and  transient  ill-efifects.      In  actual  practice  this  me^od  is 

"he  fnfecTon  of  k'''  T'"'' f^^^''  '^^"^^  considerably  shoTtened  by 
the  injection  of  a  mixture  of  toxin  and  antitoxin,  or  by  the  use  of 
peculiar  forms  of  toxin  of  diminished  activity  ^ 

It  will  be  noticed  that  in  all  these  methods  the  animal  which 
subsequently  becomes  immune  combats  with  and  ove  STmes  Se 
organism  or  its  toxin,  and  is  always  rendered  more  or  le^Ti  1  fin 
some  cases  very  slightly)  by  the  process.  For  this  reason  l^ 
termed  an  active  immunity-/...,  it  is  acquired  by  the  anfmal  s  own 
active  combat  with  and  victory  over  the  disease 


BA  CTERIOLOG  Y— INFECTION— IMM  UNITY  1 7 

Passive  immunity  is  that  which  is  conferred  on  an  animal  without 
effort  on  its  part  by  the  injection  of  serum  from  an  animal  that  has 
already  acquired  an  active  immunity  against  the  disease  in  question. 
For  example,  if  some  of  the  serum  from  a  horse  which  has  been 
actively  immunized  against  tetanus  is  injected  into  a  second  horse 
(or  other  animal),  the  latter  will  also  become  immune  to  the  tetanus 
bacillus  or  to  its  toxin.  The  second  animal  is  not  rendered  ill  by 
the  injection,  and  is  merely  the  passive  recipient  of  protective  sub- 
stances which  have  been  elaborated  by  the  first.  The  fact  that  the 
injection  of  these  sera  into  man  sometimes  causes  transient  ill-effects, 
such  as  fever,  joint-pains,  rashes,  etc.,  in  no  way  modifies  the  truth 
of  this  statement :  the  phenomena  in  question  do  not  always  occur, 
and  are  not  necessary  antecedents  of  the  production  of  the  passive 
immunity. 

Passive  immunity  cannot  be  bestowed  by  the  injection  of  serum 
from  an  animal  which  is  naturally  immune :  the  lower  animals,  for 
example,  are  naturally  immune  to  syphilis,  but  their  serum  has  no 
protective  or  curative  action  in  man.  The  diseases  in  which  the 
serum  has  the  greatest  practical  value  for  protection  or  cure  are 
those  in  which  the  specific  micro-organisms  produce  extracellular 
toxins,  especially  diphtheria  and  tetanus. 

Active  and  passive  immunity  also  diff"er  in  other  respects.  Passive 
immunity  is  produced  immediately  the  serum  is  injected,  whereas 
active  immunity  is  only  developed'  slowly  after  the  injection  of  the 
toxin,  or  of  the  living  or  dead  culture  ;  in  general,  a  week  at  least  must 
elapse  before  the  full  degree  of  immunity  is  produced.  Again,  passive 
immunity  lasts  a  comparatively  short  time,  unless,  of  course,  the  dose 
of  the  immunizing  serum  is  repeated.  In  the  case  of  a  prophylactic 
injection  of  antidiphtheritic  serum  in  man  the  duration  of  the  im- 
munity is  about  a  couple  of  months.  Active  immunity  is  usually 
much  more  lasting,  though  its  duration  varies  greatly  in  different 
cases.  In  most  cases  of  syphilis  and  small-pox  it  is  permanent, 
second  attacks  being  extremely  rare,  whereas  in  pneumonia  it  is  of 
very  short  duration. 

When  we  turn  to  the  theories  which  have  been  promulgated  to 
explain  the  facts  briefly  outlined  above,  it  must  be  borne  in  mind  that 
there  are  two  groups  of  phenomena  which  require  elucidation  :  the 
immunity  to  the  bacteria  and  the  immunity  to  their  toxins.  Thus, 
if  a  culture  of  living  diphtheria  bacilli  is  injected  together  with  their 
toxin  into  a  susceptible  animal,  the  bacilli  will  continue  to  grow  in 
its  tissues,  and  the  toxin  will  exert  its  poisonous  effects,  both  local  and 
remote.  If  the  same  culture  is  injected  into  an  immune  animal 
(whether  the  immunity  is  natural,  active,  or  passive),  the  bacteria 
will  be  killed  and  the  toxin  will  have  no  action.  This  bacterial 
immunity  must  first  be  discussed. 

Omitting  theories  which  are  merely  of  historical  interest,  we  come 
first  to  the  humoral  tJieovy,  which  asserted  that  the  destruction  of  the 
bacteria  was  due  to  certain  substances  which  are  present  in  the  blood, 
lymph,  etc.,  and  which  were  designated  alexins.     The  experimental 

2 


i8  A  MANUAL  OF  SURGERY 

foundation  for  this  theory  consists  in  the  fact  that  fresh  blood,  and 
more  especially  fresh  blood-serum,  has  very  considerable  bactericidal 
action.  This  action  is  destroyed  if  the  serum  is  exposed  to  heat 
(about  60°  C.  for  half  an  hour),  and  disappears  spontaneously  after 
a  day  or  so  ;  when  the  alexins  have  been  destroyed  by  either  process, 
the  serum  becomes  an  excellent  culture  medium  for  most  bacteria. 

Metchnikoff's  theory  of  phagocytosis  (the  cellular  theory)  was  at  first  in 
strong  opposition  to  the  humoral  theory,  but  subsequent  researches 
have  brought  the  two  closer  together.  Starting  from  the  fact  that 
unicellular  protozoa  (such  as  the  amoeba)  ingest,  digest,  and  assimi- 
late the  bacteria  found  in  water,  Metchnikoff  was  led  to  examine  the 
action  of  the  leucocytes,  or  wandering  cells  of  the  higher  animals, 
which  in  their  morphology  so  strongly  resemble  the  lower  protozoa, 
and  found  in  them  a  similar  power  of  engulfing  and  digesting  living 
micro-organisms.  This  process  he  termed  phagocytosis.  A  striking 
example  occurs  in  Daphnia  (the  fresh-water  flea),  an  animal  which  is 
so  transparent  that  the  whole  phenomenon  can  be  followed  under  the 
microscope  during  life.  It  is  affected  with  a  disease  due  to  the 
growth  in  its  tissues  of  a  fungus  known  as  Monospora.  The  spores 
of  this  parasite  are  taken  in  with  the  food,  and  penetrate  from  the 
alimentary  canal  into  the  body  cavity ;  when  unchecked,  they  con- 
tinue to  grow  until  the  whole  animal  is  filled  with  growth.  If, 
however,  but  few  spores  gain  access,  the  defensive  mechanism  comes 
into  play,  and  the  spores  are  surrounded  and  engulfed  by  the  leuco- 
cytes, submitted  to  a  process  of  digestion,  and  finally  destroyed. 
It  is  obvious  that  Daphnia  is  pa,rtially  immune  to  Monospora,  and 
that  the  immunity  depends  on  the  phagocytic  activity  of  its  leuco- 
cytes. Metchnikoff  had  no  difficulty  in  finding  many  examples  of 
the  same  process  in  man  and  the  higher  animals.  If,  for  instance, 
a  culture  of  a  non-pathogenic  organism  is  injected  into  the  peritoneal 
cavity  of  an  animal,  and  portions  of  the  peritoneal  fluid  are  examined 
from  time  to  time,  the  bacteria  will  be  seen  first  lying  free ;  then 
engulfed  iff  the  protoplasm  of  the  leucocytes,  but  retaining  their 
normal  appearance  and  staining  reactions  ;  then  less  distinct  and 
refractile  than  before,  indicating  that  they  have  undergone  partial 
digestion,  and  in  this  state  they  stain  badly.  Similar  appearances 
may  also  be  seen  in  sections  of  tuberculous  tissue,  especially  those 
that  are  healing,  though  here  the  phagocytic  cells  are  not  leucocytes, 
but  epithelioid  or  giant  cells. 

The  leucocytes  are  attracted  to  the  region  of  the  bacteria  owing  to 
the  fact  that  the  latter  give  off  soluble  substances  for  which  the 
leucocytes  have  an  affinity,  so  that  they  move  into  the  region  in  which 
these  substances  exist  in  a  high  state  of  concentration.  This  process 
is  known  as  chemotaxis,  and  it  is  one  which  is  widely  distributed 
throughout  the  lower  members  of  the  animal  and  vegetable  kingdoms. 
If,  for  instance,  a  capillary-tube  filled  with  meat-extract  is  placed 
in  a  watery  emulsion  of  typhoid  bacilli,  the  latter  will  be  attracted 
by  chemotaxis  and  enter  the  tube.  Similar  phenomena  are  seen 
in  the  formation  of  an  abscess:  the  pyogenic  bacteria  give  off  sub- 


BACTERIOLOGY— INFECTION— IMMUNITY  19 

Stances  which  attract  the  leucocytes,  so  that  they  soon  become  sur- 
rounded by  a  zone  of  these  cells,  and  at  the  same  time  some  of  these 
substances  gain  access  to  the  blood  and  attract  the  leucocytes  from 
the  bone-marrow,  giving  rise  to  a  general  leucocytosis. 

Metchnikoff  found  that  in  cases  where  phagocytosis  was  active 
recovery  usually  took  place,  and  that  when  it  failed  the  bacteria 
continued  to  grow  and  death  occurred ;  from  this  he  argued  that 
immunity  depends  entirely  on  the  leucocytes.  He  further  noted  that 
in  animals  with  acquired  immunity  the  leucocytes  had  gained  the 
power  of  ingesting  the  bacteria,  although  previously  unable  to  do  so  ; 
hence  he  explained  acquired  immunity  as  being  due  to  the  education 
which  the  leucocytes  had  gained  during  the  previous  attack.  The 
opponents  of  the  theory  urged  that  only  dead,  or  at  least  non- virulent, 
bacteria  were  taken  up  by  the  cells,  but  MetchnikofPs  great  technical 
skill  enabled  him  to  isolate  bacilli  that  had  been  actually  ingested 
by  leucocytes  and  prove  them  to  be  living  and  virulent. 

The  theory  of  phagocytosis  was  never  generally  accepted  in  its 
original  form,  and  it  was  soon  found  not  to  apply  in  certain  cases. 
Thus,  it  is  possible  to  enclose  active  bacteria  in  a  collodion  sac, 
which  will  allow  the  transudation  of  body  fluids,  but  will  prevent  the 
passage  of  leucocytes  ;  if  such  a  contrivance  is  placed  in  the  perito- 
neal cavity  of  an  immune  animal,  the  bacteria  are  often  killed. 
Further  research  also  showed  that  even  when  bacteria  are  ultimately 
destroyed  by  phagocytic  activity  they  may  lose  their  definite  out- 
line, refractility,  etc.,  and  give  other  indications  of  being  injured 
whilst  still  free  and  extracellular.  The  fact  that  this  extracellular 
injury  or  destruction  usually  occurs  when  the  bacteria  are  sur- 
rounded by  leucocytes  led  to  the  theory  that  the  alexins  are  formed 
from  or  secreted  by  the  leucocytes.  This  is  the  celhclo-huuioral  theory, 
and  it  may  be  regarded  as  a  compromise  between  the  two  views 
enunciated  above.  It  agrees  with  the  humoral  theory  in  regarding 
the  destruction  of  the  invading  bacteria  as  due  wholly  or  partly  to 
soluble  substances  present  in  the  body-fluids ;  and  with  the  cellular 
theory  in  attributing  to  the  leucocytes  the  paramount  role  in  the 
defences  of  the  body,  but  differs  from  it  in  allotting  to  them  a  doublp 
action,  partly  chemical  and  partly  phagocytic. 

Many  facts  go  to  prove  that  there  is  much  truth  in  this  com- 
promise, but  it  is  not  a  complete  explanation.  Thus,  Behring's 
investigations  on  the  subject  of  passive  immunity,  especially  in  con- 
nection with  diphtheria,  introduced  a  new  element  and  opened  up  a 
fresh  field  of  research.  It  was  found  possible  to  cure  the  disease  by 
a  suitable  serum  or  antitoxin  which  has  no  bactericidal  effect  what- 
ever, so  that  its  activity  cannot  be  attributed  to  alexins  or  other 
bactericidal  substances. 

Metchnikoff  explained  its  practical  value  by  attributing  to  it  the 
power  of  stimulating  the  leucocytes  to  more  vigorous  phagocytic 
action  ;  but  this  view  can  no  longer  be  sustained,  though,  as  we 
shall  see,  it  has  a  substratum  of  truth.  Further  researches  showed 
that  the  action  of  the  antitoxin  is  an  extremely  simple  one.     It  unites 


2b  A  MANUAL  OF  SURGERY 

with  its  specific  toxin,  and  forms  a  compound  which  is  devoid  of  toxic 
properties.  It  is  unnecessary  to  give  the  full  evidence  on  which 
this  statement  is  based,  but  one  single  proof  may  be  mentioned. 
Several  bacteria — amongst  others  the  tetanus  bacillus — produce 
toxins  which  have  the  power  of  dissolving  red  blood  corpuscles 
(haemolysis) ;  hence  these  substances  are  called  the  bacterial  haemo- 
lysins.  Experiments  on  haemolysis  can  be  carried  out  in  vitro,  and 
it  is  thus  possible  to  avoid  all  complications  arising  from  phago- 
cytosis or  the  action  of  the  living  tissues.  Now  it  is  found  that 
tetanus  antitoxin  will  prevent  the  haemolytic  action  of  the  haemolysin 
of  the  tetanus  bacillus  in  the  test-tube  as  well  as  in  the  body. 
Here,  therefore,  there  must  be  merely  a  simple  process  of  chemical 
neutralization,  which  may  be  compared  with'  the  action  of  an  alkali 
on  an  acid. 

The  discovery  of  the  antitoxins  for  diphtheria  and  tetanus  led  to 
numerous  attempts  to  form  similar  substances  for  other  poisons.  It 
was  found  impossible  to  produce  antitoxins  for  the  alkaloids,  mineral 
poisons,  etc.  Antitoxins  were^  however,  prepared  for  snake-venom, 
eel-serum,  abrin,  ricin,  etc.,  and  for  some  other  bacterial  toxins. 
These  poisons  have  these  factors  in  common :  they  are  all  formed 
in  living  organisms,  whether  animal  or  vegetable,  and  they  are  all 
proteids  or  closely-allied  substances. 

The  method  of  action  of  the  antitoxins  throws  a  certain  amount  of 
light  on  the  mechanism  of  some  forms  of  immunity.  It  has  no 
bearing  on  natural  immunity,  for  the  blood  of  an  animal  which  is 
naturally  immune,  say,  to  tetanus,  does  not  contain  tetanus  anti- 
toxin ;  but  in  recovery  from  tetanus  the  antitoxin  appears  in  the 
blood.  When  this  happens,  any  fresh  toxin  that  the  bacilli  form  will 
be  immediately  neutralized,  and  the  latter  will  thereby  be  deprived 
of  their  power  to  injure  the  cells  of  the  animal,  and  can  be  dealt  with 
by  phagocytosis  or  other  means.  In  the  production  of  passive  im- 
munity similar  phenomena  take  place ;  the  antitoxin  artificially 
injected  in  the  blood  combines  with  the  toxin  and  shields  the  cells 
from  its  action. 

But  this  leaves  the  method  of  formation  of  these  antitoxins  unexplained.  Several 
theories  have  been  advanced  to  account  for  this  phenomenon,  but  the  only  one 
of  importance  is  Ehrlich's  side-chain  theory.  It  is  somewhat  complicated,  but  the 
brilliant  way  in  which  it  accounts  for  the  chief  facts,  and  its  profound  influence 
on  modern  ideas  of  pathology,  justify  a  brief  outline  of  its  more  important 
features. 

A  toxin  possesses  two  properties,  that  of  poisoning  a  cell  and  that  of  com- 
bining with  antitoxin,  and  Ehrlich  proves  that  these  two  functions  reside  in 
different  portions  of  the  molecule.  To  the  part  that  unites  with  antitoxin  he 
gives  the  name  'haptophore,'  whilst  the  toxic  portion  is  termed  the  '  toxophore.' 

Ehrlich  next  assumes  that  a  molecule  of  living  protoplasm  may  be  con- 
sidered as  consisting  of  two  parts.  One  discharges  the  function  of  the  cell  of 
which  it  forms  part,  whilst  the  other  subserves  the  nutrition  of  the  former 
more  highly  differentiated  portion,  and  has  the  power  of  Uniting  with  molecules 
of  proteid  dissolved  in  the  blood  or  lymph,  and  then  building  them  up  into  living 
protoplasm.  This  function  is  supposed  to  be  accomplished  by  side-chains,  or 
specialized  portions  of  the  cell,  which  unite  with  the  molecules  of  food  proteid. 
It  is  assumed  that  these  latter  contain  a  haptophore  group  similar  to  that  of  a 
molecule  of  toxin,  but  no  toxophore  group  :  so  that  the  first  step  in  the  nutrition 


BACTERIOLOGY— INFECTION— IMMUNITY  21 

of  the  cell  consists  in  the  union  of  a  side-chain  with  the  haptophore  group  of  a 
molecule  of  proteid,  a  process  which  Ehrlich  compares  with  the  seizure  of 
particles  of  food  by  the  tentacles  of  a  sea-anemone.  Further,  there  are  many 
varieties  of  proteids  in  the  blood,  and  the  molecules  of  each  of  these  must  have 
their  own  peculiar  haptophore  groups.  Each  haptophore  group  must  '  fit '  a 
side-chain  (like  a  key  fitting  a  lock),  or  it  will  be  useless  for  nutrition. 

In  applying  this  view  to  the  action  of  a  toxin,  it  must  be  remembered  that  the 
toxins  are  proteids  or  similar  substances.  If  we  inject  a  solution,  e.g.,  of  tetanus 
toxin  into  an  animal,  it  may  happen  that  the  side-chains  carried  by  the  animal's 
cells  do  not  possess  haptophore  groups  which  '  fit '  those  of  the  toxin  ;  in  this  case 
no  poisoning  can  occur,  as  the  toxin  cannot  unite  with  the  cells.  If  the  cells  do 
possess  such  side-chains,  they  will  unite  with  the  haptophore  of  the  toxin,  just 
as  if  these  side-chains  had  seized  a  nutritious  molecule.  The  toxophore  radicle 
is  thus  brought  into  action,  since  it  is  united  to  the  cell  by  means  of  the  hapto- 
phore group  and  side-chain.  Presumably  it  exerts  an  injurious  influence  similar 
to  that  of  an  enzyme,  and  the  integrity  of  the  functionating  part  of  the  proto- 
plasmic molecule  is  thereby  destroyed.  In  other  words,  the  first  step  in  the. 
intoxication  of  a  cell  by  a  true  toxin  is  exactly  the  same  as  the  first  step  in 
cell-nutrition. 

Suppose,  now,  that  a  certain  number  of  the  side-chains  are  fixed  to  molecules 
of  toxin,  and  that  the  living  molecule  is  injured,  but  not  fatally.  The  side-chains 
are  necessary  for  the  nutrition  of  the  cell,  and  those  that  are  rendered  useless 
must  be  regenerated,  just  as  a  hydra  replaces  a  lost  tentacle.  If  a  second  dose  of 
toxin  is  given  this  process  is  repeated ;  and  if  we  continue  to  administer  toxin  in 
suitable  (non-lethal)  doses,  we  may  gradually  '  train '  the  cell  to  produce  side- 
chains  more  and  more  rapidly.  But  it  often  happens  that  the  reaction  of  a  living 
tissue  is  much  greater  than  the  stimulus  demands ;  e.g.,  the  formation  of  callus 
is  disproportionate  to  the  amount  of  bone  to  be  replaced.  This  may  be  presumed 
also  to  happen  in  the  production  of  antitoxins.  The  cell  produces  more  side- 
chains  than  it  has  any  necessity  for — more,  indeed,  than  can  remain  united  with 
it,  and  the  superfluous  ones  detach  themselves  from  the  cell  and  float  off  in  the 
blood.  They  still  retain  their  power  of  uniting  with  the  haptophore  group  of  a  toxin 
molecule,  thereby  rendering  the  toxin  inert,  and  thus  they  constitute  antitoxin. 

It  is  impossible  to  discuss  here  the  evidence  that  has  been  brought  forward 
in  support  of  this  theory,  but  one  remarkable  point  may  be  noticed.  For  a  cell 
to  be  poisoned  by  a  given  toxin,  it  is  necessary  that  it  should  contain  side- 
chains  which  '  fit '  the  haptophore  group  of  that  toxin.  But  antitoxin  consists 
of  such  side-chains,  so  that  it  follows  that  any  cell  which  can  be  poisoned  by  a 
toxin  may  be  made  to  produce  an  antitoxin  to  it.  There  is  evidence  that  this  is 
the  case  in  tetanus,  the  toxin  of  which  (tetano-spasmin)  acts  only  on  the  cells  of 
the  central  nervous  system.  It  was  found  by  Wassermann  that  an  emulsion 
of  the  gray  matter  of  the  brain  has  the  power  of  neutralizing  tetanus  toxin  just 
as  antitoxin  has,  but  that  this  power  is  lacking  from  emulsions  of  other  tissues. 
Thus  the  cells  of  the  central  nervous  system  are  the  only  ones  which  have  side- 
chains  that  can  unite  with  the  tetanus  toxin. 

Again,  it  would  not  be  surprising  if  some  of  these  side-chains  were  to  break  off 
and  pass  into  the  blood  under  natural  conditions.  This  actually  happens,  for 
traces  of  antitoxins  (and  other  '  antibodies  ')  frequently  occur  in  normal  blood. 

Ordinary  chemical  poisons  do  not  give  rise  to  the  formation  of  antitoxins,  since 
they  do  not  unite  especially  with  the  side-chains  as  if  they  were  nourishing 
proteids,  but  form  chemical  combinations  with  all  parts  of  the  molecule  indis- 
criminately. 

It  was  soon  found  that  substances  allied  to  antitoxin  might  be  obtained  by  the 
injection  of  proteid  substances  other  than  toxins  into  living  animals.  These  are 
known  as  antibodies,  the  term  being  used  to  include  precipitins,  agglutinins, 
cytolysins,  bacteriolysins,  etc. 

Precipitins  are  substances  formed  by  the  injection  of  proteid  solutions,  and  have 
the  property  of  forming  a  precipitate  when  mixed  with  a  solution  of  the  same 
proteid  as  was  injected.  Thus,  if  a  solution  of  egg  albumen  is  injected  into  a 
rabbit,  the  serum  of  this  animal  (after  a  week  or  so)  will  give  a  flocculent  precipitate 
with  egg  albumen,  but  not  with  other  proteids.    The  precipitins  are  tot  known  to 


ZZ  A  MANUAL  OF  SURGERY 

have  any  bearing  on  the  question  of  immunity,  except  in  that  they  form  an 
example  of  the  general  law  that  if  any  foreign  proteid  is  injected  into  a  living 
animal  it  gives  rise  to  the  production  of  an  antibody. 

Agglutinins  are  formed  by  the  injection  of  bacteria,  red  blood  corpuscles,  cells, 
etc.,  and  they  have  the  power  of  causing  the  cells  injected  to  collect  into  clumps. 
A  special  case  of  great  importance  is  in  typhoid  fever,  where  the  agglutinin  is 
formed  early  in  the  disease  and  is  of  diagnostic  value  (Widal's  reaction).  In  most 
infections  this  is  not  the  case.  Thus  in  pneumonia  the  serum  rarely  shows  any 
power  to  agglutinate  the  pneumococcus  before  convalescence  is  established.  They 
are,  however,  of  value  in  that  they  often  enable  the  bacteriologist  to  prove  the 
causal  relationship  of  an  organism  and  the  disease  it  is  supposed  to  produce. 
Thus  in  the  investigation  of  the  pathology  of  dysentery  various  organisms  are 
isolated  from  the  stools,  and  if  one  of  these  is  found  to  be  clumped  powerfully  by 
the  patient's  own  serum,  it  affords  strong  proof  that  it  is  really  the  infective 
agent.  The  agglutinins  are  also  useful  as  proving  the  identity  of  an  organism 
which  has  been  isolated  in  culture.  For  example,  if  a  culture  of  an  organism 
resembling  the  typhoid  bacillus  had  been  isolated  from  the  stools  in  a  case  of 
suspected  typhoid  fever  (or  from  drinking-v/ater,  etc.),  the  first  test  applied  to 
establish  its  nature  would  be  to  see  if  it  clumped  with  the  serum  of  an  animal 
which  had  been  injected  with  a  known  culture  of  typhoid  bacilli. 

Agglutinins  are ,  antibodies  to  the  proteids  contained  in  the  cells  injected. 
They  differ  from  the  simple  antibodies  (antitoxins)  in  that  they  are  .formed  of  a 
complex  side-chain,  which  contains  a  radicle  which  unites  with  the  haptophore 
group  of  the  proteid,  and  another  radicle  in  which  resides  the  '  clumping  ' 
properties.  The  latter  can  be  destroyed  by  heat,  and  the  agglutinin  then  retains 
its  power  of  uniting  with  the  cells,  but  does  not  clump  them.  Agglutinins  are 
not  known  to  play  any  part  in  the  production  of  immunity,  and  their  presence 
in  the  blood  does  not  necessarily  indicate  that  the  animal  is  immune,  though 
this  is  usually  the  case. 

The  next  group  of  antibodies — cytolysins  (including  the  hacterio- 
lysins,  hcemolysins,  etc.) — are  of  great  importance  in  the  doctrine  of 
immunity,  and  are  much  more  complex  in  their  structure  and  action 
than  the  preceding.  The  earliest  indication  of  their  existence  was 
obtained  by  PfeifFer,  who  immunized  guinea-pigs  to  the  cholera 
vibrio,  and  when  the  immunity  was  fully  established  injected  a 
culture  of  that  organism  into  the  peritoneal  cavity.  Some  of  the 
peritoneal  fluid  was  withdrawn  from  time  to  time,  and  the  organisms 
therein  examined  microscopically.  They  were  found  to  undergo 
remarkable  changes,  losing  their  shape,  becoming  spherical,  and 
finally  undergoing  complete  solution  ;  the  whole  process  often  takes 
half  an  hour  or  so.  This  is  called  Pfeiffer's  reaction,  and  is  specific 
— i.e.,  the  peritoneal  fluid  of  an  animal  vaccinated  against  cholera 
has  no  effect  on  the  typhoid  bacillus  or  any  organism  other  than  the 
cholera  vibrio  or  its  congeners.  Further  research  showed  that  the 
reaction  can  be  obtained  in  vitro,  provided  that  the  peritoneal  fluid 
is  perfectly  fresh ;  if,  however,  the  fluid  is  kept  a  day  or  two,  it 
loses  this  power,  but  regains  it  if  mixed  with  perfectly  fresh  serum, 
whether  this  be  taken  from  a  normal  or  from  an  immunized  animal. 
Thus: 

Fresh  normal  serum  +  cholera  vibrios  =  no  reaction. 

Fresh  serum  (or  peritoneal   fluid)   from   immunized   animal  +  cholera   vibrios 

=  solution. 
Stale  serum  from  immunized  animal  +  cholera  vibrios=no  reaction. 
Stale  serum    from    immunized    animal  +  fresh    serum    from    normal    animal 

+  cholera  vibrios  =  solution. 


BACTERIOLOGY— INFECTION— IMMUNITY  23 

It  is  obvious  from  this  that  two  substances  are  necessary  for  the 
solution  of  the  organisms  in  the  tissues  of  an  immunized  animal. 
One  occurs  only  in  the  fluids  of  the  immunized  animal,  not  in  a 
normal  one,  and  is  an  antibody  similar  to  the  agglutinins,  but  more 
complex ;  it  has  received  many  names,  and  is  usually  known  as 
amboceptor^  or  substance  sensibilatrice.  The  other  occurs  in  normal 
blood,  as  well  as  in  the  blood  of  the  immune  animal,  and  is  very 
fragile,  rapidly  disappearing  when  the  fluid  is  kept ;  it  is  also  readily 
destroyed  by  heat.  It  is  probably  the  same  as  the  alexin  referred  to 
above  in  connection  with  the  humoral  theory  of  immunity,  but 
German  writers  usually  term  it  the  complement. 

Further  research  on  the  antibodies  of  this  group  have  been  greatly  facilitated 
by  Bordet's  discovery  of  the  production  of  hsemolysins  by  the  injection  of  blood 
from  one  animal  into  another  of  a  different  species.  Thus,  rabbit's  serum  is 
without  effect  on  the  red  corpuscles  of  a  horse  ;  but  if  the  rabbit  is  injected  with 
a  horse's  red  corpuscles,  its  serum  acquires  the  power  of  dissolving  or  haemo- 
lyzing  them.  These  haemolysins  apparently  act  in  exactly  the  same  way  as  do 
the  bacteriolysins  in  Pfeiffer's  reaction,  and  are  much  more  convenient  for 
experimental  purposes.  Further,  it  appears  that  the  reaction  is  a  general  one, 
and  that  cytolysins  can  be  prepared  for  spermatozoa,  liver  and  kidney  cells,  cells 
of  the  central  nervous  system,  etc.,  and  that  in  each  case  the  reaction  depends  on 
a  stable  antibody  or  amboceptor  and  a  labile  ingredient  of  normal  blood,  the  com- 
plement or  alexin. 

When  one  of  these  cytolysins  is  mixed  with  the  cells  which  it  dissolves  (bacteria, 
red  corpuscles,  etc.),  the  first  step  in  the  reaction  is  the  combination  of  the 
amboceptor  with  the  cell ;  this  takes  place  at  a  low  temperature,  and  the  cell  is 
apparently  unaltered.  The  next  step  is  the  combination  of  the  alexin  with  the 
amboceptor  (or,  according  to  another  view,  with  the  cell  which  has  now  become 
'  sensitized  '),  and  this  takes  place  only  at  the  body  temperature.  The  third  step 
is  the  solution  of  the  cell  by  the  complement  acting  through  the  amboceptor, 
apparently  by  a  kind  of  enzyme  action.  Hence  a  molecule  of  amboceptor  must 
have  two  haptophore  groups  ;  one  to  unite  with  the  side-chain  of  the  cell,  and 
one  to  unite  with  a  molecule  of  alexin. 

In  applying  these  facts  to  the  production  of  acquired  immunity — 
e.g.,  to  the  immunization  of  an  animal  by  injections  of  small  doses 
of  cholera  vibrios— it  must  be  noted  that  the  organism  at  first 
continues  to  grow  in  the  tissues  ;  the  only  known  force  capable  of 
opposing  it  at  this  stage  is  the  action  of  the  phagocytes,  for  the  alexins 
or  complements  are  unable  to  act,  since  they  cannot  unite  directly  v/ith 
the  bacteria,  and  there  is  no  amboceptor.  After  a  time  the  cells  of  the 
host  begin  to  form  antibodies  to  the  protei  ds  of  the  bacterial  protoplasm. 
Some  of  these  may  be  antitoxins,  which  prevent  the  further  intoxica- 
tion of  the  animal ;  others  are  agglutinins,  which  are  without  known 
value  to  the  host ;  lastly,  there  are  amboceptors  which  link  the  alexin 
or  complement  of  the  blood  to  the  bacteria,  and  bring  about  the  solu- 
tion of  the  latter.  The  animal  is  now  immune,  and  when  any  further 
invasion  with  cholera  vibrios  takes  place  the  apparatus  of  ambo- 
ceptor and  complement  is  ready  for  the  defence  of  the  animal. 
Further,  the  serum  of  the  animal  contains  amboceptor,  and  when 
injected  into  a  second  animal  this  acquires  passive  immunity,  pro- 
vided that  a  suitable  alexin  is  also  present.  This  is  one  of  the 
practical  difficulties  which  prevent  the  successful  application  of  the 


24  A  MANUAL  OF  SURGERY 

bacteriolytic  sera  in  medicine.  The  alexin  present  in  the  serum  of 
the  immunized  animal  soon  disappears,  and  although  an  amboceptor 
which  is  formed  in  the  blood  of  one  animal  is  always  capable  ot 
being  'activated'  by  the  complement  of  the  same  animal,  it  cannot 
necessarily  be  activated  by  the  complement  of  other  animals.  This 
question  is  one  which  is  extremely  complex,  and  is  at  present  not 
thoroughly  investigated,  though  we  can  hardly  hope  for  any  further 
advance  in  serotherapy  until  it  has  been  elucidated. 

The  role  of  the  leucocytes  now  acquires  fresh  interest.  We  have 
already  seen  reason  to  believe  that  alexin  is  derived  from  these 
cells,  and  some  hold  that  they  are  also  the  main  source  of  the  pro- 
duction of  amboceptor  and  the  other  antibodies.  The  study  of  these 
latter  substances  has  afforded  a  further  insight  into  the  function  of 
phagocytosis.  It  was  found  (by  Mennes)  that  leucocytes  from  a 
normal  animal  had  no  power  of  ingesting  virulent  pneumococci, 
but  that  they  acquired  this  pov/er  when  mixed  with  the  serum  of 
an  animal  which  had  been  immunized  to  pneumococci.  It  is  thus 
evident  that  immune  sera  have  the  power  of  aiding  the  action  of  the 
leucocytes,  presumably  in  virtue  of  containing  an  antibody  which 
unites  with  the  bacteria  and  renders  them  vulnerable.  The  anti- 
bodies which  act  in  this  way  might  be  antitoxins,  amboceptors, 
etc.,  but  it  is  possible  that  they  may  be  fundamentally  different. 
Sir  Almroth  Wright,  who  has  done  much  in  elucidating  this  field 
of  work,  terms  them  opsonins  (from  opsono,  I  cook,  or  prepare  for 
food),  and  holds  that  the  amount  which  is  present  in  the  blood 
determines  the  degree  of  immunity  to  various  infections.  That  they 
act  directly  on  the  bacteria  may  be  proved  thus  :  Bacteria  are  mixed 
with  fresh  serum,  and  the  latter  removed  by  centrifugalization,  and 
the  organisms  freed  from  all  traces  of  serum  by  repeated  washings 
with  normal  saline  solution.  Bacteria  thus  treated  are  taken  up  by 
the  leucocytes  as  readily  as  if  the  serum  were  still  present,  from 
which  we  infer  that  they  have  retained  some  element  of  the  serum 
which  has  sensitized  or  prepared  them  for  phagocytosis.  It  is,  of 
course,  possible  that  the  serum  may  also  act  directly  on  the  leu- 
cocytes, stimulating  them  to  greater  activity,  but  there  is  no  proof 
of  this. 

These  substances  have  recently  been  the  subject  of  an  enormous 
amount  of  investigation,  both  from  the  clinical  and  scientific  aspects. 
There  is,  of  course,  no  method  by  which  the  amount  present  in  a 
given  sample  of  serum  can  be  estimated  quantitatively,  but  Wright 
has  devised  a  process  by  which  the  quantity  in  two  specimens  can 
be  compared.  An  emulsion  of  leucocytes  (mixed  with  red  corpuscles) 
is  prepared  by  taking  a  few  drops  of  blood  from  a  healthy  person, 
dropping  them  into  normal  saline  solution  containing  0-5  per  cent, 
sodium  citrate,  so  as  to  avoid  coagulation.  The  corpuscles  are 
then  centrifugaHzed  down,  the  supernatant  fluid  removed,  and  the 
corpuscular  deposit  rewashed  with  normal  saline  solution  as  often  as 
is  necessary  to  remove  all  trace  of  serum.  Next  a  suitable  emulsion 
of  bacteria  is  prepared.     Lastly,  the  specimens  of  serum  which  are 


BACTERIOLOGY— INFECTION— IMMUNITY  25 

to  be  compared  should  be  collected  about  the  same  time,  since  when 
serum  is  kept  the  amotmt  of  opsonin  undergoes  noticeable  altera- 
tions. In  practice  the  serum  of  the  patient  is  always  compared  with 
that  of  a  healthy  person,  the  ratio  between  the  two  (calculated  in  a 
manner  to  be  described  subsequently)  being  termed  the  opsonic  index. 
The  apparatus  required  consists  of  a  long  capillary  pipette,  which  at 
one  end  is  drawn  out  into  a  point,  and  at  the  other  expands  to  the 
thickness  of  a  pencil ;  this  is  fitted  with  an  indiarubber  nipple.  A 
transverse  line  about  i  inch  from  the  point  marks  an  arbitrary 
unit.  The  process  is,  in  theory,  simple  enough.  A  unit  of  washed 
corpuscles  is  sucked  into  the  fiipette ;  then  a  short  length  of  air ; 
then  a  unit  of  the  bacterial  emulsion  ;  another  short  length  of  air ; 


Fig.  7. — Phagocytosis  of   Tubercle    Bacilli  in  Opsonin    Preparation. 

(Emery.) 

and,  lastly,  a  unit  of  the  serum.  These  are  expelled  on  to  a  clean 
surface  and  mixed  together,  so  that  a  mixture  of  equal  parts  of  the 
three  is  formed ;  this  is  again  sucked  into  the  pipette,  and  the  point 
sealed  in  a  flame.  A  second  pipette  is  prepared  in  the  same  way, 
except  that  normal  serum  replaces  that  of  the  patient.  The  two 
pipettes  are  incubated  at  the  body  temperature  for  exactly  fifteen 
minutes.  Films  are  then  prepared  from  each  mixture,  suitably 
stained,  and  examined  microscopically ;  the  leucocytes  will  be  found 
to  have  ingested  some  of  the  bacteria  (Fig.  7). 

A  careful  count  is  now  made  of  the  number  in  50  or  100  (or  more) 
leucocytes  in  each  preparation,  and  the  ratio  between  the  totals 
gives  the  opsonic  index.  Thus,  if  in  the  preparation  containing 
the  normal  serum  there  were  240  organisms  {e.g.,  tubercle  bacilli) 
in  100  leucocytes,  and  in  the  other  only  120,  the  opsonic  index 
would  be  |^t  =  o'5,  showing  that  the  patient's  serum  contained 
much  less  of  the  opsonin  to  the  tubercle  bacillus  than  did  that 
of  the  healthy  person.      In  practice  the  process  is  a  difficult  one. 


26  A  MANUAL  OF  SURGERY 

and  many  precautions  are  necessary  if  accurate  results  are  to  be 
obtained. 

Opsonins  are  delicate  substances,  which  disappear  on  keeping, 
and  are  readily  destroyed  at  moderate  temperatures  (60°  C.  or  less), 
closely  resembling  the  alexins  in  this  and  some  other  respects. 
They  appear  to  be  specific  (though  this  is  disputed).  A  patient 
may  have  a  high  opsonic  index  to  one  organism  and  a  low  one  to 
another. 

Healthy  persons  approximate  closely  to  one  another  in  their 
opsonic  indices.  In  the  case  of  the  tubercle  bacillus  it  is  rare  to 
find  a  non-tuberculous  patient  with  an  index  above  1-2  or  below  o-8, 
and  in  a  doubtful  case  a  figure  decidedly  above  or  below  these  limits 
is  very  suggestive  of  tubercle.  The  diagnostic  value  of  this  test, 
however,  is  diminished  by  the  fact  that  many  tuberculous  patients 
have  normal  indices.  As  a  general  rule,  in  cases  of  acute  diseases, 
it  is  found  that  the  index  is  below  normal,  and  that  as  recovery 
occurs  it  rises  to  or  above  the  healthy  level.  This  rise  may  be 
sudden,  as  in  most  cases  of  pneumonia,  or  gradual,  as  is  usually  the 
case  in  furunculosis.  It  is  not  uncommon  to  see  patients  in  whom 
the  disease  is  progressing  though  the  index  is  high,  and  this  is 
especially  the  case  in  tubercle. 

It  is  too  early  to  form  a  definite  opinion  of  the  importance  of  the 
opsonins  in  immunity.  There  can  be  no  doubt  that  they  play  some 
part,  but  they  are  not  the  sole  agents  ;  and  their  importance  has 
certainly  been  exaggerated  by  many  authorities.  In  some  respects 
their  discovery  has  rendered  the  phenomena  of  immunity  still  more 
difficult  of  comprehension. 

Wright  has  put  the  study  of  the  opsonic  index  to  practical  use 
in  the  regulation  of  the  dosage  of  his  vaccines  (p.  27).  After  each 
injection  there  is  a  rapid  fall  in  the  opsonic  level  (the  negative 
phase),  followed  by  a  rise,  the  index  usually  going  well  above 
normal  (the  positive  phase).  The  improvement  is  supposed  to 
coincide  with  and  be  due  to  the  increased  amount  of  opsonin  in  the 
blood,  and  when  this  begins  to  diminish,  a  fresh  injection  is  given. 
A  second  injection  should  not  be  given  during  the  negative  phase, 
since  if  this  is  done  the  index  falls  still  further,  and  it  is  held  that 
danger  (of  dissemination  or  rapid  spread  of  the  disease)  might  arise. 
Wright  therefore  controls  his  injections  by  periodical  examinations 
of  the  opsonic  index,  determining  the  dose  which  gives  the  maxi- 
mum rise,  and  giving  a  fresh  injection  as  soon  as  the  effect  begins  to 
wear  off. 

Of  the  practical  value  of  the  process  in  certain  cases  (especially  in 
diseases  due  to  staphylococci)  there  can  be  no  doubt,  but  the  action 
of  the  vaccines  is  probably  complex,  and  the  elevation  of  the  opsonic 
index  only  one  (and  perhaps  not  the  most  important)  factor  in  the 
result.  It  is  doubtful  whether  future  experience  will  show  that  the 
frequent  and  laborious  estimations  of  the  opsonic  index  are  really 
necessary,  and  some  practitioners  already  claim  to  have  acquired 
sufficient  experience  to  be  able  to  dispense  with  them.     But  the 


BA  CTERIOLOGY— INFECTION— IMMUNITY  27 

vaccines  are  by  no  means  innocuous,  and  at  present^  it  seems  best 
to  be  on  the  safe  side,  and  to  check  the  injections  in  the  manner 
described,  except,  perhaps,  in  dealing  with  superficial  local  lesions 
where  there  is  no  great  danger  to  life,  and  in  which  the  good  or  bad 
eflfects  can  be  easily  recognised  by  clinical  phenomena — e.g.,  diminu- 
tion of  fever,  discharge,  or  pain,  commencing  healing  of  the  wound, 
etc.  Where  this  fails,  opsonic  control  should  be  resorted  to,  as 
also  when  dealing  with  internal  infective  processes,  especially 
if  acute  and  dangerous,  and  particularly  in  septicaemia  and  basic 
meningitis. 

The  practical  applications  of  these  researches  and  theories  oi 
immunity  are  twofold — diagnostic  and  therapeutic.  The  chief 
examples  of  their  diagnostic  application  are  the  agglutination  reaction, 
as  used  in  Widal's  test  (p.  22)  in  the  diagnosis  of  typhoid  fever  and 
to  a  less  extent  in  other  diseases,  Wassermann's  reaction  in  syphilis 
and  the  employment  of  the  opsonic  index  (p.  26). 

The  therapeutic  applications  are  more  important,  though  there  is  still 
much  to  be  done  before  their  practical  use  is  fully  understood.  The 
substances  employed  in  artificial  immunization,  and  in  the  curative 
treatment  of  disease,  fall  under  three  main  headings  : 

I.  Vaccines,  using  the  term  more  especially  in  reference  to  the 
emulsions  of  dead  bacteria  referred  to  on  p.  16.  As  used  curatively, 
they  are  prepared  as  follows :  The  organism  is  obtained  in  a  pure 
condition  from  the  patient  to  be  treated,  and  a  young  culture  is 
emulsified  with  sterile  normal  saline  solution,  and  sterilized  by  being 
heated  in  a  sealed  test-tube  to  a  suitable  temperature — e.g.,  60°  C.  for 
half  an  hour.  The  number  of  bacteria  per  cubic  centimetre  is  then 
ascertained  (there  are  several  methods,  by  which  this  can  be  done), 
and  the  emulsion  diluted  with  a  sterile  0'25  per  cent,  solution  of  lysol 
or  carbolic  acid  in  normal  saline  solution.  The  degree  of  dilution 
has,  of  course,  to  be  deterrnined  by  the  strength  of  the  original 
emulsion,  and  by  the  number  of  bacteria  which  it  is  desired  to 
administer  in  each  dose.  This  varies  greatly  with  difii'erent 
organisms ;  thus  staphylococci  and  gonococci  are  usually  tolerated 
in  large  doses  (500,000,000  or  more),  whereas  B.  coli  in  large  doses 
causes  severe  local  and  general  symptoms,  and  the  number  given 
should  be  much  smaller.  As  a  rule,  too,  the  patient  acquires  some 
degree  of  tolerance,  and  the  dose  may  often  be  slightly  increased  as 
the  treatment  progresses. 

It  is  always  advisable,  where  practicable,  to  prepare  the  vaccine 
for  each  patient  from  the  organism  which  is  attacking  him,  since 
there  are  minute  differences  between  the  various  strains  of  bacteria, 
and  a  ready-made  vaccine  may  prove  inefficacious  against  an  infec- 
tion with,  apparently,  the  same  species.  This  is  less  important  in 
the  case  of  the  staphylococci,  more  so  in  dealing  with  the  strepto- 
cocci and  B.  coli.  As,  however,  the  vaccine  takes  a  few  days  to 
prepare  (having  to  be  tested  for  sterility),  it  is  often  a  good  plan  to 
commence  the  treatment  with  a  small  dose  of  a  stock  vaccine. 

At  present  the   use  of   vaccines   must   not    be  looked   upon   as 


28  A  MANUAL  OF  SURGERY 

replacing  surgical  treatment,  but  as  an  adjunct  thereto.  Abscesses 
must  be  opened  and  drained,  dead  bone  removed  from  the  bottom  of , 
a  sinus,  etc.,  just  as  before,  .but  the  use  of  a  suitable  vaccine  may 
often  greatly  aid  the  process  of  heaiing  and  shorten  the  convalescence. 
In  cases  which  are  not  amenable  to  surgical  treatment,  or  in  which 
the  surgeon  desires  to.  wait  for  a  time  before  operating,  this  treat- 
ment should  be  tried  whenever  possible.  Boils,  however,  may  often 
be  aborted  in  a  most  striking  manner  by  an  injection  of  250,000,000 
to  500,000,000  staphylococci. 

2.  Antitoxic  Sera  are  the  antitoxins  to  tetanus,  diphtheria,  and 
possibly,  to  some  extent,  dysentery.  These,  as  has  already  been 
explained,  contain  substances  which  neutralize  the  extracellular 
toxins  of  the  organisms  in  question  :  the  problem  of  preparing  potent 
'antitoxins  for  the  intracellular  toxins  has  not  yet  been  solved.  The. 
main  point  to  notice  in  the  use  of  antitoxic  sera  is  that  they  will 
render  the  toxins  inert,  provided  that  they  are  brought  in  contact 
therewith  before  the  latter  have  combined  with  and  injured  the 
living  cells ;  hence  the  importance  of  their  early  administration. 
Time  may  also  be  saved  by  intravenous  injection,  since  it  has  been 
found  that  diphtheria  antitoxin  is  not  fully  absorbed  from  the  sub- 
cutaneous tissues  for  twenty-four  hours  or  more.  The  process  is 
simple.  The  serum  is  warpied  to  body-heat  and  sucked  into  an  all- 
glass  syringe  (carefully  sterilized).  The  skin  over  a  large  vein  of 
the  forearm  is  prepared  as  for  an  operation,  and  the  vein  itself 
rendered  prominent  by  obstructing  the  circulation  by  gentle  pressure 
with  the  finger.  All  air  is  removed  from  the  syringe  and  needle, 
and  the  latter  introduced  obliquely  at  the  side  of,  and  about  ^  inch 
from,  the  distended  vein.  It  is  pushed  gently  in  until  the  vein  is 
entered,  when  the  blood  will  rise  into  the  syringe.  As  soon  as  this 
happens,  the  finger  which  is  obstructing  the  vein  is  removed,  the 
piston  pushed  gently  down,  and  the  antitoxin  forced  slowly  into  the 
circulation.  There  is  less  object  in  administering  the  serum  by  this 
method  in  tetanus  than  in  other  cases  ;  but  even  here  the  first  dose 
may  be  given  in  this  way  with  advantage. 

3.  Other  Sera. — These  act  bactericidally  (from  containing  ambo- 
ceptor), or  perhaps  facilitate  phagocytosis.  They  are  not,  as  a  rule, 
so  potent  curatively  as  are  the  antitoxic  sera,  but,  where  these  and 
the  vaccines  are  not  available,  must  be  given  a  trial.  The  sera  most 
important  in  surgical  practice  are : 

(a)  Antistreptococcic  Serum. — This  is  prepared  by  immunizing 
horses  with  living  cultures  of  Streptococcus  pyogenes.  This  organism 
is  found  to  present'  marked  differences  in  cultures  from  various 
sources  ;  and  since  it  is  held  that  a  serum  prepared  against  one  variety 
is  useless  against  another,  polyvalent  sera  are  prepared  by  treating 
horses  with  cultures  from  many  sources,  and  should  always  be  used 
if  possible.  If  no  noticeable  benefit  follows  shortly  after  the  first 
dose,  it  is  advisable  that  the  second  should  be  from  a  different 
laboratory,  as  one  serum  may  be  efficacious  in  one  case  and  another 
in  a  different  one.     If  there  is  marked  improvement,  especially  a  fall 


BA  CTERIOLOGY— INFECTION— IMM  UNIT  Y  29 

in  the  temperature,  the  serum  should  not  be  changed.  A  transient 
rise  of  temperature  (due,  possibly,  to  solution  of  the  streptococci 
and  liberation  of  their  toxins)  is  not  necessarily  a  bad  sign,  and 
is  often  followed  by  marked  improvement.  The  dose  may  be  10  to 
20  c.c,  or  even  more. 

{h)  Anti-anthrax  Sera,  of  which  the  best  known  in  this  country  is 
that  prepared  by  Sclavo.  This  has  given  excellent  results  in  the 
treatrnent  of  localized  anthrax  (malignant  pustule),  and  the  improve- 
ment is  often  manifested  within  twenty-four  hours. 

(c)  Anti-pneiimococcic  Serum  (Pane's  or  Romer's)  may  be  tried  in 
severe  pneumococcal  infections,  more  especially  in  septicaemia  and 
peritonitis,  and  in  some  cases  seems  to  act  well.  Good  results  have 
also  been  obtained  in  pneumococcal  ulceration  of  the  cornea  fulcus 
serpens). 

There  are  numerous  other  sera,  which  do  not  call  for  notice. 

Seviim  Disease. — It  sometimes  happens,  especially  if  the  patient 
has  received  large  doses  of  antitoxin,  that  a  remarkable  series 
of  phenomena  take  place  after  an  incubation  period  of  eight  to 
twelvedaysor  more.  The  chief  are  fever;  a  skin  rash  (urticarial, 
scarlatiniform,  or  morbilliform),  usually  accompanied  by  severe 
itching  ;_  enlargement  of  the  lymph-glands,  corresponding  to  the  site 
of  infection  ;  pains  in  the  joints,  especially  the  metacarpo-phalangeal, 
wrist,  and  knee  ;  and  leucocytosis.  Though  unpleasant,  the  symptoms 
are  not  dangerous,  and  recovery  usually  occurs  in  a  few  days. 
Calcium  lactate,  in  15-grain  doses  at  the  time  of  the  injection  and 
for  a  day  or  two  subsequently,  diminishes  the  frequency  with  which 
the  disease  develops,  and  constitutes  the  best  treatment  for  the 
disease  when  developed. 


CHAPTER  II. 

INFLAMMATION. 

'  Inflammation  is  the  succession  of  changes  which  occur  in  a  living 
tissue  when  it  is  injured,  providing  the  injury  is  not  of  such  a  degree 
as  to  at  once  destroy  its  structure  and  vitaHty.'  Such  was  the 
definition  given  in  1870  by  Burdon  Sanderson,  and  it  is  sufficiently 
accurate  if  we  realize  that  the  exciting  injury  usually  involves  the 
admission  of  a  soluble  chemical  irritant,  and  in  most  cases  of  a 
bacterial  toxin  ;  we  must  also  exclude  from  the  process  of  inflammation 
the  later  stages  of  repair.  Formerly  inflammation  was  looked  on 
by  pathologists  as  always  of  a  destructive  and  harmful  nature,  but 
at  the  present  time  bacteriological  research  has  demonstrated  that 
it  is  rather  of  a  protective  or  conservative. character,  being  Nature's 
means  of  limiting  the  advance  of  noxious  micro-organisms,  and 
of  finally  eliminating  them  from  the  system.  Occasionally,  how- 
ever, the  tissue  reaction  called  into  existesce  by  bacterial  invasion 
is  so  severe  as  to  increase,  rather  than  diminish,  the  risks  of  the 
patient. 

The  causes  of  inflammation  are  varied  and  numerous.  Most 
frequently  it  is  due  to  the  admission  of  bacteria,  and  we  have  already 
alluded  (p.  15)  to  the  conditions,  local  and  general,  which  pre- 
dispose an  individual  to  such  invasion,  and  render  him  more  liable 
to  an  inflammatory  attack.  Apart  from  bacteria  inflammation  may 
be  lighted  up  by  (a)  mechanical  lesions,  such  as  blows,  sprains, 
tension,  pressure,  etc. ;  (b)  burns  or  scalds  ;  (c)  toxic  bodies,  such  as 
acids,  alkalies,  or  vegetable  and  animal  poisons ;  and  (d)  the  electric 
current,  either  in  the  form  of  lightning,  or  as  applied  by  the  surgeon, 
or  through  the  agency  of  strong  currents  as  employed  for  purposes 
of  traction  or  illumination.  It  is  but  fair  to  state  that  not  a  few 
authorities  look  on  the  tissue  reaction  caused  by  these  non-bacterial 
irritants  as  distinct  from  inflammation,  limiting  the  latter  term  to 
conditions  resulting  from  bacterial  invasion.  The  phenomena, 
however,  are  identical  up  to  a  certain  point,  and  we  see  no  advantage 
in  the  suggested  dissociation. 

The  actual  phenomena  of  inflammation  are  perhaps  best  studied  in 
the  web  of  a  frog's  foot.     If  this  is  spread  out  and  examined  under 

30 


INFLAMMATION  31 

the  microscope,  the  following  evidences  of  normal  physiological 
activity  may  be  seen  :  (a)  the  flow  of  blood  through  the  vessels, 
as  indicated  by  the  movement  of  the  corpuscles,  the  red  ones,  each 
separate  from  the  other,  flowing  in  the  central  or  axial  current,  the 
leucocytes  occasionally  seen  amongst  the  red,  or  here  and  there  one 
may  be  noticed  rolling  lazily  along  in  the  inert  corpuscle-free  peri- 
pheral portion  of  the  tube  ;  (b)  the  constant  rhythmical  changes  in 
calibre  of  the  arterioles  independent  of  the  heart's  action,  and 
influencing  in  a  marked  degree  the  flow  through  the  capillaries  ; 
and  {c)  the  changes  which  occur  in  the  pigment-cells,  and  are  mainly 
due  to  the  influence  of  light,  the  cells  contracting  or  expanding  as 
the  light  is  increased  or  diminished. 

I.  The  Vascular  Changes  in  Acute  Inflammation.  If  a  crystal 
of  common  salt,  or  some  such  irritant,  is  applied  to  the  web,  a 
momentary  contraction  may  perhaps  be  noticed  in  the  arterioles 
of  the  part,  but  this  is  only  apparent  in  inflammations  produced 
artificially,  and  is  of  no  known  significance.  It  is  followed  by 
a  condition  of  Hypersemia  of  the  inflamed  area,  as  manifested  by 
a  rapid  and  lasting  dilatation  of  the  vessels,  accompanied  by  an 
increase  in  the  rapidity  of  the  blood-flow  {acceleration).  This  is 
a  peculiarly  vital  phenomenon,  and  opposed  to  the  hydrostatic  law 
that  when  fluid  is  flowing  through  a  tube  or  channel  at  a  fixed 
pressure,  if  the  lumen  is  suddenly  widened,  the  rate  of  flow  is 
diminished.  It  is  probably  brought  about  by  some  change  in  the 
local  vasomotor  mechanism  present  in  the  smaller  arterioles.  This 
increased  rapidity  of  the  flow  lasts  for  a  while,  and  then  the  current 
gradually  becomes  slower  and  slower  (retardation),  as  if  an  ever- 
growing obstruction  existed  to  the  passage  of  the  blood ;  next 
a  period  of  oscillation  will  be  noticed,  the  crowded  corpuscles  sway- 
ing forwards  and  backwards,  and  finally  a  condition  of  stasis  or 
still-stand  is  arrived  at,  which  may  or  may  not  end  in  actual  throm- 
bosis or  intravascular  coagulation.  During  this  period  the  relations 
normaUy  existing  between  the  vessel  walls  and  the  varied  con- 
stituents of  the  blood  have  obviously  become  modified,  and  this  is 
due  in  all  probability  to  certain  invisible  changes  in  the  former 
and  not  to  any  alteration  in  the  blood.  Thus,  almost  as  soon  as 
dilatation  occurs,  the  leucocytes  collect  along  the  walls  in  the 
peri-axial  inert  layer,  seeming,  as  it  were,  to  fall  out  of  rank  ;  this 
process  first  commences  in  the  veins,  but  can  be  observed  in  all  the 
vessels.  The  red  corpuscles  also,  which  formerly  had  flowed  along 
separately,  now  tend  to  adhere  to  the  vessel  walls  and  to  each  other, 
running  into  rouleaux. 
^  The  second  factor  in  the  vascular  changes  must  now  be  con- 
sidered, viz..  Exudation,  a  proceeding  which  becomes  evident  at 
a  very  early  stage.  Every  element  in  the  constitution  of  the  blood 
participates  in  this  process.  It  has  been  already  mentioned  that  the 
leucocytes  collect  in  the  peri-axial  layer,  a  phenomenon  due  partly  to 
an  alteration  in  the  vessel  wall,  whereby  it  is  rendered  more  '  sticky,' 


32 


A  MANUAL  OF  SURGERY 


and  partly  to  chemotaxis  (p.  i8).  The  next  change  consists  in  the 
passage  of  the  leucocytes  through  the  vessel  walls,  especially  those 
of  the  smaller  veins  and  less  often  of  the  capillaries.  The  process 
is  a  strictly  vital  one,  brought  about  by  amoeboid  movement ;  a  small 
arm  or  outgrowth  of  the  leucocyte  {pseudopodium)  is  inserted  between 
the  endothelial  cells  lining  the  vessel,  whose  cohesion  has  been 
probably  interfered  with  by  the  inflammatory  process.  Into  this 
arm  the  protoplasm  of  the  leucocyte  flows,  still  further  separating 
the  endothelial  elements,  and  thus  the  cell  passes  through  the  wall 
into  the  surrounding  connective  tissues  (Fig.  9).     The  migration  of 


tiG.  8.        •  Fig.  9. 

Semi-diagrammatic  Representation  of  the  Vascular  Phenomena  of 
Inflammation  (after  Thoma). 

(On  the  left  is  a  normal  vessel  with  its  peripheral  layer  free  from  corpuscles,  and 
its  axial  stream  so  rapid  that  the  individual  corpuscles  cannot  be  seen.  On 
the  right  is  a  similar  vessel  in  a  state  of  inflammation  ;  the  blood-current  has 
been  retarded  so  that  the  individual  corpuscles  are  visible ;  the  leucocytes 
occupy  the  periphery  of  the  vessel,  and  are  in  process  of  migration,  vyhilst 
sundry  red  corpuscles  can  also  be  seen  in  the  surrounding  tissues.) 


the  leucocytes  only  lasts  as  long  as  the  blood  in  the  vessel  is  actually 
circulating  ;  as  soon  as  thrombosis  occurs,  migra4:ion  ceases.  When 
the  white  corpuscle  has  escaped  into  the  peri- vascular  tissues,  it  may 
undergo  various  changes.  In  the  first  place,  it  may  die  and  be 
at  once  disintegrated,  setting  free  fibrin  ferment,  and  thus  assist  in 
the  production  of  the  inflammatory  coagulum  to  be  shortly 
described ;  or,  again,  it  may  find  its  way  back  into  the  circulation 
through  the  lymphatics,  or  be  transformed  into  a  pus  corpuscle ; 
moreover,  prior  either  to  disintegration  or  transformation  into  a  pus 
corpuscle,  it  may  attack  and  assist  in  removing  any  dead  tissue 
which  exists  in  the  neighbourhood  of  the  inflammatory  focus,  whilst 
a  phagocytic  or  microbe-destroying  function  is  also  subserved.  Ir, 
fact,  the  leucocytes  may  be  looked  on  as  the  scavengers  of  the  body, 
or  as  advanced  guards,  which,  at  the  onset  of  mischief,  are  thrown 


INFLAMMATION  33 

out  from  the  vessels  as  Nature's  first  line  of  defence  against  the 
invading  forces,  their  chief  duty  being  to  remove  all  damaged  and 
noxious  material,  and  then,  having  limited  the  spread  of  the  destruc- 
tive process,  they  in  turn  give  place  to  the  larger  and  more  useful 
fibroblastic  cells  which  are  the  active  agents  in  the  process  cf 
repair.  At  the  present  time  the  opinion  is  gaining  ground  that  some 
at  least  of  the  fibroblastic  cells  are  actually  derived  from  the  large 
mononuclear  leucocytes. 

The  red  corpuscles  pass  through  the  walls  of  the  capillaries  by 
a  process  of  diapedesis,  the  result  of  simple  mechanical  pressure ; 
this  usually  occurs  only  in  acute  attacks.  When  once  external  to 
the  vessels  they  are  broken  up  and  their  colouring  matter  diffused 
through  the  tissues,  whence,  as  a  rule,  it  is  completely  re-absorbed ; 
in  some  cases,  however,  it  may  become  converted  into  hasmatoidin 
or  an  analogous  compound,  and  remain  for  years  as  the  only  evidence 
of  the  injury. 

The  liquor  sanguinis  is  also  extravasated.  This  is  merely  an 
exaggeration  of  a  normal  process,  but  to  such  an  extent  that 
although  for  a  time  the  lymphatics  of  an  inflamed  region  do  in- 
creased work,  yet  the  transudation  is  soon  greater  than  they  can  deal 
with.  If  the  fluid  escapes  into  the  tissues,  it  undergoes  coagulation  by 
meeting  the  necessary  coagulating  media  developed  from  the  break- 
ing-down leucocytes ;  inflammatory  lymph  forms  locally,  whilst  the 
serum  collects  in  the  meshes  of  the  tissues,  constituting  an  inflam- 
matory form  of  oedema  ;  if  there  is  a  sufficient  breach  of  surface,  the 
serum  drains  away.  If  the  exudation  takes  place  from  a  serous 
surface — e.g.,  pleura,  peritoneum,  synovial  membrane,  etc. — the  fluid 
distends  the  cavity ;  it  is  at  first  spontaneously  coagulable  {i.e., 
consists  of  plasma) ;  if  coagulation  occurs,  the  clot  or  lymph  either 
forms  an  adherent  plastic  mass  on  the  surface  or  floats  free  in  the 
fluid 

Looked  at,  therefore,  simply  from  a  vascular  point  of  view, 

Inflammation  =  Hyperemia  +  Exudation. 

A  few  brief  considerations  may  be  offered  as  to  the  method  in 
which  the  inflammatory  reaction  is  of  benefit  to  the  patient,  and  we 
shall  suppose  that  the  process  is  caused  by  the  presence  in  the  tissues 
of  a  colony  of  bacteria,  the  toxins  of  which  act  as  the  irritant.  The 
acceleration  of  the  blood-flow  serves  in  the  first  place  to  dilute  and 
to  remove  the  toxin  ;  if  the  amount  present  is  small,  the  rapid  flow 
of  blood  may  serve  to  remove  it  completely,  and  then  the  process 
begins  and  terminates  in  hypersemia.  Further,  the  increased  supply 
of  blood  must  serve  to  keep  the  nutrition  of  the  tissues  at  its  highest 
level,  so  that  if  possible  they  may  be  preserved  alive  in  spite  of  the 
action  of  the  toxin.  Lastly,  if  the  blood  contains  antitoxins,  or 
other  antibodies,  or  alexins  (complements),  which  inhibit  the  action 
of  the  toxins  or  destroy  the  bacteria,  these  will  be  brought  in  large 
amounts  to  the  region  where  they  are  required.  The  excessive 
transudation  of  the  plasma  may  be  regarded  as  an  additional  means 

3 


34  A  MANUAL  OF  SURGERY 

to  fulfil  the  desiderata  enumerated  above.  The  value  of  the  retarda- 
tion and  stasis  of  the  blood  is  less  obvious,  and  possibly  it  must 
be  considered  as  a  necessary  evil  result  of  the  action  of  the  toxin, 
and  not  as  part  of  the  defensive  reaction.  It  may  be  pointed  out, 
however,  that  it  probably  assists  the  emigration  of  the  leucocytes, 
which  might  otherwise  find  difficulties  in  attaching  themselves  to  the 
walls  when  floating  freely  in  a  rapid  blood-stream.  The  role  of  the 
leucocytes  has  been  touched  on  already.  Their  most  important  duty 
is  to  serve  as  phagocytes  and  to  ingest  bacteria,  w^hether  the  latter 
are  normal,  or  acted  on  by  opsonins,  or  rendered  innocuous  by 
antitoxins.  Moreover,  there  is  reason  to  regard  them  as  the  probable 
source  of  alexins  or  complements,  whilst  other  authorities  consider 
that  the  defensive  antibodies  are  mainly  derived  from  them,  and 
have  ascribed  to  them  the  power  of  absorbing  and  neutrahzing 
toxins. 

II.  The  Tissue  Changes  in  inflammation  cannot  be  so  easily  observed 
as  the  vascular,  but  are  of  great  importance. 

The  reaction  of  the  tissues  in  acute  bacterial  inflammations 
appears  to  depend  entirely  on  the  irritative  power  of  the  toxins, 
or  rather  on  the  relation  of  this  power  to  the  resistance  of  the 
patient's  tissues.  It  may  be  laid  down  as  a  general  rule  that  any 
irritant,  if  weak  enough  {e.g.,  when  very  diluted),  acts  as  a  stimulant 
to  the  growth  of  cells  ;  on  the  other  hand,  if  sufficiently  powerful, 
it  will  cause  some  variety  of  necrosis  or  death  of  the  tissues. 
Uncomplicated  examples  of  tissue-overgrowth  in  acute  inflammation 
are  not  often  seen  in  man,  since  the  slighter  lesions  are  rarely 
examined  microscopically.  The  process  is  best  seen-  in  the  early 
stages  of  acute  inflammations  of  the  serous  membranes  in  animals, 
where  the  endothelium  may  be  seen  several  cells  thick,  whilst  its 
nuclei  show  active  mitosis,  proving  that  cell-proliferation  was  in 
progress.  An  examination  of  the  outer  zone  of  a  mass  of  granulation 
tissue  (where  the  toxins  are  present  only  in  small  amount)  will 
often  show  similar  appearances.  In  most  cases  the  process  goes 
further  than  this,  and  the  death  of  the  tissue  results.  This  may 
be  brought  about  in  several  ways,  of  which  perhaps  the  commonest 
is  termed  coagulation-necrosis.  In  this  condition  the  tissues  and  cells 
become  soaked  in  the  coagulable  plasma  which  exudes  from  the 
vessels,  and  when  they  have  been  killed  by  the  toxins  a  coagulation 
of  the  whole  mass  takes  place.  The  result  is  that  all  structure 
disappears  from  the  area  involved  :  the  nuclei  cease  to  stain  with 
haematoxylin  or  other  basic  dyes,  and  all  the  tissues  stain  uniformly 
with  acid  stains,  such  as  eosin.  The  further  history  of  the  lesion 
depends  on  the  nature  of  the  causative  organisms.  If  these  are  of  a 
pyogenic  nature,  the  necrotic  mass  will  become  (or  has  already 
become)  infiltrated  with  polynuclear  leucocytes,  some  of  which  are 
killed  by  the  toxins,  and  suppuration  follows  (see  p.  64).  When  the 
organism  is  not  of  this  nature,  the  polynuclear  leucocytes  make  their 
appearance  in  but  moderate  numbers,  and  the  inflamed  area  becomes 
infiltrated  with  'small  round  cells,'  which  appear  to  be  identical  with 


INFLAMMATION  35 

lymphocytes.  It  is  as  yet  uncertain  whether  these  are  formed 
locally  or  whether  they  are  attracted  from  the  blood.  It  seems, 
however,  tolerably  clear  that  they  undergo  a  local  increase  by  direct 
division  in  the  inflamed  area.  If  the  bacteria  are  killed  and  the 
process  stops  at  this  stage,  the  phenomena  of  repair  supervene  : 
these  collections  of  small  round  cells  become  infiltrated  by  larger 
round  or  oval  cells  (fibroblasts),  which  gradually  become  elongated 
and  develop  into  fibrous  tissue,  or  perhaps  into  new  bloodvessels. 
The  lymphocytes  now  gradually  disappear,  and  the  lesion  only 
differs  from  normal  fibrous  tissue  in  being  immature  both  as  regards 
its  vessels  and  its  fibres.  The  source  of  the  fibroblasts  has  been  the 
subject  of  much  controversy,  the  whole  question  being  whether  they 
are  derived  from  the  pre-existing  connective  tissues  or  from  the 
leucocytes.  There  is  now  but  little  doubt  that  they  may  have  either 
origin. 

In  non-bacterial  inflammations  of  superficial  parts  the  amount  of 
effusion  between  the  individual  cells  may  be  so  excessive  as  to 
separate  and  disintegrate  them,  and  thus  colliqiiative-necrosis  may  be 
induced,  as  occurs  in  the  formation  of  blisters  after  a  burn. 

In  chronic  inflammations,  on  the  other  hand,  active  cell-prolifera- 
tion is  a  most  important  element  in  the  process,  resulting  in  sclerosis 
and  induration  of  the  parts.  This,  however,  mainly  affects  the 
interstitial  tissues,  and  thereby  the  true  structure  of  the  organ  may 
be  impaired. 

III.  The  Terminations  of  inflammation  will  therefore  vary  con- 
siderably, and  more  especially  with  the  cause  of  the  trouble,  whether 
bacterial  or  not,  with  the  intensity  and  duration  of  its  action,  and 
finally  with  the  powers  of  resistance  possessed  by  the  tissues  and  the 
individual. 

In  bacterial  inflammations  (i)  it  is  unusual  for  the  tissues  so  to 
assert  themselves  as  to  permit  of  the  occurrence  of  resolution,  or  the 
re-appearance  of  the  status  quo  ante ,  it  is,  however,  seen  occasionally. 
(2)  More  frequently  local  destruction  of  tissue  results,  and,  according 
to  the  nature  of  the  bacteria  and  the  tissues  involved,  this  may  be 
followed  by  {a)  repair,  the  necrotic  tissue  disappearing  and  scar  tissue 
taking  its  place  ;  {h)  suppuration,  in  which  the  affected  tissues  and 
the  exudate  are  liquefied  and  transformed  into  pus  ;  {c)  ulceration, 
when  the  necrotic  or  suppurative  process  affects  the  surface  ;  or 
{d)  extensive  necrosis  or  gangrene,  when  the  toxic  effects  of  the 
bacteria  are  able  to  break  down  the  tissue  resistance  to  such  an 
extent  that  the  bacteria  are  able  to  diffuse  themselves  widely  in  the 
part.  In  this  connection  it  is  interesting  to  note  that  the  more  highly 
organized  and  important  parts  are  always  more  vulnerable  than  the 
simpler  forms  of  connective  tissue,  and  this  in  spite  of  the  fact  that 
the  former  are  usually  better  supplied  with  blood.  Thus,  the  grow- 
ing end  of  the  diaphysis  in  a  child  is  a  most  delicately  organized 
region,  and  hence  is  peculiarly  liable  to  serious  destructive  inflam- 
mation from  bacterial  agents,  which  would  do  little  harm  if  developing 
under  similar  circumstances  in  the  subcutaneous  connective  tissues. 


36  A  MANUAL  OF  SURGERY 

When  the  inflammatory  attack  is  due  to  mechanical  or  other  non- 
bacterial causes,  there  is  frequently  much  effusion  of  fluid,  and  at 
first  but  little  cellular  exudation,  whilst  the  process  is  distinctly 
limited  and  has  no  tendency  to  spread.  The  most  common  termina- 
tions are  •  (a)  Resohitmt,  complete  and  absolute,  which  is  seen  net 
uncommonly  ;  (b)  the  formation  of  fibro-cicatricial  tissue,  as  seen  in 
the  organization  of  lymph  into  adhesions  ;  (c)  sometimes  the  in- 
flammatory process  becomes  chronic,  and  is  then  characterized  by 
sclerosis  or  fibroid  thickening  of  the  part,  or  by  persistent  effusion 
into  a  serous  cavity. 

Resolution,  or  the  restoration  of  the  part  to  its  natural  condition 
and  function,  can  only  occur  when  the  injury  has  not  been  so  severe 
as  to  destroy  the  vitality  of  the  affected  tissues.  The  phenomena 
are  merely  those  of  inflammation  in  a  retrograde  order — viz.,  an  oscil- 
latory movement  first  manifests  itself  amongst  the  corpuscles,  and 
then  the  blood-stream  is  gradually  restored,  slowly  at  first,  and  more 
and  more  rapidly  afterwards.  The  adhesiveness  of  the  corpuscles 
disappears  by  degrees,  but  it  is  some  time  before  the  peripheral 
inert  layer  can  be  seen.  The  exuded  leucocytes  find  their  way  back 
into  the  circulation  either  through  the  vessel  walls,  or  to  a  greater 
extent  via  the  lymphatics,  or  else  they  are  disintegrated  in  the  tissues 
and  absorbed.  The  fluid  exudate  is  removed  by  the  lymphatics. 
For  some  time  after  an  acute  attack  the  vessels  of  the  part,  especially 
the  veins,  are  dilated  from  simple  loss  of  tone,  but  this  also  gradually 
disappears. 

Clinical  Signs  of  Inflammation. 

The  Local  Phenomena  may  be  described  under  the  four  headings 
suggested  by  Celsus  (about  a.d.  50),  viz.,  heat,  redness,  swelling,  and 
pain,  with  the  addition  of  a  fifth,  viz.,  impairment  of  function. 

Heat.^An  inflamed  part  feels  hot  to  the  touch,  and  the  tempera- 
ture, if  taken  by  a  surface  thermometer,  is  definitely  raised  above 
that  of  the  surrounding  skin.  This  is  due  to  the  increased  amount 
of  blood  flowing  through  it,  for  the  temperature  of  an  inflamed  area 
is  never  higher  than  that  of  the  blood  at  the  centre  of  the  circulation, 
i.e.,  in  the  heart.  The  cause  of  the  increased  temperature  of  the 
blood  is  noted  elsewhere  (p.  39). 

Redness  is  due  to  the  hyperaemic  condition  of  the  inflamed  part. 
In  the  early  active  hyperaemia  the  colour  is  a  bright  rosy-red,  fading 
quickly  on  pressure,  and  returning  with  equal  rapidity.  During  the 
period  of  retardation  the  redness  is  more  dusky,  since  the  blood  is  longer 
in  passing  through  the  capillaries,  and  so  loses  more  of  its  oxygen ;  the 
colour  does  not  disappear  or  return  so  rapidly,  and  a  slight  yellowish 
tinge  often  remains  from  extravasated  hemoglobin.  When  stasis  is 
reached,  and  a  fortiori  when  thrombosis,  pressure  does  not  remove 
the  red  colour,  and,  should  such  a  state  persist  for  long,  permanent 
pigmentation  may  remain. 

When  the  tissue  inflamed  is  non-vascular — e.g.,  the  cornea  or  arti- 
cular cartilage — redness  is  of  course  absent  until  the  part  becomes 


INFLAMMATION 


37 


permeated  by  newly-formed  vessels.  In  the  case  of  the  cornea, 
however,  a  zone  of  deep  pink  injection  is  seen  in  the  ciliary  region. 
A  similar  absence  of  redness  is  observed  in  an  inflamed  iris,  owing  to 
the  excess  of  pigment  hiding  the  dilated  vessels  ;  if,  however,  the 
inflammation  is  very  prolonged,  the  pigment  may  be  absorbed,  and 
the  iris  becomes  obviously  red. 

Swelling  arises  from  the  same  two  causes,  viz.,  hyperasmia  of,  and 
exudation  into,  the  part.  Necessarily  the  amount  of  tumefaction 
depends  upon  the  acuteness  of  the  disturbance  and  the  distensibility 
of  the  tissue,  and  in  measure  varies  inversely  with  the  amount  of 
pain.  Where  the  inflamed  area  is  covered  by  a  thick  and  firm 
fascia,  not  only  is  the  tensive  pain  very  considerable,  but  the  chief 
swelling  may  occur  away  from  the  inflamed  area,  e.g.,  over  the  back 
of  the  hand  in  a  palmar  abscess ;  where  the  inflammatory  products 
escape  into  lax  tissues,  the  subjective  phenomena  are  diminished, 
although  the  swelling  may  be  very  great.  Similar  illustrations  of 
the  occurrence  of  cedema  at  a  distance  are  to  be  seen  in  inflamma- 
tions of  the  sole  of  the  foot,  and  in  the  swelling  of  the  eyelids  when 
the  scalp  is  inflamed.  Swelling  due  to  inflammation,  though 
diminishing  after  death,  does  not  entirely  disappear. 

Pain  results  from  the  mechanical  irritation  of  the  peripheral  nerve 
terminals,  both  by  the  increased  arterial  tension  and  by  the  pressure 
of  the  exudate,  so  that  it  is  much  greater  if,  from  the  density 
of  fascial  or  fibrous  investments,  swelling  cannot  readily  occur,  e.g., 
in  the  palm  of  the  hand,  or  in  the  eye  or  testicle.  Possibly  the 
exudate  may  have  some  direct  chemical  action  on  the  nerve  terminals, 
especially  when  destructive  changes  are  taking  place,  or  if  they  are 
insufficiently  nourished  with  healthy  blood. 

A  marked  feature  of  inflammatory  pain  is  that  it  is  always  aggra- 
vated by  pressure,  whether  intrinsic — i.e.,  by  increasing  the  blood- 
pressure — or  extrinsic,  from  outside  agencies.  Thus,  if  an  inflamed 
finger  or  hand  is  allowed  to  hang  down,  the  pain  is  much  increased, 
whereas  elevation  causes  speedy  relief. 

The  pain  of  suppuration  is  throbbing  in  character  ;  of  an  inflamed 
mucotis  membrane,  scalding,  burning,  or  gritty  ;  of  an  inflamed  serous 
membrane,  stabbing  ;  of  inflamed  bone,  aching  or  boring,  and  often 
worse  at  night ;  of  an  inflamed  testicle,  sickening.  When  the  organs 
of  special  sense  are  inflamed,  there  may  be  little  real  pain,  but  much 
exaggeration  of  the  special  sense,  e.g.,  flashes  of  light  in  retinitis  and 
noises  in  the  ears  in  otitis  interna. 

The  pain  is  not  limited  only  to  the  inflamed  part,  bui  is  sometimes 
experienced  in  distant  regions,  either  through  a  similarity  of  nerve- 
supply  or  from  the  fact  that  a  sensory  stimulus  is  always  referred  by 
a  patient  to  the  end  of  the  affected  nerve.  For  example,  in  hip 
disease  the  chief  pain  is  often  felt  in  the  knee,  because  both  joints 
derive  their  nervous  supply  from  similar  sources.  In  renal  calculus 
or  colic,  pain  is  referred  along  the  course  of  the  genito-crural  nerve 
into  the  groin  and  front  of  the  thigh,  and  is  often  accompanied  in 
the  male  by  retraction  of  the  testicle  on  the  side  affected.     In  spinal 


38  A  MANUAL  OF  SURGERY 

caries  pain  is  frequently  experienced  in  the  terminal  branches  of  the 
nerves  issuing  from  the  part  affected,  e.g.,  the  '  girdle  '  pain  in  dorsal 
disease,  and  the  so-called  '  belly-ache '  when  the  dorsi-iumbar  region 
is  affected.  Occasionally  a  sympathetic  pain  is  experienced  on  the 
opposite  side  of  the  body,  especially  when  a  bilateral  organ  such  as 
the  kidney  is  involved. 

Impairment  or  Loss  of  Function  is  due  sometimes  to  the  mechanical 
difficulty  of  using  a  swollen  organ,  sometimes  to  the  pain  elicited  by 
such  attempts,  but  often  to  the  paralyzing  effect  of  the  inflammatory 
process,  and  this  in  infective  lesions  results  from  the  direct  influence 
of  the  toxins  on  the  protoplasm  of  the  cells  affected.  Thus,  an 
inflamed  eye  is  from  various  causes  of  little  use  for  vision  ;  a  muscle, 
when  inflamed,  is  naturally  kept  at  rest ;  glandular  organs,  e.g.,  the 
liver  and  kidneys,  have  their  functions,  if  not  lost,  at  least  much 
diminished  ;  and  many  similar  illustrations  might  be  added. 

Greneral  or  Constitutional  Symptoms. — These  vary  considerably 
according  to  the  part  involved  and  the  cause  of  the  inflammation. 
(a)  If  an  important  organ,  such  as  the  heart  or  kidney,  becomes 
inflamed,  grave  mechanical  and  physiological  trouble  may  result. 
{b)  Inflammations  due  to  traumatism,  in  which  bacteria  play  no  part, 
are  not  uncommonly  associated  with  a  temporary  pyrexia,  (c)  When 
of  septic  or  pyogenic  origin,  inflammation  is  almost  alv/ays  associated 
with  well-marked  fever,  and  it  is  sometimes  astonishing  to  note  how 
much  disturbance  a  small  bead  of  pus  under  tension  will  produce.  Per 
contra  a  large  collection  of  pus  may  be  present  with  no  constitutional 
symptoms,  (d)  In  certain  infective  inflammations  a  characteristic 
toxaemia  is  produced,  due  to  a  specific  action  of  the  toxin — e.g.,  in 
diphtheria,  fever  and  perhaps  paralytic  phenomena  are  alike  produced. 

It  is  only  necessary  at  this  place  to  deal  very  briefly  with  the 
subject  of  Fever  or  pyrexia.  The  general  characteristics  of  the  febrile 
state  consist  in  a  greater  or  less  elevation  of  temperature,  accom- 
panied by  a  corresponding  acceleration  of  the  rate  of  the  heart-beat 
and  of  the  respirations.  If  it  continues,  the  patient  becomes  thin 
and  emaciated,  and  loses  muscular  power.  The  mouth  is  dry  and 
the  tongue  furred  ;  and  in  the  later  stages  the  lips  and  teeth  are 
usually  covered  with  sordes  (or  accumulations  consisting  of  inspis- 
sated mucus  and  food  debris).  The  appetite  is  impaired,  digestion 
is  imperfect,  and  the  bowels  constipated;  the  motions  are  often 
very  offensive.  The  urine  is  scanty  and  high-coloured,  and  owing 
to  the  excessive  tissue  change  contains  an  unusual  amount  of  urea 
and  urates.  The  excess  of  urea  is  demonstrated  clinically  by  adding 
an  equal  part  of  cold  nitric  acid  in  a  test-tube  to  some  urine,  when 
crystals  of  nitrate  of  urea  will  form  on  the  top  of  the  fluid,  giving 
rise  to  a  mass  somewhat  resembling  sugar-candy  in  appearance. 
The  skin  of  a  febrile  patient  is  often  dry. 

Causes  of  Fever. — The  temperature  of  the  body,  it  is  well  known,  is  controlled 
by  a  principal  heat-governing  centre  in  the  corpus  striatum,  assisted  possibly  by 
accessory  centres  in  the  cord,  and  is  maintained  by  the  establishment  of 
equilibrium  between  the  amount  of  heat  lost  from  the  skin,  by  the  breath,  and  in 


INFLAMMATION  39 

other  directions,  and  the  amount  of  heat  produced  by  the  tissue  metabolism  occur- 
ring in  the  viscera  generally,  and  especially  in  the  voluntary  muscles.  Pyrexia  is 
necessarily  due  to  one  of  two  causes,  viz.,  a  decreased  loss  of  heat,  or  an  increased 
production.  The  former  is  a  scarcely  tenable  proposition  when  we  look  at  the 
patient's  condition,  and  hence  we  are  driven  to  conclude  that  fever  is  due  to 
increased  activity  in  the  heat-forming  tissues,  especially  the  muscles,  a  fact 
which  explains  the  rapid  emaciation  and  loss  of  strength  under  such  circum- 
stances, and  the  presence  of  a  large  amount  of  extractives  in  the  urine.  In  all 
probability  this  increased  activity  is  due  to  the  excitation  of  the  heat-producing 
centres  by  some  pyrogenous  body  developed  in  connection  with  the  local  inflam- 
matory process.  Experiments  have  shown  that  fibrin  ferment,  various  products 
of  the  breaking  down  of  tissues,  and  many  of  the  toxins  produced  by  the  action  of 
micro-organisms  possess  such  a  power, 

In  regard  to  the  symptoms  of  fever,  it  may  be  stated  briefly  that  they  are  in 
large  part  due  to  the  effect  produced  by  the  increased  temperature  or  the  toxic 
products  circulating  in  the  blood  upon  the  constituent  cells  of  glandular  and 
other  organs.  The  phenomena  in  question  are  termed  by  different  pathologists 
'acute  or  cloudy  swelling,'  'granular  degeneration,'  'albuminous  infiltration,' 
etc. ,  and  are  characterized  by  the  organs  becoming  soft,  friable,  and  more  or  less 
swollen.  The  secreting  cells  of  glands  are  increased  in  size,  and  the  protoplasm 
becomes  markedly  granular,  so  that  the  nucleus  can  only  be  distinguished  with 
difficulty.  The  granules  are  albuminous  in  character,  clearing  up  completely  on 
the  addition  of  acetic  acid.  A  similar  change  is  also  evident  in  the  fibres  of  the 
cardiac  muscle,  which  lose  their  striation  and  become  granular,  a  condition 
which  must  considerably  interfere  with  their  contractility.  The  effect  produced 
upon  the  glands  of  the  digestive  system  explains  many  of  the  febrile  manifesta- 
tions. The  salivary  and  buccal  glands  are  unable  to  excrete  the  normal  amount 
of  saliva,  and  hence  the  mouth  becomes  dry.  Gastric  digestion  is  interfered  with 
in  the  same  way.  The  bile  is  not  efficiently  produced,  and  hence  its  fat- 
emulsifying  properties  are  diminished,  so  that  the  patient  cannot  properly 
digest  fats. 

The  intensity  and  character  of  the  fever  vary  with  the  preceding  condition  of 
the  patient,  and  also  with  the  nature  and  duration  of  the  disease.  In  young 
healthy  adults  of  sound  constitution,  the  fever  associated  with  an  acute  inflamma- 
tion is  usually  of  an  active  type,  pyrexia  and  its  accompanying  phenomena,  in- 
cluding a  noisy  delirium,  being  well  marked  {sthenic  inflammatory  fever).  In 
debilitated  subjects,  as  also  towards  the  close  of  a  long  period  of  pyrexia  {e.g.,  in 
the  third  week  of  enteric  fever),  and  in  grave  infections  such  as  erysipelas  and 
septicaemia,  exhaustion  and  collapse  manifest  themselves  {asthenic  fever,  or  the 
typhoid  state).  The  pyrexia  is  not  necessarily  high,  and  the  patient  often  passes 
into  a  condition  of  low  muttering  delirium,  picking  at  the  bedclothes,  passing  his 
excreta  into  the  bed,  and  more  or  less  unconscious. 

It  is  probable  that  moderate  pyrexia  is  useful  rather  than  harmful 
in  infective  diseases,  in  that  it  encourages  the  formation  of  antibodies. 
Hyperpyrexia,  however,  is  harmful  in  that  it  paralyzes  the  tissues 
and  checks  the  production  of  these  substances.  It  is  unnecessary, 
therefore,  to  employ  antipyretic  measures  except  when  the  tempera- 
ture runs  high,  and  the  chief  reliance  should  then  be  placed  on  drugs 
such  as  quinine  or  aspirin,  or  on  tepid  sponging. 

Varieties  of  Inflammation. — Many  different  terms  are  used  to  indic- 
ate the  manifestations  of  the  inflammatory  process  in  the  body,  and  to 
some  of  these  we  must  now  direct  attention. 

A  Catarrhal  inflammation  is  one  affecting  mucous  membranes, 
which  in  the  early  stages  become  dry,  vividly  red,  and  the  seat  of 
a  burning  or  scalding  pain,  whilst  in  the  later  stages  there  is  free 
secretion   of  mucus,  muco-pus,  or  pus.     At   first   the   mucigenous 


40  A  MANUAL  OF  SURGERY 

function  of  the  hyperaemic  membrane  is  abrogated,  and  any 
extravascular  exudation  passes  into  its  substance,  causing  it  to 
become  swollen.  Proliferation  of  the  epithelium  soon  follows, 
resulting  in  an  increased  formation  of  mucus ;  as  the  membrane 
becomes  more  and  more  infiltrated  with  leucocytes,  these  are 
added  to  the  discharge,  which  is  thus  transformed  into  muco-pus,  or 
even  pus.  Small  ulcers  may  develop  from  the  loss  of  superficial 
epithelium,  but  this  is  an  exception  rather  than  the  rule.  Microscopic 
examination  of  the  discharge  reveals  pus  cells,  leucocytes,  and 
epithelial  elements  in  various  conditions,  some  containing  globules 
of  mucin,  and  some  of  the  normal  type.  This  form  of  inflammation 
is  caused  by  bacteria,  or  by  the  action  of  local  irritants,  or  by  what 
is  known  as  '  taking  cold.' 

A  Croupous  or  plastic  inflammation  is  one  characterized  by  the 
formation  of  a  firm,  false-membrane,  due  to  the  coagulation  of  the 
plasma  exuded  from  the  vessels,  the  resulting  fibrin  being  deposited 
on  the  surface.  When  involving  a  serous  surface,  such  as  the 
pleura,  peritoneum,  or  synovial  membrane,  it  gives  rise  to  a  layer 
of  plastic  lymph,  which  may  organize  into  adhesions ;  it  is  also  seen 
in  the  alveoli  of  the  lungs  in  lobar  pneumonia.  On  mucous  mem- 
branes, such  as  the  conjunctiva  or  that  of  the  pharynx,  it  occasionally 
forms  white,  flaky  masses,  which  can  be  readily  detached,  leaving 
an  injected  surface  below,  with  merely  one  or  more  oozing  points, 
and  no  loss  of  substance. 

A  Diphtlieritic  inflammation  is,  properly  speaking,  one  that  is 
due  to  the  action  of  the  diphtheria  bacillus  on  a  free  surface.  The 
term  is,  however,  often  applied  +o  inflammatory  processes  due  to 
other  causes,  but  resulting  in  a  '  false-membrane '  of  similar  nature. 
This  differs  from  the  false-membrane  of  croupous  inflammation  in 
that  it  is  formed,  in  part  at  least,  by  necrosed  tissues,  and  not  simply 
by  fibrin  deposited  on  the  surface.  Hence  it  is  more  difficult  to 
'peel  off,'  and  when  this  is  done  a  raw  bleeding  surface  is  left. 

The  term  PMegmonous  is  now  but  rarely  employed.  It  was 
formerly  appHed  to  any  inflammation  of  the  subcutaneous  connective 
tissues  where  the  local  phenomena  tended  to  spread,  and  there  was 
well-marked  brawny  inflammatory  swelling. 

Parenchymatous  and  Interstitial  are  terms  which  indicate  that  in 
an  inflamed  organ  or  gland  the  process  is  mainly  limited,  either  to 
the  actual  and  active  substance  of  the  organ,  or  to  the  supporting 
fibrous  tissue. 

The  term  Metastasis  was  formerly  employed  to  indicate  a  sudden 
transference  of  an  inflammatory  attack  from  one  place  to  another  with- 
out apparent  cause.  Increased  knowledge  of  pathology  has  explained 
away  almost  all  the  formerly-described  illustrations  of  metastasis, 
and,  indeed,  the  use  of  this  term  is  now  almost  limited  to  the 
inflammation  of  testis,  ovary,  or  breast  which  follows  mumps.  It 
is  often  incorrectly  applied  to  the  secondary  abscesses  of  pyaemia 
and  to  the  secondary  deposits  of  malignant  disease,  both  of  which 
are  of  embolic  origin. 


INFLAMMATION  41 

Treatment  of  Acute  Inflammation. 

It  is  only  possible  here  to  deal  with  the  general  principles  which 
guide  us  in  the  treatment  of  inflammatory  affections  ;  the  application 
of  these  to  various  parts  of  the  body  in  various  conditions  will  be 
considered  later. 

I.  The  Local  Treatment  of  Non-bacterial  Inflammation. — i.  Remove 
the  exciting  cause,  if  evident,  and  any  contributory  causes  when 
feasible.  This  is  not  a  difficult  matter  when  the  lesion  is  a 
gross  one  and  the  exciting  cause  tangible,  e.g.,  a  foreign  body 
imbedded  in  the  conjunctiva  or  cornea,  or  the  use  of  a  chemical 
irritant  such  as  formalin  in  an  occupation  eczema.  In  the  majority 
of  cases,  however,  the  exciting  cause  has  ceased  to  act  as  in  the 
case  of  blows,  sprains,  burns,  etc.,  and  all  one  can  do  is  to  protect 
the  part  from  further  irritation  or  septic  infection,  to  relieve  the 
inflammatory  tension,  and  then  to  assist  the  tissues  towards  healthy 
repair. 

0..  Keep  the  inflamsd  part  at  vest.  Wherever  inflammation  exists, 
both  physical  and  physiological  rest  should  be  secured  as  far  as 
possible.  Thus,  an  inflamed  joint  is  immobilized  by  a  splint ; 
an  inflamed  mamma  needs  both  support  and  the  fixation  of  the  arm, 
whilst  if  in  a  condition  of  physiological  activity  this  must  be  checked 
by  suitable  treatment ;  an  inflamed  cornea  needs  the  application  of  a 
pad  and  bandage  to  prevent  the  friction  of  the  eyelid :  an  in- 
flamed retina  must  be  given  physiological  rest  by  exclusion  of  the  light. 

3.  Reduce  the  local  blood-pressure  and  hypersemia,  and  thus  diminish 
both  exudation  and  pain.  It  may  be  pointed  out  here  that,  although 
both  hypersemia  and  exudation  are  beneficial,  yet  they  are  almost 
always  present  in  excess,  and  it  becomes  needful  to  keep  them 
under  control.  Elevation  of  an  inflamed  limb  may  secure  this 
end,  and  is  a  most  essential  element  in  the  treatmaent  of  all  in- 
flammatory conditions  of  the  leg,  for  it  is  a  well-known  fact  that 
emptying  the  veins  by  gravity  in  an  elevated  limb  leads  to  reflex 
contraction  of  the  arteries.  Local  blood-letting  by  leeches,  punctures, 
scarification,  and  wet  or  dry  cupping,  is  useful  in  suitables  cases, 
and  sometimes  gives  immediate  relief.  It  may  be  as  well  to 
mention  that  a  leech  can  withdraw  about  2  to  4  drachms  of  blood, 
and  that  it  should  not  be  applied  over  a  large  subcutaneous  vein,  or 
to  parts,  like  the  scrotum  or  eyelids,  where  there  is  much  subcu- 
taneous tissue  of  a  loose  texture,  in  which  extravasation  readily 
occurs.  The  bleeding  from  a  leech-bite  usually  ceases  spontaneously, 
but  may  require  the  application  of  slight  pressure. 

Cold  wisely  utilized  is  of  the  greatest  service  in  combating  in- 
flammation, causing  contraction  of  the  arterioles,  and  so  reducing 
the  hyperaemia.  It  should  only  be  used  in  the  early  stages,  as,  although 
it  may  cause  local  depletion  of  the  bloodvessels,  at  the  same  time  it 
depresses  the  vitality  of  the  part,  and  so  may  do  more  harm  than 
good.  Again,  it  should  be  used  with  the  greatest  care  in  old  people, 
from  fear  of  causing  necrosis  of  the  skin.     There  are  various  methods 


42  A  MANUAL  OF  SURGERY 

of  applying  it,  as  by  means  of  an  ice-bag ;  or  by  irrigation  from  a 
vessel  suspended  over  the  part,  containing  iced  water  or  lotion,  from 
which  strips  of  lint  descend  to  envelop  the  inflamed  area;  or  a 
piece  of  lint  wrung  out  of  evaporating  lotion  may  be  placed  directly 
on  the  part ;  or,  better  still,  the  iced  water  may  be  run  through 
a  coil  of  leaden  pipes  (known  as  Leiter's  tubes),  fitted  carefully  to 
the  inflamed  region.  Under  any  circumstances  the  cold  must  be 
continuous,  and  not  intermittent,  as  otherwise  the  alternating  periods 
of  anaemia  and  hyperaemia  will  have  a  baneful  rather  than  a  bene- 
ficial influence. 

Heat,  especially  when  combined  with  moisture,  is  very  largely 
used  in  treating  inflammatory  affections,  and  acts  in  a  diametrically 
opposite  way  to  cold  by  relaxing  the  vessels  and  tissues,  thus 
reducing  the  tension  and  pain ;  it  also  favours  the  activity  and 
vitality  of  the  part  by  increasing  the  vascular  supply  and  facilitating 
lymphatic  absorption.  For  subcutaneous  lesions,  fomentations, 
medicated  or  not  with  opium  or  belladona,  or  spongiopiline  wrung 
out  of  hot  water,  or  simply  dry  heated  cotton  -  wool,  may  be 
employed. 

4.  In  subacute  inflammation  pressure  should  be  used  to  support 
and  constrict  the  veins.     Massage  also  may  be  indicated  (p.  47). 

II.  The  Local  Treatment  of  Inflammation  of  Bacterial  Origin. — This 
is  a  somewhat  different  problem  in  that  its  object  is  to  destroy  bacteria, 
to  eliminate  their  toxins,  and  to  attain  this  end  with  as  little  destruc- 
tion of  tissue  as  possible:.  The  chief  difficulty  lies  in  the  stagnation 
present  in  the  bloodvessels  and  lymphatics  of  the  inflamed  part,  so 
that  no  fresh  blood  is  circulating  through  it.  At  the  same  time  the 
toxins  formed  by  the  bacteria  have  the  opportunity  of  acting  on  the 
tissues,  and  are  absorbed  into  the  blood,  thereby  leading  to  its 
deterioration.  The  means  at  our  disposal  of  combating  a  bacterial 
inflammation  are :  (a)  The  antitoxic  and  bactericidal  properties  of 
the  blood,  which  can  be  influenced  beneficially  by  anti-sera,  vaccines, 
drugs,  and  diet ;  and  (b)  external  applications  and  procedures,  directed 
towards  the  removal  of  stagnant  blood  and  exudate,  and  to  the  pro- 
vision of  a  sufficient  supply  of  fresh  blood  which  shall  assist  the 
tissues  in  the  direction  of  repair.  The  actual  methods  are  as 
follows : 

1.  Remove  the  cause  if  possible,  as,  for  instance,  a  septic  foreign 
body,  or  a  buried  stitch  at  the  bottom  of  a  sinus.  In  a  few  cases  it 
may  be  possible  totally  to  excise  a  local  focus — e.g.,  a  malignant 
pustule ;  whilst  in  others,  such  as  a  carbuncle,  one  can  scrape  away 
the  infiltrated  and  sloughy  tissue  with  a  sharp  spoon. 

2.  Keep  the  inflamed  part  at  rest  as  far  as  possible,  not  only  for 
physical  and  physiological  reasons,  but  also  to  prevent  mechanical 
dissemination  of  the  infective  virus.  This  may  be  eff'ected  by  con- 
fining the  patient  to  bed,  or  by  the  use  of  splints  or  slings. 

3.  Unload  the  stagnant  vessels,  both  veins  and  lymphatics,  by 
elevation,  hot  applications,  which  soften  and  relax  the  tissues,  or 
local  blood-letting.     Scarification  is  of   great  value  in  the  slighter 


INFLAMMATION  "  43 

cases  ;  but  when  stasis  has  occurred,  free  incisions  are  often  indicated 
in  order  to  reHeve  tension,  and  also  to  allow  of  the  escape  of  bacteria 
and  their  toxins. 

4.  Promote  the  removal  of  the  exudate,  and  of  the  toxins  con- 
tained therein.  This  may  be  effected  by  the  insertion  of  rubber 
drainage-tubes  into  deep  inflamed  cavities,  such  as  abscesses  or 
sinuses,  or  by  packing  an  open  wound  with  gauze  and  covering  it 
with  a  hydrophile  dressing,  encouraging  thereby  capillary  drainage. 
In  other  cases  immersion  of  the  inflamed  area  in  a  hot  bath  at  a 
temperature  of  99°  to  105°  F.,  either  of  sterilized  salt  solution,  or  of 
some  mild  antiseptic,  such  as  boric  acid,  may  be  of  great  value  in 
diluting  and  washing  away  toxins  and  cleansing  the  part ;  but  it  must 
not  be  used  to  excess,  or  repair  may  be  hindered  by  the  tissues 
becoming  waterlogged. 

5.  Increase  the  supply  of  healthy  blood  to  the  part  by  the  applica- 
tion of  heat,  as  by  poultices  when  the  skin  is  unbroken,  or  boric  acid 
fomentations  if  there  is  a  wound,  or  by  the  use  of  methods  of  active 
or  passive  congestion  (see  Bier's  treatment,  p.  46). 

6.  Prevent  the  access  of  fresh  or  a  mixed  infection  to  an  open 
wound  by  suitable  dressings  and  antiseptics. 

III.  General  Treatment  of  Inflammation. — This  varies  consider- 
ably with  the  condition  of  the  patient  and  the  severity  of  the  attack. 
In  the  asthenic  type,  when  the  patient  is  weakly  and  feeble,  attention 
must  be  chiefly  directed  towards  maintaining  the  strength  by  a  care- 
fully regulated  diet  of  the  most  easily  digested  foods ;  indeed,  the 
recovery  of  patients  lying  in  the  typhoid  state  depends  largely  on 
the  care  and  attention  of  the  nurse.  In  many  cases  diffusible  stimu- 
lants, such  as  carbonate  of  ammonia,  or  ether,  may  be  indicated, 
whilst  champagne  and  brandy  are  sometimes  useful.  At  the  same 
time  the  elimination  of  toxins  from  the  system  must  be  secured  by 
the  use  of  suitable  purgatives,  diaphoretics,  and  diuretics. 

In  the  sthenic  type  of  inflammation  in  robust  patients  antiphlo- 
gistic means  may  be  freely  employed  so  as  to  reduce  the  general 
blood-pressure  and  remove  irritating  matters  from  the  system — e.g., 
a  smart  purge,  followed  by  low  diet  and  abstinence  from  alcohol  for 
a  few  days  ;  but  in  other  instances,  where  the  blood-tension  is  high, 
the  pulse  large  and  full,  and  the  local  signs,  pain,  etc.,  well-marked, 
it  may  be  also  necessary  to  administer  such  drugs  as  antimony, 
aconite,  full  doses  of  acetate  of  ammonia,  colchicum,  and  ipecacuanha, 
in  order  to  reduce  the  general  blood-pressure,  as  also  to  obtain 
diaphoretic  action.  In  a  few  cases — viz.,  acute  pneumonia — vene- 
section may  be  needed,  and  it  is  possible  that  this  is  an  agent  too 
little  employed  at  the  present  day. 

In  some  forms  of  specific  inflammation  a  specific  drug  may  be 
employed,  as  in  the  treatment  of  acute  rheumatism,  which  is  almost 
without  doubt  due  to  a  micro-organism  which  rapidly  yields  to 
salicylate  of  soda  or  salicin. 


44  ~  A  MANUAL  OF  SURGERY 

Clironic  Inflammation. 

The  Causes  are  similar  in  character  to  those  producing  the  acute 
mischief,  but  sHghter  and  more  prolonged  in  their  action.  The  most 
strikmg  point  in  the  aetiology  is  the  large  part  played  by  diathetic 
conditions  or  constitutional  predispositions.  Most  of  the  manifesta- 
tions met  with  in  surgical  practice  are  due  to  syphilis,  tubercle,  gout, 
or  rheumatism,  and  one  should  never  treat  chronic  cases  without 
carefully  inquiring  as  to  the  possible  existence  of  some  such  taint. 

The  Phenomena  are  essentially  the  same  as  those  of  the  acute 
process,  though  the  manifestations  are  somewhat  different.  Hyper- 
aemia  and  exudation  occur,  but  the  tissue  reaction  is  more  prominent. 
The  main  differences  between  the  two  are  as  follows : 

1.  The  hypermnia  is  less  in  degree,  but  longer  in  duration,  owing  to 
the  causative  irritant  being  frequently  of  little  activity.  The  local 
manifestations,  therefor^,  are  less  obvious  ;  pain  is  not  so  great  and 
mainly  of  an  aching  character,  whilst  there  is  less  heat,  the  redness  is 
more  dusky,  and  the  tissues  often  become  pigmented.  Considerable 
loss  of  tone  in  the  vessels,  especially  the  veins,  results  from  their 
prolonged  distension,  and  thus  there  is  greater  difficulty  in  restoring 
them  to  a  normal  state. 

2.  The  corpuscles  do  not  adhere  together  or  run  into  rouleaux  to 
the  same  extent  as  in  acute  inflammation,  and  migration,  though 
it  exists,  is  on  a  limited  scale.  The  exudation  is  more  fluid  in 
character,  containing  comparatively  little  albumen  or  fibrin  ;  in  fact, 
in  some  chronic  inflammations  of  serous  membranes  the  cavities  are 
distended  with  fluid  of  a  much  lower  specific  gravity  than  that  of 
blood  serum. 

3.  The  greatest  difference  between  the  acute  and  chronic  processes 
lies  in  the  reaction  of  the  tissues.  In  acute  inflammation,  increased 
proliferation  of  the  tissues  is  rarely  a  marked  feature,  since  the  toxin 
has  usually  sufficient  power  to  destroy  their  vitality.  In  chronic 
inflanimations  this  is  not  the  case,  at  least  not  until  the  later  stages 
of  lesions  like  those  of  tuberculosis  or  syphihs.  In  most  cases  cell- 
proliferation  is  well  marked,  especially  in  the  endothelial  cells  of 
the  vessels  and  lymph-clefts,  or  the  secreting  cells  of  the  breast, 
whilst  others  (such  as  the  cells  of  the  central  nervous  system)  never 
undergo  proliferation.  These  newly-formed  cells  usually  develop 
into  fibrous  tissue,  but  sometimes  produce  structures  more  or  less 
resembling  normal  tissues.  Organization,  therefore,  is  a  marked 
feature  of  chronic  inflammation. 

_An  area  which  is  in  a  state  of  chronic  inflammation  is  infiltrated 
with  lymphocytes,  which  are  often  grouped  in  large  numbers  round  the 
smaller  vessels.  In  the  chronic  granulomata,  this  small  round-celled 
infiltration  is  very  marked,  large  areas  composed  entirely  of  lympho- 
cytes being  met  with.  Another  cell  which  is  very  characteristic  of 
these  lesions,  and  has  recently  attracted  much  attention,  is  the  plasma- 
cell.  It  is  much  larger  than  a  lymphocyte,  and  usually  of  an  oval 
shape  ;  the  nucleus  is  about  as  large  as  that  of  a  lymphocyte,  is  usually 


INFLAMMATION  45 

divided  into  five  or  six  segments,  and  is  placed  excentrically  in  the 
cell.  The  protoplasm  has  peculiar  staining  affinities.  These  cells 
sometimes  occur  in  chronic  inflammatory  lesions  in  great  numbers, 
scarcely  another  type  being  seen  in  areas  of  considerable  size  ;  but 
usually  they  are  mixed  with  lymphocytes. 

The  Results  vary  according  to  the  part  of  the  body  aflfected,  and 
also  with  the  predisposing  diathetic  state.  In  simple  chronic  inflam- 
mation, not  due  to  tubercle  or  syphilis,  the  part  becomes  infiltrated 
and  enlarged,  mainly  from  proliferation  of  the  connective  tissues, 
and  if  this  persists,  fibrosis  or  sclerosis  will  result.  Thus,  a  bone 
is  thickened  and  condensed  in  chronic  osteitis  (osteosclerosis),  whilst 
in  chronic  periostitis  a  new  subperiosteal  formation  of  bone  occurs. 
Glands  become  enlarged  and  indurated,  mainly  by  hyperplasia  of 
the  connective  tissue,  whilst  if  the  skin  is  involved  it  either  becomes 
hypertrophied  and  thickened,  or  entirely  loses  its  characteristic 
structure,  being  converted  into  granulation  or  fibro-cicatricial  tissue, 
with  or  without  an  intervening  ulcerative  stage.  True  suppuration 
rarely  occurs,  although  certain  organisms  of  low  virulence  occa- 
sionally lead  to  its  development. 

Constitutional  symptoms  are  but  little  evident,  beyond  those 
dependent  on  the  diathetic  condition  to  which  the  local  phenomena 
are  due,  or  to  septic  changes  developed  secondarily. 

The  Treatment  of  chronic  inflammation  is  usually  more  prolonged 
and  difficult  than  that  of  acute  cases,  because  of  the  constitutional 
dyscrasia  which  exists  so  frequently  behind  it. 

1.  The  cause  must  be  removed  whenever  possible.  Dead  or  diseased 
bone  must  be  removed,  and  tuberculous  material  got  rid  of  by  the 
knife  or  sharp  spoon,  whilst  it  is  often  desirable  to  supplement  this 
by  swabbing  the  parts  over  with  liquefied  carbolic  acid.  A  chronic 
abscess  increases  the  action  of  the  original  irritant  through  the 
tension  engendered  by  its  presence,  and  hence  it  should  be  dealt  with 
as  early  as  possible. 

2.  Keep  the  part  at  rest.  This  is  just  as  much  an  essential  as  in  the 
treatment  of  acute  inflammation.  Joints  should  be  immobilized  ; 
the  spine  must  have  the  weight  taken  from  it  by  suitable  appliances, 
or,  better  still,  by  maintaining  the  recumbent  position ;  secretory 
glands  are  not  actively  exercised,  and  the  organs  of  sense  are 
protected  from  irritation. 

3.  Counter-irritation  is  one  of  the  most  useful  forms  of  treatment 
for  chronic  inflammatory  conditions.  It  is  applied  in  many  diff'erent 
ways,  according  to  the  character  of  the  disease  and  the  part  involved. 
Thus,  friction  with  the  hand,  or  with  stimulating  embrocations,  pro- 
duces a  hyperaemic  condition  of  the  skin,  and  promotes  local  activity 
in  the  superficial  parts  which  may  react  beneficially  on  deeper 
structures.  Scotfs  dressing  may  be  similarly  employed  ;  it  consists 
in  wrapping  up  the  part  {e.g.,  a  joint)  in  strips  of  lint  covered  with 
ung.  hydrarg.  co.  (containing  over  10  per  cent,  of  camphor),  and 
then  encircling  it  firmly  with  soap  plaster,  spread  preferably  on 
chamois  leather.     Iodine  paint  is  another  useful  application,  whilst 


46  A  MANUAL  OF  SURGERY 

blisters  are  most  valuable  in  suitable  cases.  The  moxa,  a  wound 
produced  by  burning  a  spirituous  solution  of  saltpetre  on  the  skin  ; 
the  issue,  the  maintenance  of  a  raw  surface,  however  produced,  by 
the  constant  presence  of  some  irritant,  such  as  the  insertion  of  a 
bead,  or  the  use  of  savin  ointment  as  a  dressing  ;  and  the  seton,  a 
double  thread  knotted  at  each  end,  passed  for  some  distance  under 
the  skin,  and  drawn  from  end  to  end  daily — all  these  are  but  little 
used  now,  although  they  might  be  occasionally  employed  with 
advantage.  The  acttial  catitery  is  the  most  severe  form  of  counter- 
irritant,  and  is  especially  useful  in  some  varieties  of  chronic  inflam- 
mation of  bones  and  joints. 

4.  Pressure  is  an  important  element  in  the  treatment  of  chronic 
inflammatory  disorders,  and  probably  acts  by  bracing  up  vessels 
which  have  become  relaxed  and  atonic  from  the  prolonged  dis- 
tension to  which  they  have  been  subjected.  It  also  favours  the 
absorption  of  inflammatory  exudations.  Firm  bandaging,  and 
especially  the  use  of  an  elastic  support,  are  the  usual  methods  of 
application. 

5.  Artificial  or  induced  hyperemia  has  recently  been  advocated  by 
Professor  Bier  as  a  means  of  treatment  for  inflammation,  whether 
acute  or  chronic.  The  hyperaemia  naturally  present  in  all  forms  of 
inflammation  is  now  considered  as  a  useful  rather  than  a  harmful 
reaction  if  it  can  be  kept  under  control ;  but  in  acute  cases  it  is 
usually  harmful,  inasmuch  as  it  is  excessive,  and  thereby  prevents 
the  access  of  fresh  healthy  blood  to  the  part.  Bier's  treatment  pre- 
supposes the  relief  of  this  natural  harmful  congestion  by  elevation, 
etc.,  and  subsequently  replaces  it  by  a  controlled  hyperaemia,  the 
parts  being  thereby  flooded  from  time  to  time  with  fresh  blood, 
which  can,  by  its  contained  antibodies,  assist  in  destroying  bacteria 
and  bringing  about  a  cure. 

Induced  hyperaemia  is  of  two  kinds,  active  and  passive.  The 
active  variety  consists  in  an  increased  flow  of  blood  to  the  part 
determined  by  vaso-dilatation,  and  is  arterial  in  origin.  It  is  best 
accompHshed  by  heat,  either  by  immersion  of  the  part  in  hot  water 
or  sand,  or  better  by  means  of  hot  air,  as  in  radiant  heat  baths,  or  the 
Sheffield-Tallerman  process.  Thermo-penetration  or  diathermy  is 
another  means  of  inducing  hyperaemia  by  means  of  heat :  an 
interrupted  current  is  passed  through  a  part,  the  terminals  being 
applied  on  opposite  sides  of  a  limb.  Thus,  in  certain  rheumatic  and 
gouty  conditions  of  the  hand,  one  terminal,  a  large,  moistened 
electrode,  is  placed  in  the  palm,  and  the  other  over  the  dorsum ;  the 
passage  of  the  current  through  the  hand  induces  heat,  and  the  strength 
of  the  current  is  gradually  increased  until  the  part  becomes  decidedly 
hot ;  this  is  repeated  time  after  time,  and  partly  by  the  relaxing 
effect  of  the  heat,  partly  by  the  induced  hyperaemia,  joints  which 
were  more  or  less  crippled  may  be  brought  again  into  functional 
activity. 

Passive  hypercBmia  is  usually  venous  in  origin,  and  is  induced  by 
a  limited  obstruction  to  the  veins  on  the  cardiac  side  of  the  lesion. 


INFLAMMATION  47 

This  may  be  effected  by  applying  a  Martin's  rubber  bandage  to  the 
limb  above  the  affected  part,  so  as  to  compress  the  veins,  and  yet 
not  to  diminish  the  arterial  supply.  It  may  also  be  produced  by 
cupping  or  the  use  of  suction  bottles.  These  methods  are  especially 
useful  for  chronic  inflammation  in  the  limbs,  but  are  also  employed 
in  such  acute  affections  as  whitlow,  carbuncle,  etc. 

6,  Massage  is  also  a  valuable  means  of  treatment  of  many  chronic 
inflammatory  affections  and  other  lesions.  In  its  simplest  variety 
it  consists  in  rubbing  with  some  embrocation  or  liniment,  and  the 
stimulating  effect  of  the  latter  may  be  of  some  value  in  determining 
hypersemia  of  the  part.  In  its  more  elaborate  forms  it  constitutes  an 
art  which  is  of  the  greatest  value,  and  concerning  which  lengthy 
text-books  have  been  written.  It  must  suffice  here  to  point  out  that 
the  chief  varieties  of  movement  are  known  as  effleurage,  petrissage, 
and  tapotement.  Effleitrage  consists  in  plain  up  and  down  rubbing 
of  the  limb  with  the  flat  of  the  hand,  the  up  stroke  being  always 
firmer  than  the  down,  so  as  to  assist  in  the  return  of  the  blood  and 
lymph  from  the  part.  In  this  way  the  circulation  is  quickened,  and 
the  vital  activities  of  the  tissues  are  increased.  The  skin  should  be 
lubricated  with  oil,  vaseline,  or  some  stimulating  embrocation,  and 
the  rubbing,  at  first  light,  so  as  only  to  affect  the  skin  and  sub- 
cutaneous tissues,  should  gradually  become  firmer  so  as  to  influence 
the  deep  structures.  Petrissage  consists  in  kneading  the  muscles  or 
others  tissues  between  the  finger-tips  and  the  palm  of  the  hand  ;  this 
necessarily  should  be  done  across  the  muscle  fibres,  working  from 
below  upwards,  and  is  especially  valuable  in  hastening  the  absorp- 
tion of  exudations.  In  Tapotement  a  series  of  blows  perpendicular  to 
the  surface  is  rapidly  delivered  by  the  ulnar  side  of  the  open  or 
clenched  hand ;  the  circulation  in  the  parts  thus  struck  is  much 
quickened,  and  when  skilfully  done  no  pain  should  be  caused. 

As  a  modification  of  the  last  proceeding,  Vibro-massage  has  been 
recently  introduced,  in  which  rapidly  repeated  blows  of  the  affected 
region  gives  rise  to  a  vibratory  effect,  which  is  often  of  the  greatest 
value.  Hand  vibrateurs  are  sold,  and  of  use  ;  but  the  best  results 
follov/  from  the  employment  of  vibrateurs  worked  by  electricity. 
Rheumatic  inflammation  of  joints  and  fasciae,  such  as  occurs  in 
lumbago,  some  forms  of  sciatica,  and  other  neuralgic  conditions,  are 
often  much  benefited  by  this  procedure. 

7.  lomc  medication*  is  also  of  value  in  the  treatment  of  many 
chronic  inflammations  of  joints  and  other  tissues,  as  also  in  dealing 
with  such  affections  as  lupus  and  rodent  ulcer  (q.v.).  An  Ion  is  an 
atom  or  molecule  with  its  electric  charge  attached  to  it.  Ions  are  set 
free  by  electrolysis,  and  can  be  driven  thereby  into  the  tissues  of  the 
body,  acting  locally  upon  the  parts  with  which  they  are  brought  into 
contact  and  those  beneath.  Metals,  various  inorganic  substances^ 
e.g.,  iodine  and  bromine,  and  some  organic,  such  as  cocaine,  quinine, 

*  For  '  The  Principles  of  Ionic  Medication,'  see  Lewis  Jones,  Proceedings  of 
the  Royal  Society  of  Medicine,  1908,  vol.  i.,  part  v.,  '  Electro  -  Therapeutic 
Section.' 


48  A  MANUAL  OF  SURGERY 

adrenalin,  can  be  introduced  ionically,  and  appear  to  act  more 
energetically  than  if  administered  by  hypodermic  medication. 
Obviously  the  range  of  possibilities  for  this  method  of  treatment 
is  very  great,  and  it  is  still  more  or  less  in  the  experimental  stage. 

8.  General  or  constitutional  treatment  must  be  adopted  to  meet 
the  specific  diatheses  which  are  commonly  associated  with  chronic 
inflammation,  e.g.,  mercury  or  iodide  of  potash  in  syphilis. 

g.  Finally,  if  the  condition  is  bacterial  in  origin,  and  the  organism 
can  be  isolated,  a  vaccine  may  be  prepared  and  treatment  carried  out 
on  the  lines  laid  down  on  p.  27.  Ordinary  surgical  methods  should, 
however,  not  be  neglected. 


CHAPTER  III. 

EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE. 

Although  an  examination  of  the  condition  of  the  blood  is  frequently 
of  great  importance  to  the  surgeon,  a  mere  outline  of  the  chief  facts 
is  all  that  can  here  be  attempted. 

The  red  blood  corpuscles  average  about  5,000,000  to  the  cubic  milli- 
metre in  men  and  about  4,500,000  in  women,  and  are  readily  counted 
by  means  of  the  Thoma-Zeiss  hsemocytometer  or  other  similar 
instrument.  The  chief  surgical  value  of  such  investigations  arises 
in  connection  with  haemorrhage,  for  they  enable  us  to  determine  the 
amount  of  blood  lost  at  a  surgical  operation  or  as  the  result  of  a 
wound,  and  to  trace  the  process  of  recovery.  It  is  usually  advisable 
to  supplement  the  counting  of  the  corpuscles  by  estimating  the 
amount  of  haemoglobin  present  by  means  of  Haldane's  or  some 
other  haemoglobinometer,  the  result  being  expressed  as  a  percentage 
of  the  normal  amount.  Thus,  blood  containing  half  the  amount 
that  should  exist  in  a  given  bulk  in  a  normal  man  is  said  to  contain 
50  per  cent,  of  haemoglobin.  It  is  also  convenient  to  calculate  the 
'  corpuscular  richness '  or  '  colour-index,'  which  is  done  by  dividing 
the  percentage  of  haemoglobin  by  the  number  of  corpuscles  expressed 
as  a  percentage  of  the  normal.  For  example,  under  normal  con- 
ditions the  haemoglobin  is  100  per  cent,  and  there  are  5,000,000 
corpuscles  per  cubic  millimetre,  so  that  the  colour  -  index  is 
i^=  I.  If  the  corpuscles  have  fallen  to  3,000,000  (60  per  cent,  of 
the  normal),  whilst  the  haemoglobin  has  fallen  to  30  per  cent., 
the  colour  -  index  is  |^  =  0-5 — that  is  to  say,  each  red  corpuscle 
contains  only  half  as  much  haemoglobin  as  it  should  do.  In  general 
a  high  colour  -  index  is  indicative  of  pernicious  anaemia,  and  one 
which  is  greatly  reduced  of  chlorosis,  though  in  cases  of  severe 
secondary  anaemia  of  long  standing  a  similar  reduction  may  be 
present. 

If  the  blood  is  examined  immediately  after  a  patient  has  suffered 
from  a  severe  hemorrhage,  it  will  naturally  be  found  to  be  normal 
in  composition  ;  part  has  been  lost,  but  the  quality  of  the  remainder 
has  not  altered.  After  a  short  time  the  volume  of  blood  is  restored 
to  normal  by  means  of  fluid  derived  from  the  tissues.  At  this  stage 
the  blood  is  more    diluted   than   normal,  the   red   corpuscles   and 

49  4 


50  A  MANUAL  OF  SURGERY 

haemoglobin  being  alike  reduced,  so  that  the  colour-index  remains  i. 
There  is  also  in  most  cases  a  temporary  increase  in  the  number  of 
leucocytes.  The  process  of  absorption  of  fluid  from  the  tissues  is 
imitated  artificially  in  the  infusion  of  saline  solutions  in  collapse  or 
after  severe  haemorrhage,  and  it  is  found  that  this  process  has  a 
beneficial  effect  in  accelerating  the  subsequent  regeneration  of  the 
blood  as  well  as  in  raising  the  blood-pressure  and  removing  the 
urgent  symptoms. 

In  the  subsequent  process  of  recovery  the  red  corpuscles  increase 
more  rapidly  than  the  haemoglobin,  so  that  the  colour-index  falls 
somewhat.  The  length  of  time  necessary  for  full  regeneration  of 
the  blood  varies  greatly,  the  process  being  more  rapid  in  men  than 
women,  and  in  young  adults  than  in  the  old  or  young.  Approxi- 
mately I  per  cent,  of  haemoglobin  is  regenerated  per  diem ;  thus  the 
blood  becomes  normal  about  twenty  days  after  the  loss  of  20  per 
cent,  of  haemoglobin  if  the  patient  is  kept  under  favourable 
conditions. 

It  is  not  possible  to  lay  down  any  definite  rule  as  to  the  amount 
of  haemorrhage  which  is  necessarily  fatal.  Other  things  being  equal, 
a  patient  will  survive  a  much  greater  loss  of  blood  if  it  takes  place 
gradually  than  if  it  takes  place  quickly.  In  the  latter  case  a 
reduction  of  the  haemoglobin  to  50  per  cent,  will  probably  be  fatal, 
whereas  in  the  former  it  may  fall  to  20  per  cent.,  or  lower,  and 
recovery  still  take  place.  Women  tolerate  loss  of  blood  better  than 
men,  and  men  tolerate  it  better  than  children. 

Anaemic  patients  are  usually  bad  subjects  for  operations,  but  it  is 
not  possible  to  formulate  any  rule  for  the  guidance  of  the  surgeon 
as  to  the  degree  of  anaemia  which  should  make  him  unwilling  to 
operate. 

It  is  important  to  notice  that  a  high  degree  of  anaemia  occurs  in 
acute  spreading  inflammation,  septic  fever,  septicaemia,  etc.,  and 
this  fact  is  occasionally  of  diagnostic  value.  The  diminution  of  the 
corpuscles  and  haemoglobin  usually  occurs  rapidly,  sometimes  with 
a  rapidity  only  second  to  that  which  occurs  after  severe  haemorrhage, 
and  gives  rise  to  a  severe  form  of  secondary  anaemia.  The  colour- 
index  is  usually  low,  the  haemoglobin  being  destroyed  more  rapidly 
than  the  corpuscles. 

The  examination  of  the  leucocytes  is  often  of  the  greatest  im- 
portance. It  comprises  an  enumeration  of  the  total  number  present 
per  cubic  millimetre,  and  a  differential  count  of  the  relative  number 
of  the  various  kinds  present.  The  former  examination  is  carried 
out  by  a  method  similar  to  that  used  in  counting  the  red  corpuscles, 
and,  as  it  takes  but  a  few  minutes  and  requires  but  little  practice, 
should  be  learnt  by  all  surgeons.  The  differential  count  is  made  on 
thin  films  of  blood,  which  are  dried  and  stained  by  a  double  or  triple 
stain,  Jenner's  stain  being  the  simplest  and  most  useful. 

Jenner's  stain  consists  of  a  solution  of  eosinate  of  methylene  blue 
in  methyl  alcohol.  To  use  it  the  blood  film  is  allowed  to  dry  spon- 
taneously and  is  then  flooded  with  the  stain,  which  is  allowed  to  act 


EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE      51 

for  about  two  minutes.  It  is  then  poured  off,  and  the  film  is  rinsed 
in  distilled  water  for  a  few  seconds,  drained,  allowed  to  dry 
spontaneously,  and  mounted  in  Canada  balsam.  This  is  then 
examined  under  a  ^^  in.  lens,  each  leucocyte  seen  being  noted  down, 
until  400  or  more  have  been  counted.  The  results  are  reduced  to 
percentages. 

In  health  the  blood  contains  from  4,000  to  10,000  leucocytes  per 
cubic  millimetre,  five  different  forms  of  cell  being  present — the 
polynuclear  leucocyte,  the  eosinophile  leucocyte,  the  mast-cell,  the 
lymphocyte,  and  the  hyaline  cell.  Of  these,  the  first  three  contain 
definite  granules  in  their  protoplasm,  the  others  do  not.  In  the 
following  description  we  assume  that  the  film  has  been  stained  by 
Jenner's  method.  If  other  staining  processes  are  used,  the  colours  of 
the  various  structures  will  naturally  be  somewhat  different. 

1.  The  polynuclear  ox  polymorphonuclear  leucocyte  (Fig.  10,  c)  is  rather 
larger  than  a  red  corpuscle.  It  is  characterized  by  having  a  twisted 
or  indented  nucleus,  which  in  badly  prepared  specimens  may  appear 
to  be  multiple,  although  with  proper  preparation  and  the  use  of  high 
powers  of  the  microscope  the  connecting  filaments  between  the 
various  parts  can  always  be  made  out.  It  contains  in  its  protoplasm 
numerous  very  minute  granules  which  have  an  affinity  for  acid 
stains,  and  hence  are  coloured  pink  by  the  eosin  in  Jenner's  stain. 
In  specimens  which  have  not  been  well  stained  these  granules 
may  not  be  visible,  but  the  cell  can  always  be  identified  by  its 
nucleus. 

The  polynuclear  leucocytes  are  the  chief  phagocytic  cells  of  the 
blood,  being  actively  amoeboid  and  endowed  with  the  power  of  in- 
gesting bacteria  or  other  small  objects.  They  are  formed,  mainly  or 
entirely,  in  the  bone-marrow,  and  constitute  in  health  from  65  to  75 
per  cent,  of  all  the  leucocytes. 

2.  The  eosinophile  leucocytes  (Fig.  10,  d)  are  about  as  large  as  the 
foregoing,  and  have  a  bilobed  or  polymorphous  nucleus.  They  have 
also  granules  which  stain  with  eosin,  but  these  are  m.uch  larger  and 
more  defined  than  those  of  the  polynuclears. 

The  eosinophiles  form  2  to  4  per  cent,  of  the  leucocytes  of  normal 
blood.  They  are  probably  formed  partly  in  the  bone-marrow  and 
partly  in  other  connective  tissues.  They  are  feebly  mobile,  and 
their  functions  are  not  definitely  known. 

3.  The  mast-cells  (Fig.  10,  1?)  have  lobed  nuclei  and  granules  which 
stain  with  methylene  blue,  though  usually  metachromatically,  taking 
a  purplish  colour.  They  are  present  in  very  small  proportions 
(about  J  per  cent.)  in  normal  blood,  and  their  functions  are  unknown. 
They  are  connective-tissue  cells,  and  are  often  present  in  considerable 
numbers  in  inflamed  tissues. 

4.  The  lymphocytes  (Fig.  10,  a)  are  devoid  of  granules,  and  their 
nuclei  are  not  polymorphous.  They  vary  in  size,  but  the  majority 
are  rather  smaller  than  the  red  corpuscles.  Each  lymphocyte  has  a 
single  circular  nucleus  which  is  situated  centrally ;  this  is  sur- 
rounded by  a  narrow  zone  of  protoplasm,  which  in  suitably  stained 


S2 


A  MANUAL  OF  SURGERY 


specimens  takes  the  methylene  blue  more  deeply  than  does  the 
nucleus  itself. 

Lymphocytes  constitute  20  to  25  per  cent,  of  the  leucocytes  of 
health.  In  children  the  proportion  may  be  much  higher,  the  poly- 
nuclears  being  correspondingly  reduced.  They  are  formed  in  the 
lymphatic  glands,  spleen,  Peyer's  patches,  and  lymph  -  adenoid 
tissue  generally.  They  are  probably  identical  with  the  '  small  round 
cell '  which  is  so  characteristic  of  non-suppurative  inflammatory  foci, 
and  in  these  lesions  we  have  reason  to  believe  that  they  can  be  pro- 
duced locally,  probably  by  a  process  of  budding  from  the  endothelial 
cells.  It  would  seem,  therefore,  that  lymphocytes  may  be  produced 
locally  in  any  part  of  the  body. 

5.  The  large  hyaline  or  large  mononuclear  cells  (Fig.  10,  b)  vary  in  size, 
but  as  a  rule  are  decidely  larger  than  the  red  corpuscles.  They 
have  a  single   circular,  oval,  or   kidney-shaped    nucleus,   which  is 


d ,  e  f 

Fig.  10. — Corpuscular  Elements  of  Normal  Blood.     (Emery.) 

a.  Lymphocyte  ;  &,  hyaline  or  large  mononuclear  cell  ;  c,  polynuclear  leucocyte  ; 
d,  eosinophile  cell ;  e,  mast-cell ;  /,  red  corpuscle,  to  show  the  relative  sizes 
of  the  other  cells. 


smaller  relatively  to  the  cell  than  the  nucleus  of  the  lymphocyte. 
The  protoplasm  stains  faintly  with  methylene  blue.  It  is  devoid  of 
granules,  but  often  shows  bluish  points,  which  are  really  nodal 
thickenings  of  the  reticulum. 

These  cells  form  2  to  4  per  cent,  of  the  leucocytes  of  normal 
blood.  They  have  considerable  powers  of  phagocytosis.  Their 
origin  and  relation  to  the  lymphocytes  is  not  definitely  known,  but 
there  is  some  reason  for  regarding  them  as  endothelial  cells  which 
have  been  detached  from  the  walls  of  the  vessels. 

An  increase  of  the  total  leucocytes  present  in  the  blood  is  termed 
leucocytosis.  Under  most  circumstances  this  increase  is  mainly  due 
to  an  increase  in  the  number  of  polynuclears  present ;  special  terms 
are  used  for  an  increase  of  other  forms  of  leucocytes.  An  increase 
in  the  eosinophiles  is  called  eosinophilia,  and  an  increase  in  the 
lymphocytes  is  called  lymphocytosis.  A  diminution  of  the  leucocytes 
is  termed  leucopenia. 


EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE      53 

Leucocytosis  occurs  under  physiological  conditions  during  digestion, 
during  pregnancy,  and  in  the  new-born  infant.  This  has  to  be 
remembered  in  interpreting  leucocyte  counts  in  disease.  The  former 
factor  is  of  especial  importance,  and  if  possible  the  blood  should  be 
collected  whilst  the  patient  is  fasting. 

Pathological  leucocytosis  occurs  in  many  conditions,  the  most 
important  being  the  infective  diseases,  and  in  these  the  highest 
counts  are  met  with  in  pneumonia  and  in  suppuration.  The  latter 
is  of  special  importance  to  the  surgeon,  as  the  presence  of  a  high 
leucocytosis  may  be  regarded  as  the  most  definite  single  sign  of  the 
presence  of  pus.  It  is  especially  valuable  in  appendicitis,  where  the 
other  evidences  of  suppuration  are  often  equivocal.  When  no  pus 
is  present,  the  blood  shows  slight  leucocytosis,  the  number  not 
usually  exceeding  15,000  per  cubic  millimetre.  When  pus  is  present 
the  number  is  much  greater,  being  usually  not  less  than  18,000,  and  it 
may  rise  as  high  as  50,000,  or  even  higher.  For  practical  purposes  a 
count  of  20,000  leucocytes  per  cubic  millimetre  may  be  taken  as  an 
almost  certain  proof  of  suppuration,  presuming,  of  course,  that  the 
other  causes  of  leucocytosis  can  be  excluded.  Figures  between 
15,000  and  20,000  are  not  sufficiently  definite  to  be  of  much  value, 
and  where  they  are  obtained  it  is  advisable  to  repeat  the  examination 
in  twenty-four  hours.  If  suppuration  is  taking  place  the  count  will 
almost  certainly  rise,  whilst  if  it  remains  at  the  same  level,  or  shows 
a  decline,  the  presence  of  pus  is  unlikely.  The  height  of  the  leuco- 
cytosis gives  no  indication  of  the  size  of  the  abscess  or  of  the  rapidity 
of  its  spread. 

The  opening  of  the  abscess  is  usually  followed  by  a  fall  in  the 
number  of  leucocytes,  and  this  is  so  rapid  as  to  be  quite  definite  in 
the  course  of  twelve  hours.  When  it  does  not  take  place,  the 
probability  is  that  a  second  abscess  is  present,  which  was  overlooked 
at  the  time  of  the  operation. 

The  absence  of  leucocytosis  is  presumptive  evidence  that  sup- 
puration has  not  occurred,  but  several  facts  have  to  be  considered  in 
applying  this  rule  in  actual  practice. 

I.  The  cause  of  the  leucocytosis  is  the  passage  of  the  bacterial 
products  from  the  inflammatory  focus  to  the  blood-stream,  where 
they  exert  a  positively  chemotactic  action,  attracting  the  leucocytes 
from  the  bone-marrow,  whilst  at  the  same  time  they  stimulate  the 
latter  to  an  increased  production  of  leucocytes.  As  long  as  the 
abscess  remains  unopened  and  is  spreading,  these  substances  gain 
access  to  the  blood-stream  with  ease,  for  it  is  the  only  path  available 
to  them.  But  when  the  abscess  is  opened  so  that  the  pus  laden  with 
bacterial  toxins  can  drain  away,  the  leucocytosis  falls,  even  although 
the  abscess  may  burrow  for  a  time.  An  example  of  this  was  seen  in 
a  patient  suffering  from  appendicitis,  in  whom  there  were  very  doubt- 
ful clinical  indications  of  pus,  and  who  showed  a  leucocytosis  of 
38,000;  this  was  regarded  as  definite  proof  of  the  existence  of 
an  abscess.  A  few  hours  after  the  count  was  made  the  patient 
suffered  from  diarrhoea,  and  pus  was  found  in  the  stools.     A  second 


54  ^  A  MANUAL  OF  SURGERY 

count  was  made  forty-eight  hours  after  the  first,  and  the  leucocytes 
were  found  to  have  fallen  to  13,500,  yet  at  the  operation  a  large 
abscess  cavity  with  extensive  ramifications  was  found.  If  the  patient 
had  been  admitted  to  the  hospital  after  the  rupture  of  the  abscess 
into  the  intestine,  the  leucocyte  count  would  have  led  to  an  erroneous 
conclusion.  For  a  similar  reason— viz.,  the  non-absorption  of  toxins 
into  the  blood  —  there  is  but  slight  leucocytosis  in  suppurative 
inflammation  of  the  mucous  membranes. 

2.  When  the  pyogenic  bacteria  have  been  killed,  the  toxins  are 
soon  carried  away  in  the  blood-stream  and  eliminated  from  the  body, 
and  when  this  has  happened  the  leucocytosis  falls,  although  there  is 
still  a  collection  of  pus  in  the  tissues.  In  other  words,  a  high  leuco- 
cytosis is  to  be  regarded  as  a  proof  of  the  process  of  suppuration 
rather  than  as  a  proof  of  the  presence  of  pus.  For  example,  such 
sterile  collections  of  unabsorbed  pus  often  occur  in  cases  of  pyo- 
salpinx  of  some  standing,  and  are  unaccompanied  by  leucocytosis, 
although  acute  suppuration  in  the  Fallopian  tubes  causes  the  usual 
reaction. 

3.  When  the  organisms  are  very  virulent  and  the  patient  of  feeble 
constitution,  so  that  the  infection  rapidly  spreads,  there  is  occasionally 
a  failure  of  leucocytosis  or  even  a  leucopenia.  This  is  notably  the  case 
in  severe  cases  of  diffuse  septic  peritonitis.  The  general  (as  well  as  the 
local)  leucocytosis  must  be  regarded  as  a  conservative  and  defensive 
reaction,  whatever  views  are  held  as  to  the  nature  of  immunity. 
Its  presence  indicates  that  the  patient  has  sufficient  resisting  powers 
to  combat  the  infection,  or  at  least  to  localize  it  for  a  time ;  its 
absence  in  a  case  where  there  is  suppuration  renders  the  prognosis 
unusually  bad. 

4.  Leucocytosis  does  not  occur  in  cases  of  chronic  or  cold  abscess. 
The  products  formed  by  the  bacteria  which  produce  these  lesions 
have  no  positive  chemotactic  action  on  the  polynuclear  leucocytes. 
The  cells  found  in  the  local  lesions  are  mostly  lymphocytes.  Hence, 
even  when  the  toxins  of  these  organisms  enter  the  blood,  they  fail 
to  attract  the  polynuclear  leucocytes  from  the  marrow.  We  might 
reasonably  expect  that  an  increase  in  the  lymphocytes  would  occur  ; 
but  these  cells  are  not  actively  motile  like  the  polynuclears,  and  are 
not  so  readily  subservient  to  chemotactic  influences. 

Another  rrtethod  sometimes  used  in  the  diagnosis  of  suppuration 
is  based  on  the  appearance  of  granules  of  glycogen  (or  an  allied 
substance)  in  the  protoplasm  of  the  leucocytes  in  septic  diseases. 
Dry  blood-films  are  mounted  in  a  recently  prepared  solution  of 
iodine  i,  iodide  of  potassium  3,  water  100,  which  has  been  saturated 
with  powdered  gum  acacia.  This  stains  the  granules  deep  brown. 
This  test  is  not  as  useful  as  the  foregoing. 

The  relations  of  some  of  the  other  infective  diseases  to  the 
leucocytes  may  be  briefly  epitomized.  In  pneumonia,  erysipelas, 
diphtheria^  scarlet  fever,  plague,  and  whooping-cough  there  is  a  high 
leucocytosis,  the  number  rarely  falling  below  20,000.  In  rheumatic 
fever  (uncomplicated),  syphilis,  and  gonorrhoea  there  is  usually  a 


EXAMINATION  OF  THE  BLOOD  IN  HEALTH  AND  DISEASE      55 

slight  rise,  and  in  tuberculosis,  typhoid  fever,  influenza,  measles,  and 
malaria  there  is  usually  no  excess,  and  often  a  diminution,  in  the 
number  of  leucocytes  (leucopenia). 

Pathological  leucocytosis  also  occurs  after  severe  haemorrhage, 
and  in  all  cachectic  conditions,  especially  in  that  due  to  malignant 
disease.  In  these  cases  it  is  almost  always  due  to  a  local  inflamma- 
tion excited  by  the  new  growth,  and  is  rarely  of  diagnostic  value. 
In  carcinoma  of  the  stomach  there  is  usually  an  absence  of  digestion- 
leucocytosis,  and  this  fact  may  assist  in  the  diagnosis.  The  leuco- 
cytes are  counted  whilst  the  patient  is  fasting,  and  two  or  three 
times  (at  intervals  of  an  hour)  after  a  meal,  which  should  include 
some  meat.  If  the  count  does  not  rise  considerably  (2,000  per  cubic 
millimetre  or  more),  it  affords  strong  presumptive  evidence  of  the 
presence  of  malignant  disease  of  the  stomach,  but,  like  all  laboratory 
tests,  must  be  considered  in  conjunction  with  the  clinical  phenomena. 

Lymphocytosis,  or  an  increase  of  the  lymphocytes,  may  be 
absolute  or  relative.  A  relative  increase  (i.e.,  such  that  the  per- 
centage of  these  cells  rises  above  25,  although  the  total  number  of 
leucocytes  of  all  sorts  does  not  exceed  the  normal)  occurs  in  typhoid 
fever,  tuberculosis,  and  malaria.  A  great  excess  of  leucocytes 
(150,000  or  more  per  cubic  millimetre),  the  great  majority  being 
lymphocytes,  occurs  only  in  lymphatic  leucocythsemia,  and  con- 
stitutes an  important  means  of  diagnosis  between  this  condition 
and  Hodgkin's  disease,  in  which  the  leucocytes  are  normal  or  but 
slightly  increased.  Children's  blood  contains  an  excess  of  lympho- 
cytes, reaching  60  per  cent.,  and  in  inflammatory  diseases  of  children 
the  increase  in  the  total  leucocytes  may  be  due  partly  to  an  excess 
of  lymphocytes,  and  not  only  of  the  polynuclears,  as  in  the  adult. 
This  is  especially  the  case  if  the  lymph-glands  are  involved  in  the 
inflammatory  process. 

Eosinopliilia,  i.e.,  a  relative  increase  of  the  eosinophiles,  occurs  in 
several  conditions :  (i)  In  infection  with  animal  parasites,  especially 
in  trichinosis,  where  the  proportion  may  be  60  per  cent,  or  more. 
They  are  sometimes  increased  in  hydatid  disease  ;  in  doubtful  cases 
this  fact  has  some  diagnostic  value,  but  a  count  in  which  there  is 
no  'increase  is  of  little  importance.  (2)  In  some  skin  diseases, 
especially  when  a  large  area  of  skin  is  involved.  (3)  In  asthma. 
(4)  In  gonorrhoea,  and  a  few  other  diseases. 

A  brief  account  of  the  blood  conditions  in  those  diseases  which 
are  especially  connected  with  the  blood-forming  organs  may  be  of 
some  value. 

I.  In  pernicious  ancsmia  the  corpuscles  are  greatly  reduced  in 
numbers,  whilst  the  haemoglobin  is  reduced,  but  to  a  lesser  extent, 
the  colour-index  being  greater  than  i.  The  red  corpuscles  are  often 
distorted  in  shape  (poikilocytosis),  and  large  (megalocytes)  or  small 
(microcytes)  forms  occur.  Large  nucleated  red  corpuscles  (megalo- 
blasts)  are  usually  present,  and  are  almost  diagnostic  of  the  disease. 
The  leucocytes  are  usually  normal  or  subnormal  in  number,  and 
there  is  a  relative  increase  of  lymphocytes. 


56  A  MANUAL  OF  SURGERY 

2.  In  chlorosis  the  haemoglobin  is  reduced  to  a  greater  extent  than 
the  corpuscles,  the  colour-index  being  less  than  i,  There_  may  be 
some  microcytes,  but  the  red  corpuscles  are  usually  normal  in  shape 
and  size,  though  of  pale  colour.     The  leucocytes  are  usually  normal. 

3.  In  splem-medullary  leucocythcemia  there  is  an  enormous  increase 
in  the  leucocytes  ;  the  number  is  usually  not  less  than  100,000  per 
cubic  millimetre  and  may  rise  to  1,000,000  or  even  more.  Of  these 
a  large  proportion  are  myelocytes,  cells  which  do  not  occur  in  normal 
blood.  They  vary  in  size,  but  are  usually  large,  and  may  be  very 
large ;  they  have  a  single  nucleus,  which  stains  badly  and  is  circular, 
oval,  or  indented,  and  often  excentrically  placed ;  they  contain 
granules  similar  to  those  of  the  polynuclear  leucocytes.  The 
eosinophile  cells  are  greatly  increased  in  absolute  numbers,  though 
their  proportion  relatively  to  the  other  cells  may  be  normal.  Eosino- 
phile myelocytes  also  occur ;  they  are  similar  in  all  respects  to  the 
myelocytes,  except  that  their  granules  are  large,  resembling  those 
of  the  eosinophiles  of  normal  blood.  The  polynuclears  are  present 
in  vast  numbers,  but  their  relative  proportion  is  less  owing  to  the 
number  of  the  myelocytes.  The  lymphocytes  are  scanty,  but  the 
mast-cells  are  often  abnormally  plentiful.  Nucleated  red  corpuscles 
occur. 

4.  Lymphatic  leucocyihamia  can  be  distinguished  from  Hodgkin's 
disease  (lymphadenoma)  only  by  an  examination  of  the  blood.  In 
the  former  disease  there  is  'a  vast  number  of  leucocytes,  the  great 
majority  (go  per  cent,  or  more)  of  which  are  lymphocytes.  In  the 
early  stages  of  Hodgkin's  disease  the  blood  is  absolutely  normal, 
whilst  later  there  is  marked  anaemia.  The  leucocytes  are  not 
usually  increased  in  numbers,  and  there  may  be  leucopenia ;  there 
is  often  a  shght  relative  increase  in  the  lymphocytes.  In  some  cases 
there  is  leucocytosis.  Hodgkin's  disease  cannot  be  differentiated 
from  tuberculosis'  of  the  lymphatic  glands  by  a  blood  count  alone. 

Tte  examination  of  the  blood  for  parasites  (including  bacteria)  is 
often  necessary.  It  may  be  carried  out  by  microscopic  examinations  of 
fresh  blood  or  blood-films,  or  by  cultures ;  the  method  to  be  selected 
must  depend  upon  the  organism  sought. 

The  diagnosis  of  malaria  may  be  made  by  an  examination  of  a'wet 
film  of  fresh  blood  made  by  taking  a  small  drop  of  the  blood  on  a 
perfectly  clean  cover-glass,  and  placing  the  latter,  drop  downwards, 
on  a  perfectly  clean  slide  ;  or  films  may  be  prepared  in  the  ordinary 
way  and  stained  by  carbol-thionin,  haematoxylin  and  eosin,  Jenner's 
stain,  or  by  other  methods.  For  a  description  of  the  organisms  and 
their  life-history  the  reader  is  referred  to  special  treatises. 

Relapsing  fever  is  due  to  a  corkscrew-like  organism  (the  Spirillum 
Obermeyeri),  which  is  about  two  or  three  times  as  long  as  the  diameter 
of  a  red  corpuscle.  They  may  be  demonstrated  by  the  method  used 
for  the  malaria  parasite,  and  in  fresh  specimens  are  as  a  rule  actively 
motile. 

The  diagnosis  of  filaviasis  is  best  made  by  examining  with  a  low- 
power  lens  thick  layers  of  fresh  blood  taken  at  night,  if  F.  nocturna 


EXAMINATION  OF  THE' BLOOD  IN  HEALTH  AND  DISEASE      57 

is  suspected;  in  the  daytime,  in  the  case  of  F.  diuvna ;  and  at  any 
time  if  F.  perstans  is  sought. 

Where  bacteria  are  sought  for  in  the  blood,  cultural  methods  are 
almost  always  necessary,  for  their  numbers  are  usually  so  small  that 
the  chance  of  finding  even  a  single  specimen  in  a  stained  blood-film 
is  remote.  The  blood  must  be  drawn  directly  from  a  vein  with  a 
sterilized  hypodermic  needle  and  syringe  (or  better  with  a  hypo- 
dermic needle  mounted  on  a  short  length  of  glass  tubing  and  the 
whole  sterilized  by  heat),  and  full  precautions  must  be  taken  in 
sterilizing  the  skin.  At  least  3  or  4  c.c.  should  be  taken  and 
inoculated  directly  into  broth  or  melted  agar,  which  is  incubated 
and  examined  at  the  end  of  twenty-four  and  forty-eight  hours.  It 
is  worse  than  useless  to  attempt  to  make  a  bacteriological  examina- 
tion of  blood  obtained  from  a  skin  puncture,  however  carefully  the 
skin  may  have  been  sterilized. 

In  septicaemia,  pyaemia,  ulcerative  endocarditis,  and  other  diseases 
due  to  the  pyogenic  bacteria,  the  organisms  may  or  may  not  be 
found  in  the  blood.  A  positive  result  is  most  likely  to  be  obtained 
in  severe  cases,  especially  when  the  blood  is  collected  during  a  rigor ; 
it  is  of  evil  omen,  although  such  cases  are  by  no  means  necessarily 
fatal.  Cultures  in  which  staphylococci  are  the  only  organisms  to 
develop  must  be  interpreted  with  caution,  as  being  possibly  due  to 
accidental  contamination.  A  negative  result  is  usually  of  little  value 
in  diagnosis,  as  organisms  may  be  absent  from  the  blood  for  long 
periods  in  cases  of  septicaemia. 

It  is  sometimes  necessary  to  examine  the  blood  for  bacteria  in  the 
diagnosis  of  typhoid  fever,  especially  when  the  infection  is  not  due  to 
the  ordinary  typhoid  bacillus,  but  to  one  of  its  congeners  (the  para- 
typhoid bacillus^  etc.).  In  general,  the  diagnosis  is  made  by  means 
of  Widal's  reaction. 


Typical  Blood-Counts. 

It  must  be  understood  that  the  series  of  blood -counts  here 
appended  are  to  be  looked  on  merely  as  typical  illustrations ;  in  any 
particular  instance  considerable  differences  from  the  figures  given 
may  be  manifested. 


Normal  Blood — 

Red  corpuscles 

Haemoglobin  - 
Colour-index  - 


Morphology  of  red 
corpuscles  - 


5,120,000      per 
c.mm. 

100  per  cent. 
I  (nearly). 
{ No  abnormal 
forms  seen. 
Corpuscles 
uniform  in 
size,  and  stain 
only  with  the 
acid  stain 
(Eosin). 


Normal  Blood — continued : 

Leucocytes     -         -      7,oooperc.mm. 
Polynuclears  -     72-0  per  cent. 
Lymphocytes-     22-8- 
Eosinophiles    -       2^4         ,, 
Large  hyalines       2-4         ,, 
Mast-cells        -       0*4         ,, 
No  other  forms  of  leucocytes  seen. 

Secondary  Ansemia  from  repeated  slight 
haemorrhages — 
Red  corpuscles       -     4,200,000      per 

c.mm. 
Haemoglobin  -         -     72*00  per  cent. 
Colour-index  -         -         -85 


58 


A  MANUAL  OF  SURGERY 


Secondary  knssmia—contmucd . 

^Co  rp  u  sc  1  e  s 


Morphology  of  red 
corpuscles  - 


stain  a  little 
faintly ;  no 
nucleated 
forms  seen. 
(N.B. — In  severer  cases  of  secondary  anaemia, 
and  especially  in  case-s  of  profound  anaemia  after 
a  single  large  haemorrhage  in  a  previously  healthy 
person,  normoblasts  may  be  seen,  and  are  a  good 
sign.) 

Malignant  Disease  with  cachexia — 
Red  corpuscles       -    3,200,000      per 
c.mm. 
00  per  cent, 

75 

/The  corpuscles 
stain  some- 
what faintly ; 
normoblasts 
are  present, 
but  in  scanty 

\     numbers. 

12,000  per  c.mm. 
82 '4  per  cent. 
i4'8 


Haemoglobin  - 
Colour-index  - 


Morphology  of  red 
corpuscles  - 


Lymphatic  Leucocjrbhsemia — 


Leucocytes     - 

Polynuclears  - 
Lymphocytes  - 
Large  hyalines 
Eosinophiles  - 
Mast-cells 

Morphology  of  leu- 
cocytes 


•6         ,. 
•4 

Nothing        ab- 
normal seen. 


Suppuration  (acute  appendix  abscess)- 


Red  corpuscles 


4,500,000 
c.mm. 


per 


Haemoglobin  - 

85  00  per  cent. 

Colour-index  - 

■95 

Morphology  of  red 

corpuscles  - 

Normal 

Leucocytes     - 

23,000  perc.mm. 

Polynuclears  - 

86-2  per  cent. 

Lymphocytes  - 

II-6 

Eosinophiles  - 

I'O           ,, 

Large  hyalines 

1-2 

No  abnormal  forms  seen. 

Some  of  the  poly- 

nuclears  show  '  glycogenic ' 

degeneration. 

Tubercle  (not  complicated  with  second- 

ary infections) — 

Red  corpuscles 

4,112,000      per 

c.mm. 

Haemoglobin  - 

76  0  per  cent. 

Colour-index  - 

■9 

Morphology  of  red 

corpuscles  - 

Normal 

Leucocytes     - 

4,200  per  c.mm. 

Polynuclears  - 

64-2  per  cent. 

Lymphocytes  - 

328         ., 

Large  hyalines 

2-8 

Eosinophiles   - 

'2            ,, 

Morphology  of  leu- 

cocytes 

Normal 

Red  corpuscles 

Haemoglobin  - 
Colour-index  - 


Morphology  - 


Leucocytes     - 

Polynuclears  - 
Lymphocytes 

(nearly      all 

small)  - 
Eosinophiles   - 
Myelocytes 


per 


2,600,000 
c.mm. 
360  per  cent. 

•7 

'The  corpuscles 
staiji  some- 
what faintly ; 
normoblasts 
are  present, 
but  in  scanty 
numbers. 

112,000     per 
c.mm. 
8 '2  per  cent. 


91 '2  per  cent. 

■4 
■2 


(N.B. — In  lymphatic  leucocythaemia  there  is 
not  necessarily  a  great  total  increase  in  the  num- 
ber of  the  leucocytes,  but  the  relative  increase 
in  the  lymphocytes  is  usually  very  marked.) 


Leucocythaemia  (splenomedullary)- 
Red  corpuscles 


Haemoglobin  • 
Colour-index  ■ 


3,200,000 
c.mm. 
52*0  per  cent 


per 


Morphology  of  red 
corpuscles  - 


Leucocytes 


^Normoblasts 
present  in 
rather  large 
numbers 
(about  one  in 
every  two 
fields  of  a 
J-inch  lens). 

456,000  per 
c.mm. 


Myelocytes  and 
cells  inter- 
mediate be- 
tween them 
and  polynu- 
clears  - 

Polynuclears  - 

Eosinophiles 
and  eosino- 
phile  myelo- 
cytes    - 

Mast-cells  and 
mas  t  -  c  e  1 1 
myelocytes  - 

Lymphocytes 
and  large 
hyalines 

Many  of  the  polynuclear  leucocytes  .show  signs 
of  degeneration,  having  faintly  stained  nuclei  and 
few  granules ;  some  are  difificult  to  distinguish 
from  myelocytes.  Some  of  the  myelocytes 
are  also  deficient  in  granules,  and  almost  indis- 
tinguishable from  large  hyaline  leucocytes. 


42  o  per  cent. 
39"o         ,i 


8-4 


7-6 


3'o 


CHAPTER  IV. 

NON-SPECIFIC*  PYOGENIC  INFECTIONS. 

In  this  chapter  we  propose  to  deal  with  a  series  of  affections  associated 
with  or  allied  to  suppuration,  and  due  to  non-specific  bacteria.  These 
organisms,  usually  termed  pyogenic,  cause  an  inflammatory  reaction 
in  the  tissues,  which  sooner  or  later  is  associated  with  liquefaction  of 
both  tissue  and  exudate,  the  liquefied  material  being  known  as  pvis, 
and  the  process  which  leads  to  its  formation  as  suppuration.  Any 
localized  collection  of  pus  in  the  tissues  is  known  as  an  abscess,  and 
this,  according  to  its  course,  may  be  acute  or  chronic,  the  latter  only 
occasionally.  Sometimes  the  infection  involves  the  cellular  tissue 
of  a  part  in  a  more  or  less  diffuse  manner,  the  pus  burrowing  widely ; 
this  condition  is  termed  cellulitis.  Constitutional  phenomena  are 
associated  with  these  local  manifestations,  and  may  be  of  two  types : 
{a)  When  toxic  products  alone  are  absorbed,  resulting  in  toxaemia, 
or  some  modification  of  the  same  ;  and  ih)  when  the  bacteria  invade 
the  blood-stream  and  become  disseminated  to  distant  parts,  thereby 
giving  rise  to  either  septicaemia  or  pycemia.  Each  of  these  various 
conditions  must  be  dealt  with  separately,  but  one  must  first  describe 
in  some-little  detail  the  organisms  common  to  the  whole  group. 

Bacteriology. — The  following  are  the  more  important  pyogenic 
bacteria  : 

I.  The  Staphylococcus  pyogenes  (Plate  I.,  Fig.  i)  is  perhaps  the  most 
common  organism  of  acute  localized  suppuration,  especially  in  con- 
nection with  the  skin  and  subcutaneous  tissues.  It  is  a  coccus  of 
medium  size  which  occurs  in  the  pus  in  characteristic  clusters, 
which  have  been  compared  to  bunches  of  grapeS;  It  stains  hy 
Gram's  method,  and  liquefies  gelatin  or  solidified  blood-serum,  as  it 
produces  a  powerful  peptonizing  enzyme,  and  is  readily  cultivated 
on  almost  all  media  ;  it  grows  best  when  an  abundant  supply  of 
oxygen  is  present. 

Cultures  on  solid  media  develop  rapidly,  and  the  colonies  spread, 
the  surface  being  soon  covered  by  a  uniform  thickish  film  of  growth. 
This  may  be  orange-yellow,  lemon-yellow,  or  white  in  colour,  and 
three  organisms— Staphylococcus  pyogenes  aureus,  citreus,  and  albus, 
respectively — have  been  recognised.     Under  certain  circumstances, 

*  For  the  significance  of  the  term  non-specific,  see  p.  12. 
59 


6o  A  MANUAL  OF  SURGERY 

however,  the  one  may  change  into  the  other,  and  there  is  little 
doubt  that  the  three  really  constitute  one  species. 

Staphylococci  are  very  widely  distributed,  being  common  in  air, 
dust,  etc.  They  are  frequently  found  in  or  on  the  human  skin, 
though  apparently  not  normal  inhabitants  of  that  structure.  Sup- 
purative inflammations  of  the  skin  and  subcutaneous  tissue  are 
due  to  staphylococci  in  the  vast  majority  of  cases;  and  when  the 
inflammation  is  caused  by  other  organisms  in  the  first  instance,  a 
secondary  infection  with  staphylococci  almost  always  takes  place 
later.  Impetigo  contagiosa,  a  disease  due  primarily  to  streptococci, 
may  be  taken  as  an  example  of  this,  and  the  vesicles  of  small-pox  or 
vaccinia  another,  for  in  each  case  a  secondary  staphylococcic  invasion 
takes  place.  The  chief  skin  lesions  due  to  staphylococci  are  abscesses, 
boils,  carbuncles,  pustular  acne,  etc.  In  some  cases  diffuse  spreading 
cellulitis  depends  on  the  same  cause,  but  this  is  unusual.  Deep- 
seated  suppuration,  such  as  osteomyelitis,  peritonitis,  empyema,  etc., 
may  also  be  due  to  staphylococci ;  in  fact,  they  may  cause  suppura- 
tion in  any  part  of  the  body.  Lastly,  staphylococcic  septicaemia, 
pyaemia,  and  ulcerative  endocarditis  occur,  but  are  less  common 
than  the  forms  due  to  streptococci,  and  the  prognosis  appears  to 
be  slightly  less  grave. 

Most  cases  of  suppuration  occurring  after  operations  in  which  the 
antiseptic  or  aseptic  precautions  have  been  inadequate  are  due  to 
staphylococci,  either  alone  or  in  admixture  with  other  organisms. 

2.  The  Streptococcus  pyogenes  is  an  organism  in  which  the  individual 
cocci  are  arranged  in  longer  or  shorter  chains  (Plate  I.,  Fig.  2).  It 
stains  with  Gram,  and  does  not  grow  very  easily  on  artificial  culture 
media.  A  temperature  approximating  to  that  of  the  body  is  desir- 
able, and  hence  it  does  not  grow  well  on  gelatin.  The  colonies  are 
small  and  translucent,  and  do  not  tend  to  spread  or  become  con- 
fluent. It  forms  no  peptonizing  enzyme,  and  hence  does  not  liquefy 
solidified  blood-serum.     The  cultures  readily  die  out. 

On  comparing  cultures  of  Stveptococctis  pyogenes  from  diff"erent 
sources,  slight  differences  may  be  noted,  e.g.,  in  the  length  of  the 
chains,  the  size  of  the  cocci,  the  appearance  of  the  colonies,  etc.  It 
is  as  yet  uncertain  whether  these  are  sufficient  to  diff"erentiate  several 
species,  or  whether  they  merely  indicate  unimportant  (and  perhaps 
not  permanent)  varieties  of  a  single  species. 

*The  Streptococcus  pyogenes  is,  on  the  whole,  a  more  virulent 
organism  than  the  staphylococcus,  and  tends  to  produce  an  acute 
spreading  inflammation  rather  than  a  localized  abscess,  although  the 
latter  lesion  is  quite  commonly  due  to  it.  Erysipelas  is  (in  most  cases) 
caused  by  a  streptococcus  which  has  been  held  to  be  a  distinct 
species,  although  the  differences  are  so  unimportant  that  the  two  are 
generally  considered  identical.  Cellulitis,  too,  is  usually  due  to  the 
Streptococcals  pyogenes.  The  organism  plays  its  most  important  role, 
however,  in  connection  with  septicaemia  and  pyaemia,  whether 
puerperal  or  not,  and  is  the  usual  cause  of  ulcerative  endocarditis. 

3.  The  Pneumococcus  (Plate  I.,  Fig.  4),  generally  present  in  lobar 


NON-SPECIFIC  PYOGENIC  INFECTIONS  6t 

pneumonia,  is  a  diplococcus,  the  individual  cocci  having  usually  a 
triangular  or  lancet  shape,  with  the  bases  facing  one  another.  When 
it  occurs  in  pus  or  other  animal  fluids,  it  is  surrounded  by  a  clear 
capsule.  In  cultures  it  closely  resembles  the  Streptococcus  pyogenes. 
It  is  chiefly  of  importance  in  suppuration  connected  with  the  lungs, 
especially  empyema.  It  occurs  almost  constantly  in  all  inflam- 
matory lesions  of  the  lung,  whatever  their  origin,  as  a  secondary 
infection ;  thus,  in  the  walls  of  a  tuberculous  cavity  suppuration  is 
almost  always  due  to  pneumococci  alone  or  in  conjunction  with 
other  organisms.  It  is  a  common  cause  of  middle-ear  disease,  and 
of  its  cranial  or  intracranial  complications.  Pneumococci  also  cause 
arthritis,  which  may  or  may  not  result  in  suppuration  ;  the  arthritis 
usually  follows  an  attack  of  pneumonia,  but  this  is  not  necessarily 
the  case.  Peritonitis  is  also  due  to  this  organism  in  young  children, 
and  may  be  primary  or  secondary  to  some  pulmonary  lesion.  The 
pneumococcus  frequently  enters  the  blood  and  causes  septicaemia, 
with  or  without  ulcerative  endocarditis. 

4.  The  B.coli  communis  (Plate  II.,  Fig.  26)  occurs  in  great  numbers 
in  the  contents  of  the  healthy  intestine.  It  is  a  short  motile  bacillus 
which  does  not  form  spores,  and  is  not  stained  by  Gram's  method. 
It  grows  best  in  presence  of  oxygen,  but  is  a  facultative  anaerobe ; 
no  peptonizing  enzyme  is  produced,  so  that  gelatin  is  not  liquefied, 
but  an  abundance  of  foul  gas  is  developed.  The  B.  coli  is  one  of  the 
most  important  putrefactive  organisms,  and  it  breaks  down  proteids, 
forming  indol  and  allied  bodies,  and  gases  with  faecal  odour.  It  is 
closely  allied  to  the  typhoid  bacillus,  and  is  distinguished  therefrom 
by  its  action  on  various  sugars ;  thus,  the  typhoid  bacillus  produces 
acid,  but  no  gas,  when  grown  in  broth  containing  glucose,  whereas 
the  B.  coli  produces  both  acid  and  gas.  These  tv/o  bacteria  are 
members  of  a  large  and  important  group  of  micro-organisms  which 
have  a  close  morphological  resemblance  to  one  another,  but  differ  in 
their  chemical  activities. 

Under  normal  conditions  the  bacilli  of  this  species,  which  occur  m 
the  intestinal  contents,  are  not  very  virulent,  but  when  any  patholo- 
gical condition  arises  in  the  gut — 'e.g.,  strangulation,  ulceration, 
perforation,  etc. — their  virulence  appears  to  be  increased,  and  an 
active  invasion  of  the  tissues  may  follow.  It  is  thus  a  common  cause 
of  appendicitis,  acute  peritonitis,  etc.,  and  pus  due  to  its  action  has 
usually  a  faecal  odour.  It  can  also  ascend  the  bile-ducts,  and  give 
rise  to  cholecystitis  and  cholangitis.  Lastly,  the  B.  coli  is  one  of  the 
commonest  causes  of  cystitis.  It  has,  however,  no  power  to  render 
the  urine  alkaline;  this  is  due  to  the  presence  of  a  micrococcus, 
formerly  known  as  M.  vivcce,  but  now  believed  to  be  identical  with 
M.  epidennidis  albiis,  an  organism  of  constant  occurrence  in  the  skin. 

5.  The  typhoid  bacillus  (Plate  II.,  Fig.  21)  sometimes  causes 
abscesses,  especially  in  connection  with  the  bones  or  joints,  after  an 
attack  of  typhoid  fever.  In  some  cases  the  organism  may  lie  latent 
for  years  before  suppuration  occurs.  It  has  also  been  proved  that 
some  persons  continue  to  give  off  these  bacilli  in  the  urine  or  faeces 


62  A  Manual  op  surgery 

for  many  years  after  an  attack  of  typhoid  fever ;  in  the  latter 
instance  the  gall-bladder  has  sometimes  been  the  infected  focus. 
These  '  typhoid  carriers,'  as  they  are  termed,  may  at  any  time  initiate 
an  epidemic  of  the  disease,  which  may  thus  appear  to  arise  without 
reason, 

6.  The  B.  pyocyaneus  is  a  comparatively  rare  cause  of  suppuration. 
The  pus  produced  by  it  turns  bluish-green  when  exposed  to  the 
atmosphere.     It  sometimes  gives  rise  to  a  general  infection. 

7.  The  Gonococcus  (see  p.  133). 

8.  The  M.  tetragenus,  an  organism  in  which  the  individual  cocci 
occur  in  tetrads,  is  rarely  met  with. 

Many  cases  of  suppuration  are  due  to  a  mixed  infection  with  two  or 
more  of  the  species  of  bacteria  enumerated  above.  In  other  cases 
an  abscess  may  be  formed  by  the  action  of  one  of  the  pyogenic 
bacteria,  and  be  subsequently  inoculated  with  other  species,  which 
may  be  simple  saprophytes  that  have  the  power  of  growing  in  dead 
pus,  but  cannot  invade  the  living  tissues.  This  accident  is  very 
likely  to  occur  in  a  large  abscess  when  the  drainage  is  insufficient 
and  the  dressings  are  not  performed  with  sufficient  care ;  it  should 
be  studiously  avoided,  for,  as  a  general  rule,  lesions  due  to  a  mixed 
infection  heal  with  difficulty  ;  it  would  seem  as  though  the  tissues 
can  more  easily  acquire  immunity  to  a  single  organism  than  to  two 
or  more  at  the  same  time.  The  fact  that  a  wound  is  already  infected 
is  not  any  reason  for  neglecting  to  treat  it  with  the  fullest  antiseptic 
precautions. 

I.  Acute  Abscess. 

.etiology. — {a)  It  may  be  taken  as  established  that  suppuration  as 
met  with  in  surgical  practice  is  always  due  to  the  action  of  bacteria.  It 
is  true  that  in  laboratory  experiments  on  animals  it  is  possible  to 
obtain  aseptic  suppuration  by  the  use  of  certain  chemical  irritants, 
such  as  croton  oil,  etc.,  but  these  conditions  never  occur  in  man.  It 
is  also  true  that  in  certain  abscesses,  notably  in  the  liver  and  in 
pyosalpinx,  no  organisms  can  be  found  in  the  pus  on  microscopical 
or  cultural  examination.  This  is  usually  due  to  the  fact  that  the 
pus  has  not  been  examined  until  the  bacteria  have  been  destroyed 
and  the  abscess  has  ceased  to  spread.  In  other  cases  the  organisms 
may  be  present  in  very  small  numbers,  or  may  not  grow  on  the 
ordinary  culture  media  ;  and  in  this  connection  it  may  be  well  to 
point  out  that  new  varieties  of  pathogenic  bacteria  are  frequently 
being  discovered. 

(b)  Bacteria  can  reach  the  area  which  becomes  inflamed  either  from  with- 
out the  body  or  from  within.  The  former  method  is  the  more  usual, 
and  is  illustrated  by  the  observations  of  Garre  and  Bockhardt,  who 
rubbed  cultures  of  Staphylococcus  pyogenes  aureus  into  the  skin  of  their 
arms,  and  produced  acute  suppuration,  commencing  in  superficial 
pustules,  and  finishing  as  boils  or  carbuncles.  The  Staphylococcus 
pyogenes  is  commonly  present  in  the  skin,  and  frequently  deposited  on 
instruments,  dressings,  etc.,  from  the  air,  and  it  is  to  infection  from 


NON-SPECIFIC  PYOGENIC  INFECTIONS  63 

without  due  to  bacteria  gaining  access  from  one  or  other  of  these 
sources,  that  the  majority  of  cases  of  suppuration  are  due. 

In  some  cases,  however,  bacteria  may  gain  access  to  the  tissues 
from  the  blood,  and  this  without  any  obvious  pre-existing  disease. 
For  instance,  it  sornetimes  happens  that  a  deep  lesion  (such  as  a 
ruptured  muscle  or  ligament)  results  in  suppuration,  although  the  skin 
over  it  is  unbroken,  and  the  tissues  between  it  and  the  abscess  are 
apparc  itly  healthy.  Here  we  must  assume  the  possibility  of  auto- 
infection  (p.  7). 

In  other  cases  abscesses  may  be  due  to  organisms  which  have 
lain  lateiit  in  the  tissues,  it  may  be  for  long  periods.  This  is  never 
very  easy  to  prove,  but  the  possibility  of  such  latency  is  shown  by 
the  fact  that  a  patient  may  develop  leprosy  many  years  after  exposure 
to  infection.  A  more  common  example  may  be  seen  in  the  bone 
abscesses  which  sometimes  develop  months  or  years  after  an  attack 
of  typhoid  fever,  and  which  are  due  to  the  typhoid  bacillus,  though 
in  this  case  we  cannot  exclude  the  possibility  of  a  subsequent  infection 
with  the  same  certainty  as  in  the  case  of  leprosy.  In  what  state  the 
bacteria  lie  latent  in  the  tissues  and  the  nature  of  the  conditions 
which  excite  them  into  activity  are  unsolved  problems  ;  we  should 
expect  the  latter  phenomenon  to  be  due  to  general  ill-health  or  to 
local  injury,  but  cases  occur  in  which  no  such  factors  can  be  traced. 
It  is  probable  that  they  would  regain  their  activity  if  an  operation 
took  place  in  the  region  in  which  they  were  deposited ;  suppuration 
would  then  follow  in  spite  of  perfect  asepsis. 

Abscesses  of  a  very  different  nature  occur  when  pyogenic  bacteria 
are  carried  from  a  suppurative  lesion  in  one  part  of  the  body  to 
another ;  these  are  termed  secondary  embolic  abscesses  and  develop  in 
pyaemia,  gonorrhoea,  etc. 

(c)  Sterilized  foreign  bodies  {e.g.,  silver  wire  or  glass  splinters)  do  not 
produce  suppuration,  except  in  the  rarest  of  cases,  by  auto-infection. 
Thus,  a  ragged  splinter  of  glass,  i  J  inches  long  and  i|  inches  wide, 
the  result  of  the  bursting  of  a  soda-water  bottle,  was  cut  out  of  the 
neck  of  a  hotel  porter  ten  months  after  it  had  entered  ;  it  was  en- 
capsuled  and  had  caused  no  trouble.  This  fact  is  constantly  made 
use  of  at  the  present  day  in  surgical  practice ;  deep  layers  of  the 
tissues  are  brought  together  by  carefully  sterilized  buried  sutures, 
and  divided  structures  such  as  bones,  ligaments,  etc.,  are  approxi- 
mated and  held  in  position  by  wire,  screws,  pegs  or  other  buried 
appliances,  which  would  cause  endless  trouble  but  for  their  complete 
sterilization. 

In  conclusion,  therefore,  although  we  have  to  admit  that  suppura- 
tion may  be  experimentally  induced  in  animals  in  the  absence  of 
micro-organisms,  in  man  for  all  ordinary  conditions  suppuration  does  not 
occur  apart  from  the  presence  and  vital  activity  of  pathogenic  bacteria. 

The  causes  of  an  acute  abscess  may  be  grouped  for  practical 
purposes  under  the  three  following  headings:  (i)  The  individual 
affected  is  possibly  in  a  depressed  and  unhealthy  state,  and  the 
germicidal  power  of  his  tissues  may  be  defective.     When  abscesses 


04 


A  MANUAL  OF  SURGERY 


have  occurred  more  than  once  in  the  same  individual,  one  may  rightly 
suspect  the  existence  of  some  intrinsic  source  of  infection,  such  as 
oral  sepsis,  or  some  external  contamination  as  from  defective  drains, 
leading  to  escape  of  sewer  gas.  (2)  A  local  nidus  must  exist,  which 
is  in  a  condition  of  lowered  vitality  from  injury,  cold,  or  otherwise  ; 
and  (3)  this  spot  becomes  infected  with  pyogenic  organisms  brought 
to  it  either  from  within  or  without  the  body. 

Formation  and  Structure  of  an  Acute  Abscess. — The  bacteria  which 
have  gained  access  to  the  tissues  grow  and  produce  their  toxins,  and 
these  diffuse  into  the  surrounding  structures,  giving  rise  to  acute  in- 
flammation ;  the  Y>essels  djlate,  acceleration  of  the  blood-stream  occurs, 


mmmwi 

Fig.  II. — Formation  of  Abscess  in  the  Kidney.     (Thoma.) 

In  the  centre  is  a  zooglcea  mass  of  organisms ;  around  it,  a  zone  of  devitalized 
tissue;  and,  still  further  out,  an  infiltration  of  the  living  tissues  with 
polynuclear  leucocytes. 

and  is  followed  by  retardation  and  thrombosis,  and  the  leucocytes 
emigrate.  The  toxins  then  act  still  more  powerfully  on  the  injured 
tissues  and  destroy  their  vitality,  usually  by  a  process  of  coagulation- 
necrosis.  A  section  through  the  lesion  at  this  stage  will  show  two 
well-differentiated  zones  (Fig.  11) :  a  central  area  in  which  the  tissues 
are  dead,  have  lost  their  staining  properties,  and  contain  the  pyogenic 
bacteria  ;  and  a  peripheral  zone  of  ordinary  acute  inflammation,  which 
fades  gradually  into  the  surrounding  healthy  tissues.  The  inflamed 
zone,  as  is  usual,  is  thickly  infiltrated  with  leucocytes,  and  on  ex- 
amination these  will  be  found  to  be  mainly  of  the  polynuclear  variety. 
This  is  quite  characteristic  of  suppurative  inflammation;  the  products 


NON-SPECIFIC  PYOGENIC  INFECTIONS  65 

of  the  pyogenic  bacteria  have  special  attractive  (chemotactic)  power? 
over  the  polynuclear  leucocytes. 

The  central  necrotic  mass  which  contains  the  bacteria  is  at  this 
stage  still  attached  to  the  surrounding  living  tissues,  and  if  the  lesion 
is  incised  it  will  appear  as  a  small  slough,  which  can  only  be  removed 
with  difficulty.  But  this  condition  soon  changes  ;  the  bacteria  con- 
tinue to  elaborate  their  toxins,  and  polynuclear  leucocytes  are  attracted 
in  large  numbers,  accompanied,  of  course,  by  the  plasma  exuding 
from  the  vessels.  The  tension  in  the  inflammatory  focus  becomes 
so  great  that  the  cohesion  of  the  tissues  around  the  central  slough  is 
destroyed,  and  a  third  zone — of  polynuclear  leucocytes  swimming  in 
fluid — is  formed  between  it  and  the  inflamed  outer  zone.  Where 
the  toxins  have  a  peptonizing  enzyme  action,  it  is  possible  that  this 
plays  some  part  in  liquefying  the  tissues,  but  its  importance  is  prob- 
ably less  than  was  formerly  attributed  to  it. 

The  fate  of  the  small  slough  varies  according  to  circumstances. 
It  may  occasionally  be  recognised  when  a  small  abscess  is  opened 
— e.g.,  the  core  of  a  boil— but  in  most  cases  it  is  absorbed  by  the 
leucocytes  or  digested  by  the  peptonizing  enzymes  which  many 
pyogenic  bacteria  form,  and  no  trace  remains.  It  may  even  happen 
that  no  definite  slough  is  ever  formed  (Fig.  12),  the  earliest  effect  of  the 
bacteria  being  to  attract  the  leucocytes  in  vast  numbers  into  inflamed 
but  still  living  tissues,  which  are  then  killed  and  digested  cell  by  cell. 

This  collection  of  leucocytes  suspended  in  fluid  and  surrounded 
by  a  zone  of  inflamed  tissue  constitutes  an  abscess.  The  leucocytes 
and  fluid  are  collectively  termed  pits,  and  it  is  important  to  recognise 
that  the  characteristic  cells  of  the  pus  from  an  acute  abscess  are  the 
polynuclear  leucocytes.  These,  however,  differ  somewhat  from 
those  seen  in  blood-films.  Many  of  them  are  killed  by  the  toxin 
(as  can  be  seen  from  their  loss  of  motion  when  the  fresh  pus  is 
examined  on  a  warm  stage),  and  undergo  various  degenerative 
changes.     Some  of  them  may  contain  bacteria. 

At  first  the  abscess  often  extends  rapidly,  but  after  a  day  or  two 
(in  most  cases)  a  certain  amount  of  local  immunity  is  produced,  and 
the  abscess  spreads  more  slowly.  This  is  an  indication  of  the  fact 
that  the  tissues,  which  were  at  first  overwhelmed  by  the  action  of 
the  bacteria  and  their  toxins,  are  now  carrying  on  the  contest  on 
more  even  terms.  At  this  period  the  cavity  becomes  lined  by 
granulation  tissue  (p.  250),  which  forms  a  thick,  soft  layer  of  velvety 
appearance  and  bright-pink  colour.  It  is  composed  of  large  numbers 
of  loops  of  newly-formed  bloodvessels  embedded  in  a  mass  of 
leucocytes  and  tissue-cells  in  a  state  of  active  proliferation.  Its 
appearance  does  not  necessarily  indicate  that  the  abscess  has  entirely 
ceased  to  spread,  for  the  toxins  may  still  be  powerful  enough  to  kill 
the  delicate  newly-formed  tissue  cell  by  cell ;  but  in  most  cases  it  is 
the  first  indication  of  repair  and  of  the  ultimate  victory  of  the 
tissues.  Leucocytes  continue  to  pass  from  the  thin-walled  vessels 
of  new  formation  into  the  abscess  cavity,  being  attracted  chemo- 
tactically  by  the  substances  present  in  the  pus  ;  hence  the  layer  of 


66  A  MANUAL  OF  SURGERY 

granulation  tissue  appears  to  secrete  pus,  and  was  formerly  called  a 
♦  pyogenic  membrane.'  Its  appearance  was  anxiously  looked  for  by 
surgeons  in  the  days  when  suppuration  was  considered  essential  for 
the  healing  of  wounds,  and  for  a  very  good  reason.  It  opposes 
a  strong  barrier  to  the  bacteria  and  their  toxins,  and  in  large  measure 
prevents  their  entering  the  blood-stream.  Thus  the  formation  of 
thick,  creamy  pus  of  a  yellowish  colour,  such  as  is  produced  by  such 
a  pyogenic  membrane,  was  looked  upon  as  a  sign  that  the  patient 
was  practically  out  of  danger  of  septic  absorption.  Such  pus  was 
termed  '  laudable.' 

Abscesses  do  not  as  a  rule  spread  equally  in  all  directions,  since 
certain  structures,  especially  bone  and  fascia,  are  more  resistant  than 
cellular  tissue  or  fat ;  moreover,  large  collections  of  pus  may  be 
influenced  by  gravity.  The  process  of  extension  continues,  the 
abscess  becoming  larger  and  larger,  until  it  points,  and  subsequently 
bursts  through  the  skin  or  into  the  alimentary  canal  or  other  cavity. 
When  this  happens,  the  bacteria  and  their  toxins  alike  are  able  to 
escape,  and  in  consequence  their  action  on  the  pyogenic  membrane 
is  less  profound,  so  that  the  contest  between  the  defensive  powers  of 
the  tissues  and  the  destructive  powers  of  the  bacteria,  in  which  the 
latter  were  victorious  at  first,  turns  in  favour  of  the  tissues.  The 
bacteria  which  remain  are  attacked  with  greater  effect  by  the  leuco- 
cytes, and  are  gradually  removed  ;  the  supply  of  toxin  diminishes  ; 
the  inflammatory  process  in  the  abscess  wall  becomes  less  severe, 
and  finally  organization  of  the  granulation  tissue  commences.  This 
is  carried  out  by  a  process  quite  similar  to  that  which  occurs  when  a 
wound  heals  by  second  intention  (p.  253)  ;  it  begins  at  the  bottom  of 
the  abscess  cavity,  the  walls  of  the  upper  portions  being  kept  apart 
from  one  another  by  the  pus  which  is  still  secreted,  though  in  gradually 
diminishing  quantity.  The  result  is  that  the  abscess  cavity  fills  up 
from  the  bottom,  and  finally  heals  altogether.  This  process  is  facili- 
tated if  efficient  drainage  is  provided,  so  that  the  bacteria  and  toxins 
find  a  ready  exit. 

Occasionallj?-,  but  rarely,  the  defensive  powers  of  the  body  are 
sufficient  to  kill  off  the  bacteria  after  pus  has  been  formed,  and  before 
it  has  been  evacuated.  When  this  happens,  the  pus  may  become 
absorbed  and  the  cavity  obliterated,  or  the  fluid  part  only  may  be 
removed  and  the  leucocytes  (which  undergo  fatty  degeneration) 
remain  as  a  cheesy,  structureless  mass.  In  either  case  the  abscess 
wall  organizes  into  fibrous  tissue,  constituting  a  deep  scar,  in  the 
centre  of  which  may  be  the  inspissated  pus.  It  is  rare,  however,  for 
this  to  happen,  except  in  the  abdomen. 

The  Cliijical  Signs  and  Symptoms  of  an  acute  abscess  may  be 
arranged  under  three  headings  : 

I.  The  local  signs  consist  of  a  patch  of  inflamed  tissue,  indicated  by 
heat,  pain,  redness  and  swelling,  which  latter  is  at  first  hard  and 
brawny,  but  when  pus  forms,  the  centre  becomes  soft  and  elastic, 
whilst  superficial  oedema  is  more  marked,  and  the  pain  throbbing  in 
character.     Naturally,  the  amount  of  this  pain  depends  entirely  upon 


Fig.  12.— Early  Stage  of  Abscess  Formation  Three  Days  Old.     (  x  30). 

For  the  loan  of  the  specimens  from  which  this  photomicrograpb  and  Fig.  lo  were  taken  we  are  indebted 
to  Mr.  G.  Lenthal  Cheatle.  The  abscess  was  produced  experimentally  by  the  intravenous  injection 
of  .staphylococci.  It  involves  fatty  tissue,  and  one  can  see  fat  infiltrated  with  leucocytes  at  the 
periphery,  and  in  the  centre  a  cellular  exudate  just  becoming  purulent. 

c 


Section  of  Abscess  Wall  Eight  Days  Old. 


\,  Limiting  zone  of  fibro-ctcatricial  tissue,  with  spindle-shaped  nuclei  ;  B,  vascular  granulation  tissue, 
with  vessels  cut  transversely  ;  C,  superficial  layer  of  granulations  undergoing  necrotic  charges  at 
the  surface.  A  few  capillaries,  running  perpendicular  to  the  surface,  are  seen,  but  some  of  the 
larger  ."spaces  are  due  to  shrinking  of  the  specimen  during  its  preparation.  (Much  less  highly 
magnified  than  Fig.  g.) 


NON-SPECIFIC  PYOGENIC  INFECTIONS  69 

the  density  of  the  tissue  affected  and  the  supply  of  sensory  nerves  to 
the  part,  suppuration  beneath  a  resisting  membrane,  such  as  the 
palmar  fascia,  being  always  intensely  painful.  Fluctuation  is  the 
most  characteristic  sign  of  the  presence  of  fluid ;  it  is  obtained  by 
making  firm  pressure  with  the  finger  or  fingers  of  one  hand  on  one 
part  of  the  swelling,  whilst  the  fingers  of  the  other  hand  placed  on 
another  part  receive  the  impulse  transmitted  across  the  intervening 
space  in  the  form  of  a  fluid  wave.  Some  soft  solids  give  a  sensation 
of  fluctuation — e.g.,  lipomata  and  soft,  rapidly-growing  sarcomata; 
whilst,  on  the  contrary,  it  may  be  absent  when  the  fluid  is  under  great 
tension,  or  surrounded  by  a  thick  wall,  or  widely  diffused  in  such 
a  structure  as  the  glandular  tissue  of  the  breast. 

Sometimes,  when  the  pus  is  small  in  quantity,  all  that  can  be 
detected  is  a  feeling  of  elastic  resistance  in  the  centre  of  the  brawny 
hyperaemic  mass  ;  but  this,  to  the  practised  finger,  is  quite  as  con- 
clusive of  the  presence  of  fluid  as  fluctuation.  When  the  pus  is 
placed  deeply  under  muscular  and  fascial  planes,  very  careful 
examination  may  be  needed  in  order  to  determine  its  presence  ;  the 
surgeon  must  not  be  misled  by  the  sense  of  fluctuation  obtained 
across  the  fibres  of  a  muscle  ;  none  is  noticed,  however,  by  palpating 
alone  the  course  of  its  fibres.  Marked  and  increasing  cedema  is 
frequently  conclusive  of  the  presence  of  deeply-seated  pus — e.g.,  in 
acute  osteomyelitis,  and  suppurating  mastitis. 

If  left  to  itself,  an  abscess  sooner  or  later  points  and  bursts.  As  it 
increases  in  size,  it  exerts  pressure  in  all  directions,  and  naturally 
seeks  to  find  an  exit  in  the  line  of  least  resistance,  and  so  may  either 
find  its  way  to  the  surface,  or  may  burrow  along  muscular  and 
fascial  planes,  or  into  adjacent  cavities.  The  actual  bursting  of  an 
abscess  is  often  due  to  some  injury — it  may  be  a  slight  one — but  is 
usually  preceded  by  ulceration  of  the  integument,  or  perhaps,  if  the 
abscess  is  a  large  one,  by  necrosis. 

2.  Pressure  effects  are  mainly  due  to  the  mechanical  influence  of 
the  swelling  upon  surrounding  structures.  The  most  evident  are 
those  due  to  the  irritation  of  nerves,  as  a  result  of  which  neuralgic 
pain  may  be  present,  or  the  patient  may  refer  the  pain  to  some 
distant  unaffected  region.  In  some  cases,  where  large  bloodvessels 
traverse  the  suppurating  focus,  the  surrounding  tissues  may  be 
destroyed,  leaving  them  exposed  in  the  abscess  cavity  as  bands. 
Thrombosis  and  subsequent  obliteration  may  result,  especially  in 
the  veins  ;  or  occasionally  haemorrhage  follows,  due  to  sloughing 
of  the  arterial  wall  (suppurative  periarteritis),  preceded  perhaps 
by  an  aneurismal  dilatation  of  the  vessel,  owing  to  its  loss  of 
external  support.  Such  effects  occur  both  in  acute  and  chronic 
abscesses. 

3.  The  general  effects  of  the  formation  of  an  acute  abscess  are  those 
of  increased  fever,  sometimes  amounting  to  a  rigor,  and  leucocytosis. 
A  rigor  consists  of  a  definite  series  of  phenomena,  the  result  of  the 
stimulation  of  the  thermogenic  centres  by  an  accumulation  of  toxin 
in  the  blood.    It  is  very  similar  in  nature  to  an  attack  of  ague,  being 


?o  A  MANUAL  OF  SURGERY 

ushered  in  by  a  feeling  of  intense  cold  and  discomfort ;  the  features 
are  pinched,  and  the  teeth  chatter.  The  skin,  however,  feels  dry 
and  hot,  and  the  temperature  of  the  body  rapidly  rises.  The  sensa- 
tion of  cold  is  partly  due  to  the  contact  of  air  at  a  maintained  normal 
temperature  with  the  hot,  dry,  unperspiring  skin,  and  also  possibly 
to  the  condition  of  superficial  anaemia  which  is  present.  After  this 
stage  has  lasted  a  variable  period,  the  patient  gradually  begins  to 
feel  warmer,  the  face  becoming  flushed,  the  thermometer  ceasing  to 
rise,  and  the  skin  commencing  to  act.  Finally  there  is  a  rapid  fall 
of  temperature  accompanied  by  profuse  perspiration,  which  probably 
eliminates  the  toxin,  but  leaves  the  patient  more  or  less  ex- 
hausted. For  leticocytosis  and  its  value  in  the  diagnosis  of  suppura- 
tion, see  p.  53. 

Pus  and  its  Constituents. — Normal,  or  as  it  was  formerly  called, 
healthy  or  laudable  pus,  is  a  thick,  creamy  fluid,  having  a  specific 
gravity  of  about  1030,  an  alkaline  reaction,  no  smell  (unless  putre- 
fying or  due  to  the  activity  of  the  B.  coli),  and  containing  85  to 
go  per  cent,  of  water.  If  allowed  to  settle,  it  separates  into  two 
layers,  an  upper  or  fluid  part,  the  liquor  puris,  which  is  usually 
clear  or  slightly  opalescent,  and  colourless,  and  a  deposit  of  a 
yellowish-gray  colour,  which  is  usually  more  bulky  than  the  fluid 
portion.  The  liquor  puris  is  derived  from  the  plasma  exuded  ffom 
the  vessels.  It  may  undergo  coagulation  after  removal  from  the 
body,  a  very  loose  clot  being  formed.  Frequently,  however,  this 
does  not  happen,  perhaps  because  it  has  already  coagulated  within 
the  abscess,  and  the  resulting  fibrinous  network  has  been  dissolved 
by  the  peptonizing  ferment  of  the  toxins,  or  destroyed  by  the  leuco- 
cytes. It  consists  chemically  of  an  albuminous  fluid  very  similar  to 
serum,  but  more  dilute,  and  contains  bacterial  toxins,  enzymes, 
proteoses  formed  by  the  digestion  of  proteids,  etc.  Sometimes 
(when  the  abscess  involves  a  region  containing  fat)  a  few  globules 
of  oil  float  on  the  surface  or  occur  in  an  emulsified  form  in  the 
fluid. 

The  solid  portion  consists  in  the  main  of  polynuclear  leucocytes, 
most  of  which,  as  has  been  already  pointed  out,  are  dead  and 
degenerated,  whilst  a  few  are  still  alive  and  capable  of  spontaneous 
movements.  In  addition,  there  are  fragments  of  cells  and  nuclei 
from  the  tissues,  shreds  of  fibrous  tissue,  granular  debris,  and 
bacteria.     A  few  red  blood  corpuscles  are  often  present. 

When  pus  is  mixed  with  blood,  it  is  termed  sanious  (short  for 
sanguineous)  ;  when  thin  and  acrid,  it  is  ichorous  ;  curdy,  when  mixed 
with  curdy  shreds,  as  is  more  usually  seen  in  chronic  suppuration  of 
a  tuberculous  nature.  Muco-pus  is  of  a  sticky,  glairy  character,  and 
arises  from  inflammatory  conditions  of  mucous  membranes  ;  sero-pus 
is  thin  and  more  liquid  from  admixture  of  serum,  and  is  derived  from 
serous  membranes. 

Occasionally  an  abscess  contains  not  only  pus,  but  also  gas.  This 
may  be  due  to  the  existence  of  a  direct  communication  with  some 
hollow  viscus — e.g.,  the  stomach  or  intestine — and  hence  is  met  with 


NON-SPECIFIC  PYOGENIC  INFECTIONS  71 

in  many  cases  of  subphrenic  abscess.  In  some  of  the  many  types 
of  abscess  associated  with  appendicitis  the  gas  is  due  to  the 
activity  of  the  B.  coli  either  alone  or  mixed  with  other  germs.  _  It 
is  sometimes,  however,  the  result  of  infection  with  a  gas-producing 
organism — e.g.,  the  B.  aerogenes  capsidatm  or  B.  cedematis  maligni, 
and  is  then  usually  associated  with  an  acute  spreading  cellulitis  or 
gangrene. 

Treatment  of  Acute  Abscess. — When  an  inflamed  area  is  threatening 
to  suppurate,  the  formation  of  pus  can  be  but  rarely  prevented.  In 
the  early  stages,  elevation  and  rest  of  the  part,  together  with  the 
application  of  evaporating  lotions  and  the  administration  of  quinine 
with  iron,  m.ay  sometimes  succeed  in  accomplishing  this.  Bier's 
treatment  by  induced  hyperaemia  may  be  useful  in  a  few  instances, 
whilst  in  acute  periostitis  a  free  incision  through  the  inflamed  tissues 
is  often  the  best  treatment  when  suppuration  is  threatening. 

In  a  few  regions  of  the  body,  pus  may  be  absorbed  after  its  forma- 
tion, but  only  when  situated  in  a  cavity  of  highly  absorbing  powers, 
such  as  the  anterior  chamber  of  the  eye  (hypopyon),  or  the  peri- 
toneal cavity.  In  the  former  the  process  of  absorption  may  certainly 
be  observed  under  the  influence  of  local  and  general  treatment. 

As  a  rule,  however,  one  relieves  pain  and  encourages  suppuration 
by  applying  fomentations  (medicated  with  opium  or  belladona)  or 
poultices  to  the  part,  and  then  as  soon  as  pus  is  present,  an  incision 
is  made  to  evacuate  the  abscess  cavity.  The  opening  must  be  large 
enough  to  prevent  re-accumulation  :  it  should  be  placed  at  a  spot 
suitable  for  drainage,  but  as  far  as  possible  from  sources  of  septic 
contamination,  and  in  such  a  direction  that  movements  of  the  part 
do  not  close  it.  Where  the  opening  is  not  dependent,  it  may  be 
desirable  to  make  a  counter  -  opening  by  pushing  the  finger  or  a 
probe  through  the  abscess  wall  amongst  the  tissues,  making  it  pro- 
trude beneath  the  skin  at  some  dependent  spot,  and  cutting  down 
upon  it  in  this  direction.  In  dealing  with  deep  abscesses  in  dangerous 
regions,  Hilton's  method  may  be  advantageously  employed.  This 
consists  in  dividing  merely  the  skin  and  superficial  structures,  and 
then  thrusting  a  pair  of  sinus  or  dressing  forceps  into  the  abscess 
cavity.  On  forcibly  separating  the  blades  a  sufficient  opening  is 
made  to  insert  the  finger  and  subsequently  a  drainage-tube.  Rigid 
antiseptic  precautions  must  be  taken  in  opening  abscesses,  for 
although  bacteria  are  present,  it  is  most  essential  that  no  fresh 
germs  be  admitted,  thereby  giving  rise  to  a  mixed  infection,  the 
presence  of  which  is  most  unfavourable  to  rapid  repair. 

It  is  advisable  to  remove  any  sloughs  that  are  present,  and  when 
the  abscess  has  burrowed,  or  if  the  cavity  is  large,  it  should  be 
explored  with  the  finger,  but  adhesions  or  bands  crossing  it  should 
not  be  indiscriminately  broken  down,  as  they  may  contain  large 
bloodvessels.  All  that  is  subsequently  needed,  if  there  is  no  com- 
plication, such  as  the  presence  of  dead  or  diseased  bone,  is  to 
arrange  for  drainage,  as  by  inserting  a  drainage-tube  or  a  slip  of 
protective,  and  to  exclude  sepsis  by  a  carefully-applied  antiseptic  or 


72  A  MANUAL  OF  SURGERY 

aseptic  dressing ;  in  other  cases  it  may  be  desirable  to  pack  the 
cavity  with  gauze  soaked  in  an  iodoform  emulsion  (lo  per  cent.). 
There  is  often  a  considerable  loss  of  blood  during  the  first  twenty- 
four  hours  from  the  yielding  of  the  capillaries  in  the  abscess  wall, 
owing  to  the  sudden  relief  of  tension  ;  but  this  usually  ceases  ol 
itself,  or  yields  to  moderate  pressure.  When  once  the  abscess  has  been 
evacuated,  no  move  pus  is  formed  if  external  contamination  [mixed  infection) 
has  been  avoided,  the  discharge  being  merely  serous,  and  the  wound 
rapidly  closing  and  healing,  and  this,  in  spite  of  the  fact  that  bacteria 
are  for  a  while  present  ;  they  are  evidently  unable  to  develop  or  do 
any  harm  as  the  result  of  a  local  immunity.  An  abscess  cavity 
which  has  contained  foul  or  stinking  pus  usually  runs  a  healthy 
course  if  aseptic  conditions  are  maintained,  and  if  no  communication 
with  the  bowel  exists,  the  discharge  becoming  free  from  smell  in 
a  few  days. 

The  persistent  discharge  of  pus  from  an  abscess  which  has  been 
opened  means  either  that  the  opening  is  too  small,  or  that  matter  is 
pent  up  in  an  undrained  loculus,  or  that  a  mixed  infection  has 
occurred,  or  occasionally  that  the  vital  powers  of  the  patient  are  so 
deteriorated  that  it  is  difficult  to  establish  healthy  repair,  or  that  the 
part  is  not  kept  at  rest.  Free  drainage,  the  improvement  of  the 
general  health,  and  keeping  the  affected  part  at  rest  are  essential 
elements  in  the  successful  treatment  of  an  abscess.  A  small 
opening  must  be  enlarged :  loculi  must  be  drained,  and,  if  need  be, 
a  counter-opening  made.  Debilitated  patients  may  sometimes  need 
to  be  sent  to  the  seaside  before  healing  will  occur. 

Chronic  Abscess  of  Pyogenic  Origin. 

A  chronic  abscess  may  be  defined  as  a  collection  of  pus  which 
forms  slowly  and  without  any  signs  of  active  inflammation,  so  that 
it  is  sometimes  termed  a  cold  or  congestive  abscess.  The  vast  majority 
are  tuberculous  in  origin,  but  a  few  may  be  due  to  the  liquefaction 
of  other  granulomatous  masses,  to  an  infection  with  pyogenic  bacteria 
of  low  vitality,  or  to  chronic  pyaemia.  The  clinical  phenomena  are 
alike  in  the  two  types,  and  will  be  dealt  with  later  (p.  172),  but 
there  is  one  important  distinction  between  them,  in  that  the  lining 
membrane  of  the  pyogenic  variety  is  merely  granulation  tissue  more 
or  less  active,  whilst  in  the  tuberculous  form  it  contains  living  tuber- 
culous materia}.  Hence,  whilst  a  simple  incision  under  aseptic 
precautions  is  all  that  is  required  in  the  former,  the  latter  also  needs 
removal  of  the  tuberculous  tissue  by  scraping  or  some  such  agency. 

Sinus  and  Fistula. 

When  an  abscess  has  been  opened,  and  does  not  heal  completely, 

a  communication  often  persists  between  the  original  seat  of   the 

I  disease  and  the  exterior,  which  is  known  as  a  sinus  or  fistula.     A 

Sinus  is  a  narrow  track  lined  with  granulations,  penetrating  into 


NON-SPECIFIC  PYOGENIC  INFECTIONS  73 

the  tissues,  open  at  one  end  and  closed  at  the  other  ;  the  dis- 
charge is  purulent  or  merely  serous,  according  to  whether  or  not 
sepsis  is  present.  A  Fistula  is  an  abnormal  communication,  con- 
genital or  acquired,  between  two  cavities,  or  between  a  cavity  and 
the  external  surface.  When  such  conditions  result  from  the  non- 
closure of  an  acute  or  chronic  abscess  of  pyogenic  origin,  the  walls 
consist  of  an  external  fibro-cicatricial  vascular  layer,  passing  on 
the  outside  into  healthy  tissues,  and  an  internal  lining  of  more  or 
less  healthy  granulation  tissue.  Should  the  abscess  have  been  of 
tuberculous  origin,  the  lining  membrane  will  also  contain  tubercles. 
If  the  fistulous  track  is  short,  the  granulating  wall  is  likely  to  become 
covered  with  epithelium,  and  under  such  circumstances  the  fistula 
cannot  be  expected  to  close  until  the  epithelium  has  been  removed, 
and  a  raw  surface  again  exposed. 

It  is  often  a  matter  of  difficulty  to  secure  the  healing  of  a  sinus  or 
fistula,  and  the  following  are  the  main  causes  of  their  non-closure  : 
(i)  The  presence  of  some  chronic  irritant  in  the  depths  of  the  wound, 
such  as  a  piece  of  the  clothing,  a  catgut  ligature,  a  piece  of  silk  or 
silver-wire  used  in  an  operation,  or  of  some  diseased  tissue,  such  as 
a  fragment  of  dead  or  carious  bone  ;  (2)  the  irritation  of  discharges 
finding  an  exit  through  the  abnormal  opening,  such  as  urine,  faeces, 
or  foetid  pus  ;  (3)  insufficient  drainage  of  a  deep  cavity,  so  that  there 
is  always  a  certain  amount  of  tension  in  the  wound  ;  (4)  want  of  rest 
to  the  part,  due  either  to  voluntary  movements,  as  in  the  limbs,  or 
to  involuntary  muscular  action  in  the  immediate  neighbourhood,  as 
in  fistula-in-ano  ;  (5)  tuberculous  infection  of  the  wall,  or  a  tuber- 
culous deposit  at  the  bottom  of  the  sinus  ;  (6)  the  growth  of  epithe- 
lium down  the  sinus  or  round  the  margin  of  the  fistula  ;  or  (7) 
constitutional  debility. 

The  orifice  of  a  sinus  often  looks  depressed  from  the  amount  of 
infiltration  around,  but  when  the  surrounding  tissues  are  healthy, 
puckering  in  of  the  orifice  is  a  good  sign  ;  in  cases  where  foreign 
bodies  are  lodged  within,  or  where  diseased  bone  exists,  it  is  usually 
surrounded  by  prominent  fungating  granulations. 

Treatment. — The  removal  of  the  cause  is  the  first  thing  to  accom- 
plish in  dealing  with  a  sinus  or  fistula.  The  passage  must  be 
dilated  or  slit  up  to  allow  of  access  to  the  deeper  parts  of  the  wound, 
to  remove  any  foreign  body  which  may  be  present,  or  to  allow  of  the 
satisfactory  drainage  of  a  deep  cavity.  The  making  of  a  dependent 
counter-opening  often  suffices  to  cure  a  sinus.  A  thorough  purifi- 
cation of  the  part  by  pure  carbolic  acid  or  chloride  of  zinc  (40  grains 
to  I  ounce)  must  also  be  undertaken,  and  the  wound  dressed  by 
packing  with  suitable  material  and  kept  at  rest,  whilst  the  general 
health  of  the  patient  is  improved  by  tonics.  Occasionally,  the 
pressure  of  a  roller  bandage  to  immobilize  the  part  is  all  that  is 
required,  or  the  application  of  a  suitable  splint.  ••  The  most  complete 
and  certain  method  is  to  lay  the  sinus  open  and  destroy  the  lining 
granulation  tissue  by  scraping  or  cauterizing,  and  then  to  pack  the 
wound,  allowing  it  to  heal  from  the  bottom  by  granulation. 


74  A  MANUAL  OF  SURGERY 

Should  a  fistula  have  become  lined  with  epithelium,  the  edges  will 
require  paring,  and  some  form  of  plastic  operation  must  be  under- 
_taken  to  close  the  opening. 

Sinuses  often  react  well  to  vaccine  treatment,  and  this  is  especially 
the  case  with  those  left  after  empyemata,  when  a  single  injection  of 
50,000,000  to  100,000,000  dead  pneumococci  will  often  prove  effica- 
cious. Tuberculous  sinuses,  such  as  may  be  left  after  an  operation 
for  glands  in  the  neck,  etc.,  are  sometimes  curable  by  the  use  of 
tuberculin  (TR),  but  there  is  not  much  chance  of  success  if  the 
non-healing  is  due  to  dead  bone,  movement,  etc. 

Results  of  Long- continued  Suppuration. 

When  an  abscess,  acute  or  chronic,  pyogenic  or  tuberculous,  is 
emptied  antiseptically,  and  maintained  in  an  aseptic  condition,  the 
formation  of  pus  usually  ceases ;  the  wound  may  not  heal  for 
months,  but  the  discharge  is  merely  serous,  and  no  constitutional 
results  will  be  manifested.  The  temperature  remains  normal,  and 
the  general  health  unimpaired,  if  no  other  disease  is  present.  Should 
a  tuberculous  abscess  become  infected  with  pyococci,  or  a  mixed 
infection  occur  in  a  pyococcal  abscess,  the  discharge  of  pus  continues 
or  reappears,  and  fever  to  a  varying  degree  follows.  When  an 
extensive  or  deep  abscess  is  thus  involved,  the  discharge  may 
become  very  profuse,  high  fever  may  supervene,  grave  visceral 
changes  may  follow,  and  the  patient  may  lose  his  life  through 
toxaemia  and  exhaustion.  Long -continued  suppuration  is  always  an 
evidence  of  sepsis,  and  prominent  amongst  the  conditions  which  arise 
therefrom  may  be  mentioned  hectic  fever  and  lardaceous  disease  of 
the  viscera. 

Hectic  Fever  may  be  defined  as  a  chronic  toxaemia  due  to 
the  continued  absorption  of  small  doses  of  toxins,  and  is  met 
with  in  any  condition  of  chronic  sepsis,  e.g.,  after  acute  or  chronic 
suppurative  affections  of  bones  or  joints,  in  tuberculous  disease  of 
the  lungs,  and  in  septic  syphilitic  or  cancerous  disease.  It  is 
characterized  by  a  regular  elevation  of  temperature  during  the 
afternoon  or  evening,  when  the  face  becomes  flushed  [hectic  flush 
of  the  cheeks),  the  eyes  are  bright  and  sparkling,  the  pupils 
dilated,  and  the  patient  feels  better  and  stronger.  The  pulse, 
however,  is  small,  compressible,  and  ten  or  twenty  beats  quicker 
than  it  should  be ;  the  tongue  becomes  red  at  the  edges  and  tip. 
This  condition  continues  till  late  in  the  night,  by  which  time  the 
temperature  may  have  risen  four  or  five  degrees.  It  then  com- 
mences to  fall  as  rapidly  as  it  had  formerly  risen,  and  usually  drops 
to  the  normal,  or  even  below  it,  and  in  the  early  morning  a  profuse 
perspiration  breaks  out,  which  soaks  the  patient's  clothes,  and  leaves 
him  in  a  much-exhausted  condition.  Day  by  day  this  continues, 
the  fever  and  sweating  together  causing  a  marked  diminution  in  the 
patient's  strength. 

Amyloid,  Albumenoid,  or  Lardaceous  Disease  of  various  organs  is  a 
condition  as  to  the  exact  cause  of  which  but  little  is  known ;  either  from 


NON-SPECIFIC  PYOGENIC  INFECTIONS 


75 


the  deleterious  effects  of  toxic  compounds  circulating  in  the  blood,  or 
from  the  loss  of  some  special  substance  in  the  discharge — e.g.,  alkaline 
phosphates — the  walls  of  the  smaller  arteries  and  the  protoplasm  of 
certain  of  the  viscera  are  converted  into  or  infiltrated  with  a  waxy 
substance,  from  which  lardacein,  an  extremely  insoluble  proteid 
body,  may  be  obtained.  The  name  '  amyloid  '  is  an  entire  misnomer, 
as  this  material  is  in  no  way  akin  to  starch.  It  occurs  as  a  waxy 
homogeneous  material,  becoming  a  dirty  brown  on  the  application  of 
tincture  of  iodine,  and  an  inky  blue  when  sulphuric  acid  is  sub- 
sequently   added.      With    methyl-violet   the   amyloid   substance   is 


)^f%m^p 


(ZlEGLER.) 

a,  Normal  capillary 


e      h 

Fig.   14. — Amyloid  KidneV  in  Early  Stage. 

(Treated  with  Miiller's  fluid  and  perosmic  aeid.      x  300.) 

loop  ;  h,  amyloid  capillary  loop ;  c,  fatty  epithelium  of  glomerulus  ;  c\,  fatty 
epithelium  of  capsule ;  A,  oil-drops  on  the  capillary  wall ;  e,  fatty  epithelial 
cells  in  situ ;  /,  loosened  fatty  epithelial  cells ;  g,  hyaline  coagula  (forming 
'  casts  ') ;  h,  fatty  cast  in  section  ;  i,  amyloid  artery  ;  k,  amyloid  capillary  ; 
I,  infiltration  of  connective  tissue  with  leucocytes  ;  m,  round  cells  (leuco- 
cytes) within  a  uriniferous  tubule. 

coloured  ruby-red,  whilst  normal  tissues  are  stained  blue  or  indigo. 
The  organs  mainly  affected  are  the  liver,  spleen,  kidneys,  and  villi 
of  the  intestines,  and  the  capillaries  and  muscular  coats  of  the 
arterioles  (Fig.  14,  h  and  i)  are  the  parts  first  attacked,  the  change 
gradually  spreading  to  the  parenchyma  of  the  organ.  The  liver 
becomes  evenly  enlarged  to  a  considerable  degree,  often  reaching 
from  the  fifth  rib  to  the  umbilicus,  or  lower  ;  it  is  firm  in  consistency, 
like  indiarubber,  painless,  and  waxy-looking  on  section.  The 
arterioles  and  capillaries  in    the  intermediate  zone  of  the  lobules 


?6  A  MANUAL  OF  SURGERY 

are  those  first  affected,  but  the  cells  soon  participate  in  the  change. 
The  glycogenic  and  bile-producing  functions  are  naturally  interfered 
with,  so  that  the  digestive  process,  and  especially  the  power  of 
absorbing  fats,  is  impeded.  The  kidneys  become  similarly  enlarged, 
the  change  commencing  in  the  arterioles  leading  to  the  glomeruli 
(Fig.  14),  but  the  capillaries  and  the  tubal  epithelium  are  also  early 
affected.  In  this  stage  the  urine  is  very  abundant  (from  the  increased 
filtration  through  the  degenerated  walls),  pale,  limpid,  and  containing 
a  few  hyaline  casts  and  fatty  cells  ;  later  on,  when  the  tubules  are 
more  largely  involved,  there  is  less  urine,  with  a  higher  specific 
gravity,  and  a  considerable  amount  of  albumen.  The  spleen  increases 
in  size,  but  not  always  to  so  great  an  extent  as  the  other  viscera  ;  the 
Malpighian  bodies  are  the  chief  seat  of  the  mischief.  The  capillaries 
in  the  villi  of  the  intestines  become  lardaceous,  and  allow  of  an  increased 
transudation  of  the  fluid  parts  of  the  blood,  resulting  in  diarrhoea ; 
the  absorption  of  nutriment  is  thereby  much  lessened,  and  thus  both 
by  increased  excretion  and  diminished  absorption  of  food  the  strength 
of  the  patient  is  steadily  undermined. 

Amyloid  changes  in  the  viscera,  far  from  being  a  contra-indication 
to  operation,  are  rather  to  be  considered  as  a  sign  that  radical  treat- 
ment is  urgently  necessary,  unless  the  general  condition  of  a  patient 
is  such  that  he  cannot  stand  the  strain  of  it.  If  by  an  operation — 
e.g.,  excision  or  amputation — the  local  disease  can  be  eradicated,  the 
amyloid  changes  in  the  viscera  may  totally  disappear.  At  the  same 
time  one  must  not  forget  that  the  kidneys  are  seriously  damaged, 
and  that  antiseptics,  such  as  carbolic  acid,  which  are  absorbed  into 
the  blood  and  eliminated  in  the  urine,  may  light  up  an  acute  nephritis 
with  possibly  fatal  results. 

Persistent  suppuration  is  present  in  a  large  series  of  other  conditions 
than  those  following  the  opening  of  an  abscess,  prominent  amongst 
them  being  that  known  as  oral  sepsis.  The  lesion  usually  present 
is  pyorrhoea  alveolaris  (g^v.),  in  which  suppurating  pouches  form  in 
the  gums  around  the  roots  of  teeth,  which  are  generally  dirty,  decayed, 
and  covered  with  tartar ;  the  tongue  is  coated,  and  the  breath 
offensive.  Grave  results  may  follow,  partly  from  the  constant 
swallowing  of  bacteria  and  their  toxins,  partly  by  their  direct 
absorption  through  the  granulation  tissue  which  surrounds  the  teeth, 
(i)  The  ingestion  of  pyogenic  bacteria  and  their  toxins  acts  in- 
juriously upon  the  gastric  and  intestinal  mucous  membranes,  so 
that  the  natural  antiseptic  powers  of  the  gastric  juice  are  lost  or 
diminished ;  and  thus  a  chronic  gastritis  may  ensue,  as  also  gastric 
or  duodenal  ulcers,  whilst  it  is  a  noticeable  fact  that  a  septic  state 
of  the  mouth  due  to  bad  teeth  is  constantly  found  in  the  subjects  of 
appendicitis.  In  this  connection  it  is  advisable  to  note  that  careful 
disinfection  of  the  buccal  cavity  should  always  follow,  as  well  as 
precede,  such  operations  as  gastro-enterostomy,  excision  of  the 
tongue,  removal  of  the  jaw,  etc.,  so  as  to  minimize  the  risks  which 
might  follow  sepsis.  (2)  The  air-passages  may  become  infected  as 
an   outcome   of  oral   sepsis,  in   the  form  of   a   tracheitis  with   an 


NON-SPECIFIC  PYOGENIC  INFECTIONS  77 

abundant  muco-purulent  expectoration.  Aspiration  pneumonia  may 
follow  the  administration  of. an  anaesthetic  in  such  cases.  (3)  A  mild 
anaemia  of  a  secondary  type  may  develop,  characterized  by  a  blood 
count  showing  3,000,000  or  so  red  corpuscles,  60  to  70  per  cent,  of 
haemoglobin,  and  a  moderate  leucocytosis.  Occasionally  the  anaemia 
may  be  of  a  graver  type,  corresponding  to  the  pernicious  variety 
(Hunter).  It  is  also  interesting  to  note  that  in  lymphatic  leukaemia 
ulceration  of  the  mouth  is  often  present.  (4)  Many  other  general 
conditions  may  ensue — e.g.,  a  constant  feeling  of  malaise,  headache, 
mild  furunculosis,  and  various  phenomena  due  to  neuritis.  Occa- 
sionally severe  pyrexia  of  a  typhoid  type  has  supervened,  the 
temperature  falling  rapidly,  and  the  patient  recovering  as  soon  as  the 
mouth  and  teeth  had  received  attention.  Chronic  osteitis  and 
arthritis  also  occur,  and  the  condition  described  hereafter  as  chronic 
osteo-arthropathy  is  due  to  the  chronic  absorption  of  septic  material. 

II.  Cellulitis. 

Cellulitis  (or,  as  it  used  to  be  termed,  diffuse  .phlegmon)  is  a  disease 
characterized  by  the  existence  of  a  spreading  inflammation  of  the 
subcutaneous  or  cellular  tissues,  due  to  the  activity  of  pyogenic 
organisms,  and  running  on  to  suppuration,  sloughing,  or  even  to 
extensive  gangrene. 

Causation. — The  one  essential  is  the  infection  of  the  cellular  tissues 
with  organisms  which  gain  an  entrance  through  an  operation  wound 
which  has  been  allowed  to  become  septic,  or  through  an  accidental 
breach  of  surface  which  has  not  been  rendered  aseptic,  or  even 
through  the  slightest  graze,  prick,  or  scratch.  Deep  septic  wounds 
which  are  not  properly  drained  are  amongst  the  most  favourable  for 
the  development  of  this  condition,  especially  if  the  general  health  of 
the  individual  is  bad,  if  he  is  suffering  from  albuminuria  or  diabetes, 
or  if  his  surroundings  are  of  an  insanitary  nature.  Wherever  much 
loose  cellular  tissue  is  present,  inflammatory  phenomena  readily 
supervene,  owing  to  the  absorption  of  septic  material  from  neigh- 
bouring contaminated  structures — e.g.,  pelvic  cellulitis  arising  from  a 
septic  uterus,  or  cellulitis  of  the  neck  from  a  septic  throat. 

Bacteriology. — The  Streptococcus  pyogenes  is  the  organism  most 
frequently  found  in  cases  of  cellulitis,  particularly  when  there  is 
much  tendency  to  spread.  In  some  of  the  more  localized  forms  the 
Staphylococcus  pyogenes  is  present,  whilst  in  the  gravest  and  most 
acute  manifestation  the  B.  cedematis  maligni  is  responsible  for  the 
trouble  (p.  113),  and  the  disease  is  then  identical  with  what  is  usually 
known  as  acute  emphysematous  or  infective  gangrene. 

Clinical  History. — The  symptoms  necessarily  differ  somewhat 
according  to  the  site  of  inoculation  and  the  virulence  of  the  causative 
microbes,  and  hence  anything  from  a  localized  suppuration  to  the 
acutest  form  of  spreading  gangrene  may  result.  In  a  case  of 
moderate  severity,  due  to  a  prick  or  abrasion  which  has  become 
infected,  there  is  often    a   period  of  quiescence  for  a  day  or  two, 


7S  A  MANUAL  OF  SURGERY 

and  the  site  of  inoculation  shows  but  slight  signs  of  inflammation, 
beyond_  being  a  little  tender.  The  patient,  though  feeling  somewhat 
seedy,  is  able  to  continue  his  work,  but  is  finally  obliged  to  give 
up,  owing  partly  to  the  increased  pain,  partly  to  his  general  con- 
dition. Fever  will  almost  always  be  present  to  a  greater  or  less 
degree,  and  in  the  more  severe  types  one  or  more  rigors  occur,  or 
the  temperature  may  be  subnormal,  owing  to  the  intensity  of  the 
toxaemia.  The  affected  part  is  found  to  be  hot,  tender,  and  infil- 
trated ;  if  superficial,  it  looks  red  and  angry,  and  feels  brawny.  In 
some  cases  local  haemorrhages  or  petechial  spots  are  found  in 
addition  to  the  other  inflammatory  phenomena.  The  course  of  the 
case  depends  to  a  very  large  extent  upon  the  treatment  adopted ;  if 
freely  incised,  the  process  may  become  limited,  and  although  sup- 
puration and  sloughing  may  occur,  repair  is  readily  affected  ;  if, 
however,  the  virus  is  very  active,  or  the  patient's  power  of  resistance 
low,  or  if  the  inflamed  area  is  left  to  itself  or  merely  poulticed,  the 
process  may  spread  rapidly,  and  extensive  destruction  follow.  Intense 
pain  and  sleeplessness,  accompanied  perhaps  with  delirium,  form  the 
most  prominent  symptoms,  and  these,  together  with  the  toxic  fever, 
rapidly  exhaust  the  patient's  strength.  Suppuration  at  length  occurs, 
but  is  often  of  slow  development,  and  the  swelling  may  remain  hard 
and  brawny  for  some  time  in  such  a  region  as  the  neck  with  no 
evidence  of  softening,  so  that  it  may  be  difficult  to  determine  whether, 
pus  is  present  or  not.  The  infiltrated  cellular  tissues  are  likely  to 
slough,  and  in  a  limb  extensive  subcutaneous  necrosis  may  occur, 
although  the  skin  only  gives  way  in  places  ;  hence  it  is  often  possible 
to  pass  a  probe  between  the  skin  and  the  deep  fascia  over  a  con-' 
siderable  area.  Sometimes  the  inflammation  skips  a  part  of  the 
lirnb,  the  chief  focus  of  mischief  being  found  at  a  distance  from  the 
original  site  of  inoculation,  whilst  the  intervening  portion  is  but 
little  affected,  or  shows  the  characteristic  features  of  acute  lymph- 
angitis (q.v.).  This  is  probably  due  to  the  organisms  or  their 
toxins  being  transmitted  along  the  lymphatics,  and  then  arrested  at 
a  higher  level.  Occasionally  the  trouble  spreads  along  the  deeper 
areolar  planes,  involving  muscular  bellies,  which  may  be  infiltrated 
with  pus  or  may  actually  slough.  This  is  most  likely  to  occur  when 
the  disease  is  due  to  septic  inflammation  following  a  penetrating 
wound,  such  as  a  gunshot  injury  or  a  bad  compound  fracture.  In 
all  these  more  severe  forms  the  patient  runs  a  considerable  risk  of 
developing  general  septicaemia  or  pyaemia. 

Treatment.— Careful  attention  to  the  dicta  of  antiseptic  surgery 
can  prevent  the  occurrence  of  cellulitis  to  a  very  large  extent  in 
casualty  and  operative  work.  Abrasions  and  small  punctured 
wounds  should  always  be  protected,  and  all  penetrating  injuries 
disinfected,  especially  if  the  patient  runs  exceptional  risk  of  infection 
owing  to  his  occupation  or  surroundings,  or  to  the  nature  of  the 
injury.  Should  inflammatory  phenomena  supervene,  the  application 
of  antiseptic  fomentations,  such  as  the  boracic  poultice,  may  prevent 
their  extension,  whilst  the  bowels  should  be  freely  acted  upon  and 


NON-SPECIFIC  PYOGENIC  INFECTIONS  79 

the  general  health  attended  to.  If  suppuration  is  present  or  is 
threatening,  free  incisions  in  the  long  axis  of  the  limb  should  be 
made  into  the  brawny  tissues,  so  as  to  give  exit  to  the  serous  and 
irritating  discharges,  and  to  allow  sloughs  to  be  cut  or  scraped 
away ;  the  wounds  thus  made  are  lightly  packed  with  iodoform 
gauze,  over  which  the  usual  dressings  are  applied.  The  object  of 
this  is  to  drain  the  fluids  from  the  parts  by  capillary  action,  and 
hence  an  effective  junction  must  be  maintained  between  the  gauze 
drain  and  the  surrounding  dressing.  It  is  often  wise  to  incorporate 
a  piece  of  sterilized  gutta-percha  tissue  or  mackintosh  in  the  outer 
folds  of  the  dressing,  so  as  to  keep  the  parts  moist  and  encourage  a 
free  discharge.  Extension  of  the  mischief  requires  further  incisions, 
and  the  surgeon  must  follow  up  the  disease  with  the  knife.  At  the 
same  time  the  patient's  health  and  strength  must  be  maintained 
by  the  administration  of  suitable  food,  drugs,  such  as  quinine,  and 
stimulants. 

After  the  bleeding  caused  by  the  incisions  has  ceased,  the  limb 
should  be  daily  immersed  in  a  warm  bath  for  some  hours  so  as  to 
dilute  the  toxins  and  render  them  innocuous.  The  bath  should  not 
continue  for  more  than  three  or  four  hours  at  a  time,  for  fear 
of  the  tissues  becoming  sodden.  Sterilized  salt  solution  at  a 
temperature  of  105°  to  110°  F.  does  perfectly  well ;  antiseptics  are 
practically  useless  in  checking  the  disease  when  once  started ;  the 
surgeon  has  to  depend  mainly  on  relief  of  tension,  the  removal  of 
toxic  discharges,  and  the  antiseptic  power  of  the  tissues.  At  the 
same  time  the  utmost  care  must  be  taken  to  prevent  any  fresh  or 
mixed  infection  of  wounds  from  decomposition  of  discharges. 

Polyvalent  antistreptococcic  serum  (p.  28)  has  also  been  employed 
as  a  curative  agent,  with  a  view  to  destroy  the  streptococci  (probably 
by  a  bacteriolytic  action)  and  immunize  the  system  to  their  further 
development.  A  dose  of  20  c.c.  (i  c.c.  =  n^xvii.)  may  be  given  to 
start  with,  followed  by  10  c.c.  twice  a  day  beneath  the  skin  of  the 
back  or  abdominal  wall.  The  results  have  been  very  variable ; 
sometimes  it  is  apparently  effective,  but  not  unfrequently  the  results 
have  been  most  disappointing.  In  the  less  acute  cases  vaccine 
treatment  may  be  beneficial. 

Special  Varieties  of  Cellulitis. 

Cellulitis  of  the  Axilla  not  unfrequently  follows  an  infected  wound  of  the  hand, 
such  as  occurs  in  the  post-mortem  room,  and  hence  is  not  uncommon  in  medical 
practitioners,  students  or  nurses.  It  may  also  be  caused  by  extension  from  an 
axillary  lymphadenitis.  The  tissues  of  the  armpit  become  hard  and  brawny,  the 
pain  is  severe,  especially  on  movement  of  the  shoulder,  and  the  disease  is  liable 
to  spread  towards  the  chest  walls  under  or  between  the  pectoral  muscles  ;  it  may 
also  travel  upwards,  and  lay  open  the  shoulder -joint  from  sloughing  of  the 
capsule,  and  so  give  rise  to  an  acute  arthritis.  Early  and  extensive  incisions  are 
required  in  order  to  prevent  such  complications,  but  respect  must  be  paid  to  the 
important  vessels  and  nerves  contained  in  the  cavity. 

Cellulitis  of  the  Scalp  usually  results  from  a  septic  wound  which  has  traversed 
the  occipito-frontalis  aponeurosis,  and  opened  up  the  subjacent  layer  of  loose 
areolar  tissue ;  it  may,  however,  follow  a  simple  laceration  of  the  scalp  and  remain 


8o  A  MANUAL  OF  SURGERY 

superficial.  In  the  latter  case  the  scalp  becomes  red,  oedematous  and  tender,  but 
the  inflammation  remains  more  or  less  localized  ;  in  the  former,  pus  forms  beneath 
the  aponeurosis,  and  extends  to  its  limits  of  attachment,  so  that  abscesses  are 
likely  to  point  in  the  forehead  just  above  the  eyebrows,  over  the  zygoma,  or  along 
the  superior  curved  line  of  tlie  occipital  bone.  The  whole  scalp  may  be  lifted  up, 
and  the  patient  runs  a  risk  of  necrosis  of  the  cranial  bones  and  of  various  intra- 
cranial complications.  The  scalp  itself,  however,  rarely  sloughs  owing  to  its 
abundant  vascular  supply.  In  both  conditions  the  temperature  is  often  high  and 
the  patient  severely  ill.  The  treatment  consists  in  making  early  and  free  incisions 
parallel  to  the  lines  of  the  vessels,  and  the  insertion  of  drainage-tubes  when  the 
pus  is  beneath  the  aponeurosis. 

Cellulitis  of  the  Orbit  is  not  an  uncommon  sequela  of  penetrating  wounds  in 
this  region,  owing  to  the  difficulty  of  rendering  them  aseptic  and  of  draining 
them.  It  may  also  result  from  inflammation  of  the  bony  walls,  secondary  to 
suppuration  within  the  cranial  sinuses.  The  orbital  tissues  become  infiltrated 
and  swollen,  the  lids  are  oedematous,  and  the  eyeball  is  thrust  forwards  (proptosis). 
The  infla^Timation  may  spread  to  the  meninges,  owing  to  the  dura  mater  being 
continuous  with  the  orbital  periosteum  through  the  foramina  by  which  the  nerves 
and  vessels  enter.  Necrosis  of  the  orbital  walls  may  also  occur,  whilst  the  eye 
itself  may  suffer  either  from  an  infective  panophthalmitis  due  to  lymphatic 
infection,  or  from  optic  neuritis  secondary  to  retro-ocular  inflammation  and 
pressure,  or  at  a  later  date  from  optic  nerve  atrophy  secondary  to  cicatricial  con- 
traction around  the  nerve.  If  the  cellular  tissue  of  the  orbit  sloughs,  the  subse- 
quent movements  of  the  globe  may  be  much  hampered,  or  indeed  lost,  whilst  the 
lids  may  be  drawn  back  to  such  an  extent  as  to  prevent  their  complete  closure. 
Treatment. — No  penetrating  wound  of  the  orbit  ought  to  be  closed  if  there  is  any 
question  of  its  infection  ;  indeed,  it  is  often  wise  to  increase  its  size  slightly,  so 
as  to  enable  the  deeper  parts  to  be  explored  and  drained.  If  cellulitis  follows,  the 
original  wound  must  be  opened  up,  and  possibly  fresh  incisions  made  either 
through  the  lids  or  through  the  fornix  conjunctivas.  Antiseptic  fomentations  are 
then  applied.  If  panophthalmitis  supervenes,  the  eyeball  must  be  incised 
crucially  ;  this  is  a  safer  proceeding  than  enucleation,  which  is  more  liable  to  be 
followed  by  meningitis. 

Cellulitis  of  the  Neck  is  usually  secondary  to  a  septic  throat,  and  therefore 
associated  with  follicular  tonsillitis,  diphtheria, or  scarlatina,  the  process  probably 
starting  in  a  deep  lymphatic  gland  ;  it  occasionally  follows  operations  on  the 
neck.  The  tissues  beneath  the  deep  cervical  fascia  become  infected,  usually 
with  streptococci,  and  sooner  or  later  suppuration  occurs.  The  affected  side  of 
the  neck  is  swollen,  red  and  brawny  ;  severe  pain  of  a  deep  tensive  character 
is  experienced,  and  this  is  increased  by  movements  of  the  head  or  jaw. 
The  swelling  is  often  peculiarly  hard  and  resistant  (the  u'oody  angina  of  French 
writers)  and  although  osdema  may  be  present,  it  may  be  several  days  before  the 
surgeon  can  detect  any  focus  of  softening  suggestive  of  suppuration.  During  this 
period  the  constitutional  symptoms  are  severe;  fever  may  be  high,  and  the  pain 
and  subsequent  sleeplessness  may  exhaust  the  patient,  whilst  the  difficulty  of 
swallowing  hinders  his  nutrition.  Dangerous  symptoms  arise  from  pressure  on 
important  vessels  and  nerves,  from  extension  of  the  inflammation  to  the  medi- 
astinum or  to  the  glottis,  causing  oedema  and  consequent  dyspnoea,  or  from  the 
supervention  of  pyaemia  owing  to  venous  thrombosis.  The  process  usually  ends 
in  sloughing  of  the  cellular  tissue  and  suppuration,  the  pus  burrowing  widely  if  a 
free  exit  by  incisions  through  the  deep  fascia  is  not  provided. 

Treatment. — The  causative  lesion  in  the  throat  must  be  attended  to,  any 
operation  wound  freely  opened  up  and  drained,  and  the  general  condition 
improved  by  the  administration  of  nourishing  fluid  food,  stimulants,  and  quinine. 
Antistreptococcic  serum  may  also  be  injected,  but  sometimes  antidiphtheritic 
serum  (given  hypodermically  or  by  mouth)  has  been  found  more  useful.  Locally, 
fomentations  are  applied  in  the  first  place ;  but  on  the  onset  of  suppuration,  or 
before,  if  the  pressure  symptoms  are  severe,  or  if  the  affection  is  obviously 
extending,  free  incisions  must  be  made  along  lines  of  safety  beneath  the  deep 
fascia,  so  as  to  relieve  tension  and  give  exit  to  discharges.  It  must  be  remem- 
bered that  the  tissues  are  malted  together  in  such  a  way  as  renders  their  recogni- 


NON-SPECIFIC  PYOGENIC  INFECTIONS  8i 

tion  difficult ;  and  inasmuch  as  the  pus  often  lies  deeply,  the  greatest  caution  has 
to  be  taken  to  avoid  injury  of  important  structures. 

Special  inteiest  has  been  directed  to  a  form  of  this  affection  which  occurs  in 
the  submaxillary  region,  and  is  known  as  Ludwig's  angina.  It  is  usually  secondary 
to  some  buccal  focus,  or  may  occasionally  result  from  the  extension  of  inflam- 
mation beyond  the  capsule  of  lymphatic  glands,  or  may  originate  in  disease  of  the 
middle  ear,  the  mischief  spreading  down  along  the  posterior  belly  of  the  digastric. 
The  swelling  in  these  cases  extends  forwards  beneath  the  chin,  and  may  involve 
the  floor  of  the  mouth  and  base  of  the  tongue,  pushing  that  organ  forwards,  and 
even  making  it  protrude  from  the  mouth.  CEdema  of  the  glottis  may  supervene, 
or  a  sublingual  abscess  form.  Treatment  is  similar  to  that  indicated  above,  and 
one  or  more  incisions  may  be  required.  CEdema  of  the  glottis  will  probably 
require  tracheotomy. 

Pelvic  Cellulitis  is  a  septic  inflammation  of  the  loose  cellular  tissue  which 
ensheaths  the  pelvic  viscera.  It  may  result  from  any  penetrating  wound, 
accidental  or  operative,  which  encroaches  on  this  region— ^.^.,  extraperitoneal 
rupture  or  perforation  of  the  bladder,  suprapubic  or  lateral  lithotomy,  injudicious 
catheterism,  curetting  the  uterus,  and  sometimes  attempts  to  induce  abortion.  It 
may  also  be  due  to  the  lymphatic  absorption  of  septic. material  contained  within 
any  of  the  pelvic  viscera — e.g.,  the  bladder,  prostate,  rectum,  uterus,  or  Fallopian 
tube.  It  is  associated  with  all  the  local  and  general  signs  of  deep  inflammation, 
and  often,  indeed,  with  peritonitis,  giving  rise  to  a  tense,  firm,  painful  swelling, 
to  be  felt  per  rectum  or  per  vaginam,  and  sometimes  to  an  indurated  mass  of 
inflammatory  effusion,  dull  oh  percussion,  above  the  pubic  arch.  Abscesses  may 
form,  bursting  either  externally  above  Poupart's  ligament  or  into  some  of  the 
viscera,  or  possibly  in  both  directions,  producing  very  intractable  forms  of  urinary 
or  faecal  fistulae,  whilst  venous  obstruction  and  pyaemia  are  very  likely  to  develop. 

The  surgeon  may  be  called  on  to  deal  with  such  cases  either  in  the  early  pre- 
suppurative  stage,  when  rest,  limitation  of  diet,  small  doses  of  opium,  and 
fomentations  to  the  hypogastrium,  conjoined  perhaps  with  hot  antiseptic  rectal 
or  vaginal  douches,  should  be  adopted  ;  or  at  a  later  date,  when  pus  has  formed 
and  the  abscesses  need  to  be  opened.  An  incision  is  generally  made  just  above 
Poupart's  ligament  and  close  to  the  pubic  spine  ;  the  abdominal  muscles  are 
divided  to  a  sufficient  extent  to  enable  the  surgeon  to  work  downwards  between 
the  transversalis  fascia  and  the  peritoneum,  which  must  be  pushed  aside  in  order 
to  reach  the  broad  ligament,  where  pus  is  frequently  found.  As  soon  as  the  sub-  ^ 
peritoneal  tissue  is  opened,  the  knife  should  be  discarded,  and  only  blunt  instru- 
ments or  the  fingers  employed.  The  cavity  of  the  abscess  should  be  well  washed 
out  and  efficiently  drained,  and  possibly  a  counter-opening  through  the  vagina 
may  be  required. 

Intestinal  obstruction  may  develop  as  a  remote  sequela  from  the  contraction  of 
cicatrices,,  and  hydronephrosis  may  arise  in  the  same  way  from  pressure  on  the 
ureter. 

III.  Sepsis  and  Toxaemia. 

Sepsis  is  a  term  somewhat  loosely  applied  to  indicate  that  a 
wound  or  sore  has  become  infected  with  micro-organisms  in  such 
a  way  as  to  interfere  with  healthy  reparative  action.  It  is  seen  in 
connection  with  casualty  wounds,  and  less  frequently  in  operation 
cases  ;  it  occurs  in  abscess  cavities,  and  in  connection  with  other 
unprotected  sores  and  abrasions,  and  the  offensive  odour  which  so 
often  accompanies  neglected  syphilitic  or  cancerous  lesions  is  simply 
due  to  this,  and  is  no  essential  part  of  the  causative  affection. 

The  organisms  present  are  of  the  ordinary  pyogenic  type,  especially 
the  staphylococci  and  streptococci ;  but  other  germs,  perhaps  sapro- 
phytic, are  frequently  found,  constituting  a  mixed  infection. 

In  casualty  work  it  is  often  unavoidable,  and  due  to  the  dirty 

6 


82  A  MANUAL  OF  SURGERY 

state  of  the  skin  or  the  nature  of  the  accident ;  and  however  thorough 
the  subsequent  disinfection,  it  may  be  impossible  to  render  the  parts 
sterile.  Sepsis  of  an  operation  wound  is  usually  due  to  some  avoid- 
able mistake  or  oversight,  rarely  to  auto-infection. 

The  local  trouble  may  manifest  itself  merely  as  an  acute  or  sub- 
acute suppurative  process  within  the  wound,  or  as  an  active  cellulitis 
spreading  into  the  adjacent  tissues.  It  may  commence  deeply  around 
a  buried  stitch,  or  superficially.  In  the  latter  case  the  lips  of  the 
wound  look  red  and  puffy,  the  tissues  often  swell  up  between  the 
stitches,  which  look  as  if  they  were  too  tight,  and  on  introducing  a 
probe  pus  may  escape  ;  the  patient  complains  of  pain,  usually  of  a 
throbbing  nature,  and  there  is  some  rise  of  temperature,  and  in  bad 
cases  even  a  rigor.  In  the  milder  forms,  the  trouble  is  Hmited  to 
the  immediate  neighbourhood  of  the  wound ;  but  if  neglected,  or  in 
an  unhealthy  subject,  or  if  due  to  virulent  germs,  the  phenomena  of 
an  acute  cellulitis  may-  supervene. 

When  the  process  starts  quietly  in  the  deeper  parts  of  the  wound, 
nothing  may  be  obvious  on  the  surface  for  a  few  days,  except  perhaps 
some  fulness  and  tenderness  on  pressure.  It  will  usually  be  found, 
however,  that  the  temperature  is  slightly  raised,  and  that  some 
■  tensive  pain  is  present.  Sooner  or  later  an  abscess  develops  and 
comes  to  the  surface. 

The  local  treatment  of  a  septic  wound  consists  essentially  in  the 
relief  of  all  tension,  and  the  application  of  warmth  and  moisture  to 
the  part,  to  encourage  the  local  reparative  activity  of  the  tissues. 
Stitches  must  be  immediately  removed,  and  the  wound  widely 
opened  up,  care  being  taken  to  ascertain  whether  or  not  the  pus  has 
burrowed,  as  if  so  it  must  be  followed  up  ;  sloughs  may  be  out  or 
scraped  away  under  an  anaesthetic,  or  left  to  separate  by  natural 
processes.  The  parts  are  then  thoroughly  washed  with  warm  salt 
solution  or  dilute  antiseptics,  and  may  be  treated  with  peroxide 
of  hydrogen  (lo-volume  solution)  ;  it  must  not  be  forgotten  that, 
when  bacteria  have  invaded  the  living  tissues,  no  antiseptic  is  likely 
to  kill  them — at  any  rate,  not  without  also  destroying  the  tissues, 
and  therefore  powerful  or  irritating  antiseptics  should  be  avoided. 
The  wound  is  then  lightly,  though  thoroughly,  packed  with  gauze, 
and  if  there  is  a  deep  cavity,  it  may  be  desirable  to  introduce  a 
drainage-tube,  especially  when  suppuration  is  present,  since  pus 
does  not  easily  escape  along  a  gauze  drainage-wick.  Warm  moist 
dressings,  such  as  an  antiseptic  fomentation,  are  then  applied,  or  the 
limb  is  immersed  in  a  bath  at  a  temperature  of  105°  to  110°  F.  for 
some  hours  daily.  At  the  same  time  the  bowels  must  be  freely 
opened,  and  the  general  health  of  the  patient  carefully  watched. 
The  more  serious  cases  are  dealt  with  in  the  same  manner  as  an 
attack  of  cellulitis  (p.  78). 

The  general   phenomena  connected    with    septic    conditions   vary 
chiefly  in  respect  of  the  dose  of  toxins  absorbed  : 

I.  Acute  Toxaemia  results  from  the  absorption  of  a  large  dose  of 
toxic  material  from  some  focus  of  infective  inflammation  of  sufficient 


NON-SPECIFIC  PYOGENIC  INFECTIONS  83 

extent  and  virulence.  A  small  collection  of  pus  under  pressure  is 
capable  of  giving  rise  to  marked  toxic  symptoms,  whilst  in  spreading 
inflammations,  such  as  erysipelas-aiid-GelUii4tis,  the  manifestations 
are  often  of  a  grave  type.  The  same  is  true  of  infective  inflamma- 
tion of  the  peritoneal  cavity,  especially  when  the  upper  half  is 
involved,  since  the  communication  with  the  lymphatics  of  the 
diaphragm  is  very  free.  Toxaemia  is  not  unfrequently  associated 
with  a  true  septicemia,  and  clinically  it  may  be  almost  impossible 
to  distinguish  between  the  two. 

The  Symptoms  are  characterized  by  fever,  except  in  some  of  the 
gravest  cases,  when  the  .temperature  may  be  subnormal,  although 
the  pulse  may  still  remain  high.  This  is  accompanied  by  loss  of 
appetite,  a  dry  tongue,  a  quick  pulse,  rapidly  becoming  weak, 
severe  headache,  and  nocturnal  delirium  of  some  intensity.  The 
patient  is  at  first  constipated,  but  vomiting  and  diarrhoea  may  ensue 
from  gastro-intestinal  irritation,  followed  by  fatal  exhaustion  and 
collapse ;  or  he  may  become  comatose  and  unconscious  for  sorne 
time  before  death,  according  to  whether  the  toxins  act  principally 
upon  the  alimentary  or  nervous  systems.  Dyspnoea  from  pulmonary 
congestion,  and  albuminuria  also  occur.  Effective  treatment  of  the 
cause,  as  by  opening  an  abscess,  or  drainage,  may  lead  to  a  speedy 
disappearance  of  the  symptoms,  but  in  spreading  inflammation  the 
toxaemia  may  not  subside  for  some  time. 

Post-mortem  Appearances. — Decomposition  is  early,  rigor  mortis 
feeble,  and  cadaveric  lividity  well  marked,  especially  along  the  lines 
of  the  superficial  veins  and  posteriorly.  The  blood  coagulates 
imperfectly,  and  is  dark  and  tarry  in  colour ;  if  allowed  to  stand, 
the  serum  which  separates  from  the  corpuscles  is  much  stained  from 
the  breaking  up  of  the  red-blood  cells  which  occurs  in  all  septic  and 
infective  cases.  This  condition  explains  the  amount  of  cadaveric 
lividity,  and  also  the  post-mortem  staining  of  the  endocardium  and 
tunica  intima  of  the  larger  vessels,  which  is  such  a  marked  feature 
in  these  cases,  and  which  was  formerly  supposed  to  result  from 
a  diffuse  arteritis.  Most  of  the  serous  cavities  contain  a  certain 
amount  of  blood-stained  fluid,  and  under  almost  all  the  serous  mem- 
branes are  well-marked  petechiae,  especially  under  the  pericardium 
and  pleura.  The  lungs  are  deeply  congested,  particularly  at  the 
back,  and  very  oedematous  ;  the  liver,  spleen,  and  kidneys  are 
enlarged,  pulpy,  soft,  and  congested,  notably  the  spleen.  The 
epithelium  of  most  of  the  secreting  glands,  if  examined  micro- 
scopically, gives  evidence  of  cloudy  swelling. 

The  Treatment  of  acute  toxaemia  must  be  chiefly  directed  to  the 
local  cause,  which  is  dealt  with  by  suitable  surgical  means.  General 
treatment  is  merely  symptomatic.  Possibly  a  good  purge  may  be 
advisable  in  the  early  stages,  but  in  the  later  a  supporting  and 
stimulating  plan  of  treatment  must  be  adopted.  Recently  it  has 
been  proposed  to  deal  with  the  acute  toxaemia  of  peritonitis  and 
similar  conditions  by  the  repeated  injection  into  the  veins  or  rectum 
of  large  quantities  of  saline  solution  (3i.  ad  Oi.),  and  excellent  results 


84  A  MANUAL  OF  SURGERY 

have  been  obtained  by  this  means;  the  injections  being  followed  by 
diuresis  and  diarrhoea,  which  presumably  assist  in  the  elimination 
of  the  poison.  In  these  cases  it  may  be  desirable  to  insert  the  needle 
of  the  infusion  apparatus  directly  into  a  vein  without  dissection,  as 
the  wound  might  otherwise  become  septic. 

2.  Septic  Traumatic  Fever  is  the  term  occasionally  applied  to  the 
phenomena  caused  by  the  absorption  of  a  moderate  dose  of  toxin 
after  an  operation  or  injury,  which  is  followed  by  septic  inflamma- 
tion. A  burn  or  compound  fracture  which  is  not  rendered  aseptic  is 
always  accompanied  by  fever,  ranging  from  102°  to  104°  F.  for  some 
days,  until  the  wound  is  securely  sealed  off  by  the  development  of 
granulation  tissue.  When  once  this  has  occurred,  the  fever  usually 
disappears,  unless  pus  is  retained  under  pressure. 

3.  When  the  dose  is  small,  but  absorbed  regularly  and  for  a  long 
time,  a  definite  diurnal  range  of  temperature  follows,  known  as 
hectic  fever  (p.  74). 

4.  Acute  Sapraemia  is  a  term  that  is  now  rarely  employed  in 
surgical  practice,  but  is  rather  retained  for  a  condition  which  occurs 
during  the  puerperiijm,  due  to  the  decomposition  of  a  portion  of 
retained  placenta,  as  the  result  of  a  mixed  infection.  The  symptoms 
are  moderately  severe,  and  entirely  due  to  chemical  poisoning. 
Removal  of  the  putrid  mass  results  in  almost  immediate  cessation 
of  the  fever  and  all  its  symptoms. 

IV.  Septicaemia. 

Septicaemia  is  an  acute  general  infective  disorder,  arising  from  the 
development  of  some  variety  of  pyogenic  organism  in  the  blood.  It 
differs  from  pyaemia  in  the  absence  of  secondary  abscesses  (although, 
as  explained  later,  it  may  be  associated  with  it),  and  from  toxaemia 
or  sapraemia,  by  the  fact  that  the  latter  are  merely  due  to  the  absorp- 
tion into  the  blood  of  toxins  generated  in  a  diseased  focus  in  which 
the  bacteria  themselves  remain  localized.  In  septicaemia  the  organ- 
isms circulate  in  the  blood,  though  in  many  cases  in  but  scanty 
numbers,  so  that  it  is  necessary  to  take  rather  large  quantities  of 
blood  (5  c.c.  or  more)  for  a  bacteriological  examination.  Further, 
even  in  severe  cases  of  septicaemia  periods  occur  in  which  no  bacteria 
can  be  detected  in  the  blood,  so  that  too  much  weight  should  not  be 
attached  to  a  single  negative  result.  In  sapraemia,  on  the  other 
hand,  the  bacteriological  examination  of  the  blood  shows  it  to  be 
invariably  sterile. 

Bacteriology.  —  The  commonest  organism  is  undoubtedly  the 
Streptococcus  pyogenes,  which  is  found  in  about  50  per  cent,  of  all 
cases;  it  is  almost  always  present  in  the  septicaemia  dependent  on 
puerperal  diseases,  though  in  these  cases  it  may  be  associated  with 
other  organisms.  It  is  also  the  most  frequent  cause  of  ulcerative 
endocarditis,  a  disease  practically  identical  with  septicaemia,  except 
in  so  far  as  the  lesion  in  the  heart  acts  as  the  source  of  the  bacteria 
in  the  circulating  blood.     Next  in   frequency  is  the  Pneumococcus, 


NON-SPECIFIC  PYOGENIC  INFECTIONS  85 

which  often  causes  septicaemia,  even  when  no  pulmonary  or  other 
local  lesion  can  be  traced.  The  Staphylococcus  pyogenes  is  also  a  fairly- 
common  organism  in  this  disease,  and  the  prognosis  is  then  decidedly- 
better  than  in  cases  due  to  the  streptococcus  or  pneumococcus. 

Rare  causes  are  the  B.  coli  and  allied  organisms,  B.  pyocyaneus, 
B.  cedeniatis  maligni,  and  the  Gonococciis. 

Clinical  History. —  Septicaemia  occurs  most  commonly  from  direct 
inoculation  with  suitable  organisms  through  small  lesions,  such  as 
post-mortem  wounds,  or  from  scratches  or  punctures  with  infected 
pins  or  instruments  ;  it  also  in  rarer  cases  follows  operation  wounds 
and  severe  lacerated  injuries.  It  is  the  usual  accompaniment  of 
acute  spreading  gangrene  (p.  113),  and  may  be  met  with  in  cellulitis 
and  cancrum  oris  (p.  114).  As  a  rule,  the  individual  attacked  is  in  a 
depressed  and  debilitated  condition,  perhaps  deteriorated  by  alcoholic 
or  other  excesses,  so  that  the  inherent  germicidal  activity  of  the 
tissues  is  markedly  insufficient  to  cope  with  the  inroads  of  the  disease. 

The  point  of  inoculation  may  be  the  seat  of  any  of  the  forms  of 
local  trouble  which  we  have  already  described  under  the  title  of 
cellulitis,  and  this  may  vary  from  a  slight  inflammatory  blush  to  the 
acutest  form  of  spreading  gangrene. 

The  General  Symptoms  are  those  of  fever,  often  ushered  in  by  a 
distinct  and  severe  rigor;  the  temperature  reaches  104°  or  105°  F. 
and  usually  remains  high,  with  but  slight  remissions  and  no  inter- 
missions. Malaise  is  present,  with  loss  of  appetite,  and  the  tongue 
is  brown  and  parched.  The  pulse  is  quick  and  feeble,  the  heart- 
sounds  are  weak,  and  the  heart  itself  dilated.  The  skin  has  often  a 
slight  icteric  tinge,  and  petechiae  are  present.  Diarrhoea  usually 
ensues,  and  may  be  blood-stained,  whilst  the  urine  is  albuminous, 
and  contains  blood.  The  patient,  after  a  period  of  delirium,  becomes 
comatose,  and  dies.  Dyspnoea  sometimes  precedes  the  fatal  issue, 
whilst  the  temperature  may  be  exceedingly  high,  or  occasionally 
subnormal ;  the  association  of  a  low  temperature  with  a  very  rapid 
pulse  is  always  of  grave  import.  Leucocytosis  is  usually  present 
and  well  marked  in  the  earlier  stages,  but  is  absent  in  the  worst  cases 
and  towards  the  fatal  issue  ;  even  under  these  circumstances  there  is 
a  relative  increase  in  the  number  of  polynuclears,  and  the  glycogenic 
degeneration  will  be  present. 

Illustrative  Cases.— A  servant-girl,  aged  about  twenty-two,  complained  one  hot 
summer's  day  that  she  had  been  stung  near  the  inner  canthus  by  a  fly ;  possibly 
the  insect  had  come  from  some  infected  material,  and  thus  poisoned  the  wound. 
In  twenty-four  hours  she  was  feeling  ill  and  feverish,  and  had  some  chills  and 
flushes  ;  a  painful  swelling  developed  at  the  inner  canthus,  which  rapidly  increased 
in  size  and  spread  downwards.  At  the  end  of  four  days,  when  we  saw  her,  the 
eye  was  protruding  and  much  congested,  and  a  definite  band  of  inflammatory 
thickening  could  be  felt  reaching  from  the  roof  of  the  nose  across  the  face  to  the 
neck  and  jugular  region,  probably  the  thrombosed  facial  vein,  the  clot  doubtless 
extending  to  the  cavernous  sinus.  The  temperature  was  high,  and  the  girl  was 
delirious.  An  incision  was  made  into  the  orbit  with  the  view  of  relieving  tension 
and  giving  exit  to  any  pus  that  might  be  present,  but  with  no  result.  She  rapidly 
became  unconscious,  and  died  within  a  week. 

An  elderly  man,  addicted  to  drink,  fell  in  the  street,  and  grazed  the  inner  side 


86  A  MANUAL  OF  SURGERY 

of  his  hand.  Within  twenty-four  hours  the  whole  arm  was  puffy  and  swollen, 
and  in  two  days  gangrene  had  manifested  itself,  the  infiltration  reaching  beyond 
the  shoulder.     The  patient  was  dead  from  acute  septicaemia  in  five  days. 

The  Post-mortem  Signs  are  those  found  in  all  cases  of  acute  septic 
poisoning,  described  above  (p.  83),  with  the  addition  that  on  micro- 
scopical examination  bacteria  can  sometimes  be  demonstrated  in  the 
blood  and  internal  organs,  especially  the  spleen. 

The  Diagnosis  has  to  be  made  from  the  more  virulent  forms  of  the 
acute  exanthemata,  in  which  the  patient  is  destroyed  before  the  charac- 
teristic appearances  are  manifested  ;  in  such  cases  a  definite  opinion 
as  to  the  nature  of  the  affection  is  often  impossible,  if  there  is  no 
clue  as  to  the  origin  of  the  infection.  Saprcemia  is  always  associated 
with  some  very  obvious  focus  of  putrefaction,  whilst  septicaemia  may 
occur  with  but  slight  local  manifestations.  Septic  traumatic  fever,  or 
toxiPjnia,  due  to  wound  infection,  may  be  so  severe  as  to  cause  grave 
anxiety  for  a  time  as  to  whether  or  not  septicaemia  is  present ;  but 
if  the  wound  is  freely  opened  up  and  drained,  the  rapid  disappearance 
of  the  fever  proves  that  the  mischief  was  merely  a  local,  and  not  the 
more  serious  general,  affection.  A  blood  examination  by  cultural 
methods  may  assist  in  clearing  up  the  diagnosis.  From  pyamia  it  is 
known  by  the  absence  of  repeated  rigors  and  secondary  abscesses. 

The  Prognosis  of  septicaemia  is  always  very  grave,  but  it  is  to  be 
hoped  that  the  modern  plans  of  treatment  mentioned  below,  especially 
serotherapy,  may  prove  beneficial  in  diminishing  the  mortality. 

The  Treatment  consists  in  dealing  actively  with  any  local  focus  of 
inflammation,  either  by  free  incisions,  purification,  and  drainage,  or 
by  amputation  ;  but  unfortunately  this  is  seldom  likely  to  be 
successful,  as  blood  infection  has  probably  already  occurred.  In 
addition  to  such  means,  tonics  and  stimulants,  with  plenty  of  suitable 
nourishment,  must  be  administered. 

It  is  possible  that  even  this  grave  disease  may  become  amenable 
to  some  of  the  therapeutic  measures  which  have  been  suggested  of 
recent  years.  Thus,  the  antistreptococcic  serum  (p.  28)  may  be 
utilized  when  the  streptococcus  is  .responsible  for  the  trouble,  and 
cases  have  been  reported  as  cured  by  its  agency.  Another  plan 
which  has  been  adopted  is  t  at  of  the  intravenous  injection  of  con- 
siderable quantities  of  normal  sahne  solutiop,  repeated  two  or  three 
times  a  day  ;  by  this  means  diuresis  and  diarrhoea  are  induced,  and 
it  is  hoped  that  thereby  the  organisms  and  their  products  may  be 
eliminated.  This  treatment  will  probably  be  of  greater  value  in 
cases  of  sapraemia  than  in  those  of  true  infective  septicaemia. 

A  few  cases  have  been  successfully  treated  by  means  of  specific 
vaccines  prepared  from  cultures  from  the  patient's  blood,  and  when 
time  permits  (the  preparation  of  the  vaccine  takes  three  or  four  days) 
this  method  should  be  tried.  In  the  interval  a  stock  vaccine 
prepared  from  similar,  but  exogenous,  organisms  may  be  employed. 
It  is  not  likely  to  be  of  much  value  in  the  acute  and  rapidly  fatal 
cases,  for  which  the  serum  treatment  is  still  the  best  method  at  our 
disposal. 


NON-SPECIFIC  PYOGENIC  INFECTIONS 


S7 


V.  Pyaemia. 

Pyaemia  (Greek  ttvov,  pus,  and  aifia,  blood)  is  a  disease  characterized 
by  fever  of  an  intermittent  type,  associated  with  the  formation  of 
multiple  abscesses  in  different  parts  of  the  body,  arising  from  the 
diffusion  of  pyogenic  materials  from  some  spot  of  local  infection. 

Bacteriology. — Any  pyogenic  organism  may  cause  pyaemia,  and, 
theoretically,  pyaemia  may  arise  as  a  complication  following  any  acute 
abscess.  As  a  rule,  however,  there  is  a  sufficiently  rapid  develop- 
ment of  granulation  tissue  to  limit  the  spread  of  infection.  The 
organism  most  commonly  found  is  the  Streptococcus  pyogenes,  but  in  a 
few  cases  the  Staphylococcus  pyogenes  aureus  has  been  observed,  and 
less  commonly  the  Pnemnococcus,  Gonococcus,  or  B.  typhosus.  The 
mere  injection  of  cocci  into  the  circulation  is  not  sufficient  to  give 
rise  to  pyaemia ;  if  they  are  few  in  number,  a 
transient  pyrexia  may  supervene,  and  then 
the  germicidal  powers  latent  in  the  blood 
destroy  them  ;  but  if  the  dose  is  large,  or  the 
individual  is  not  in  a  very  resistant  condition, 
septicaemia,  and  not  pyaemia,  results,  unless 
special  conditions  are  present  which  determine 
the  formation  of  embolic  abscesses.  If  the 
cocci  to  be  injected  are  mixed  with  such  a 
material  or  aggregated  into  such  masses  that 
the  organisms  are  car/ied  on  particles  too 
large  to  pass  through  the  terminal  arterioles 
and  capillaries,  abscesses  develop  wherever 
they  lodge.  In  human  pathology  the  infective  li 
emboli  consist  of  zooglcea  masses  of  organisms,  ^ 
or  of  infected  particles  of  disintegrating  blood-  Fig. 
clot  (Fig.  15). 

The  Ca.use  of  pyaemia  may  be  stated  to  be 
any  condition  which  leads  to  the  formation 

and  detachment  of  infective  emboli  in  the  jj^g  ^p^^'^f  the  clot  pro- 
circulation,  such  conditions  occurring  mainly  jects  into  a  larger  trunk, 
in  the  veins  from  disintegration  of  a  thrombus 
(infective  phlebitis),  but  occasionally  in  the 
heart  (infective  endocarditis).  Acute  infective 
inflammation  of  the  cancellous  tissue  of 
bones  is  very  commonly  associated  with  pyaemia,  owing  to  the 
veins  being  abundant  and  thin-walled,  and  considerable  tension 
present  from  the  unyielding  condition  of  the  surrounding  bony  struc- 
tures. Inflammation  of  the  cranial  bones  coming  on  in  the  course 
of  middle-ear  mischief,  and  causing  thrombosis  of  the  lateral  sinus, 
also  leads  to  its  development.  The  presence  of  large  open-mouthed 
veins  in  the  puerperal  uterus  favours  the  onset  of  the  disease  after 
parturition  if  septic  material  is  present  in  their  vicinity. 

When  an  infective  embolus  lodges  in  any  region  of  the  body,  a 
thrombus  forms  upon  it,  and  in  this  the   micro-organisms  rapidly 


15.  —  Disintegra- 
ting Clot  lying  in  a 
Vein  in  a  Case  of 
Pyemia.    (After  Till- 

MANNS.) 


which  circulating 
blood  is  present,  and 
from  it  infected  emboli 
would  be  detached. 


88  A  MANUAL  OF  SURGERY 

develop,  and  thence  pass  through  the  vessel  wall  into  the  surroundmg 
tissues,  causing  inflammation,  which  is  likely  to  end  in  suppuration. 
In  the  lung  many  such  foci  occur,  distributed  mainly  along  theposterior 
border  and  near  the  surface  ;  each  is  sharply  limited  to  a  wedge- 
shaped  area  of  tissue,  with  the  base  directed  towards  the  periphery. 
It  is  at  first  reddish  in  colour  from  effusion  of  blood  (a  hceniorrhagic 
infarct),  but  soon  becomes  grayish-yellow  from  the  formation  of  pus. 
These  abscesses  are  small,  and  rarely  give  rise  to  any  physical  signs. 
Similar  collections  of  pus,  preceded  or  not  by  an  infarct,  may  be  found 
in  any  organ  of  the  body.  The  lungs,  acting  as  a  filter  to  emboli 
derived  from  the  systemic  veins,  are  naturally  the  first  organs  to  be 
affected,  and  from  the  abscesses  formed  therein  infection  of  the  arterial 
system  may  take  place,  resulting  in  fresh  suppurative  foci  in  the  liver, 
spleen,  kidneys,  brain,  and  in  or  around  joints,  etc.  If,  however,  the 
causative  phlebitis  is  situated  in  the  portal  area,  the  emboli  are  lodged 
primarily  in  the  liver,  giving  rise  to  what  is  known  as  Pylephlebitis. 
When  the  emboli  are  many  in  number,  the  symptoms  are  severe, 
constituting  acute  pysemia  ;  this  is  sometimes  associated  with  a  de- 
velopment of  micro-organisms  in  the  blood,  producing  pyosepticceniia, 
the  patient  perhaps  dying  before  the  secondary  abscesses  have  fully 
developed.  In  other  cases  the  general  symptoms  are  due  rather  to 
the  absorption  of  toxins  from  the  local  foci  than  to  the  development 
of  organisms  in  the  blood.  If  the  emboli  are  few  in  number,  and 
there  is  little  or  no  development  of  microbes  in  the  blood,  the  disease 
is  termed  chronic  pysemia. 

Clinical  History. — The  most  marked  symptom  indicating  the  onset 
of  a  case  of  Acute  Pysemia  is  the  occurrence  during  a  period  of  febrile 
disturbance  of  a  severe  rigor,  which  is  repeated  with  a  sort  of  irregular 
periodicity,  most  frequently  at  intervals  of  about  twenty-four  to 
forty-eight  hours,  somewhat  simulating  an  attack  of  ague.  The  rigors 
do  not  differ  from  those  occurring  in  other  diseases,  but  they  are  very 
severe,  and  usually  followed  by  profuse  sweating.  Between  the  rigors 
the  temperature  may  fall  to  the  normal,  but  more  commonly  remains 
above  it.  The  skin  is  hot  and  soon  develops  an  earthy  or  dull  yellow 
tint,  together  with  erythematous  or  petechial  patches.  A  sweet, 
mawkish,  hay-like  smell  of  the  breath  is  very  characteristic. 
Symptoms  of  grave  depression  supervene,  and  the  patient  rapidly 
wastes.  The  pulse  becomes  soft  and  weak,  the  excretions  are  dimin- 
ished, and  a  certain  amount  of  nocturnal  delirium  is  noticed,  but  no 
loss  of  consciousness.  The  presence  of  a  bruit  in  the  precordial 
region  may  suggest  the  existence  of  an  infective  endocarditis,  which 
is  not  very  uncommon.  The  tongue  varies,  but  is  often  red  with 
very  prominent  papillae,  and  becomes  dry  and  brownish.  Towards 
the  end  of  the  first  week  secondary  abscesses  appear  ;  they  are  some- 
times unaccompanied  by  local  pain  or  tenderness,  and  form  very 
rapidly.  Joints  are  not  infrequently  involved,  and  may  fill  with  pus, 
with  little  or  no  pain.  Unless  treated  early,  rapid  disorganization 
and  dislocation  may  follow.  The  effusion  may  be  puriform,  or  thin 
and  oily ;  it  is  always,  however,  swarming  with  organisms.     In  the 


NON-SPECIFIC  PYOGENIC  INFECTIONS  89 

viscera  the  abscesses  are,  as  a  rule,  small  and  numerous  ;  if  they  occur 
in  vital  organs,  such  as  the  heart  or  brain,  death  may  result  from  their 
local  development.  They  are  characterized,  at  first,  by  the  almost 
total  absence  of  a  barrier  of  granulation  tissue,  and  hence,  even 
when  opened  early  and  aseptically,  are  likely  to  extend  and  con- 
tinue secreting  pus,  instead  of  following  the  usual  course  of  rapid 
repair  which  succeeds  the  aseptic  opening  of  an  ordinary  acute 
abscess. 

Not  uncommonly  in  these  cases  painful  patches  occur  here  and 
there  in  the  subcutaneous  tissues,  accompanied  by  hyperaemia,  which 
fades  away  after  a  few  days ;  such  are  probably  due  to  the  presence 
of  small  infective  emboli,  which  the  patient  has  sufficient  vitality  to 
get  rid  of  without  suppuration. 

In  Chronic  Pyaemia  the  febrile  symptoms  are  much  less  marked  ; 
the  abscesses  are  few  in  number,  and  not  dangerous  unless  forming 
in  important  structures.  Thus,  a  fatal  result  ensued  from  a  single 
abscess  which  developed  in  the  lateral  ventricle  of  the  brain  of  a 
patient  who  had  no  other  symptom  of  pyaemia  except  an  oscillating 
temperature :  it  followed  an  operation  on  a  septic  sinus  leading  to  a 
kidney  already  disorganized. 

If  the  disease  results  from  an  external  wound,  the  condition  of  the 
latter  is  always  most  unsatisfactory.  It  gapes  open  and  presents  an 
inactive,  dry,  glazed  surface,  any  newly-formed  scar  tissue  breaking 
down.  A  layer  of  healthy  granulations  is  an  almost  certain  barrier 
against  the  occurrence  of  pyaemia,  on  account  of  the  germicidal  power 
of  its  constituent  cells.  If  the  disease  arises  in  connection  with  bone, 
the  latter  structure  is  usually  seen  lying  bare  at  the  bottom  of  the 
wound,  denuded  of  its  periosteum,  and  the  cancelli  filled  with  sloughy 
foetid  medulla  or  pus. 

Post-mortem  Appearances. — i.  The  appearance  of  any  external 
wound  has  already  been  described.  2.  The  veins  leading  from  it 
may  be  in  a  healthy  condition,  but  are  more  commonly  in  a  state  of 
infective  phlebitis  ;  the  coats  are  thickened,  and  the  lumen  is  filled 
with  soft,  pale,  disintegrating  clot,  which  extends  for  a  considerable 
distance ;  the  tissues  surrounding  the  vein  are  also  involved  in  the 
suppurative  process.  3.  Secondary  abscesses  are  found  in  various 
parts  of  the  body,  most  frequently  in  the  lungs,  and  their  different 
stages  can  be  clearly  demonstrated  from  the  embolic  colonies  of 
micrococci,  through  the  stage  of  haemorrhagic  infarction  to  the  com- 
plete abscess.  4.  The  general  signs  common  to  all  cases  of  septic 
poisoning  (p.  83)  will  also  be  manifest. 

The  Diagnosis  of  pyaemia  should  not  be  difficult  in  the  majority  of 
cases  ;  but  when  it  originates  without  any  obvious  external  wound 
from  a  deep-seated  focus,  or  if  the  importance  of  some  local  lesion 
has  not  been  appreciated,  the  initial  symptoms  may  be  mistaken  for 
thos3  of  acute  rheumatism  or  ague. 

The  Prognosis  depends  upon  the  inherent  vitality  of  the  patient 
and  the  virulence  of  the  disease.  In  acute  cases  it  is  extremely  grave, 
probably  terminating  in  a  week  or  ten  days,  whilst  in  the  chronic 


90  A  MANUAL  OF  SURGERY 

type  recovery  is  not  only  possible,  but  probable,  if  the  local  abscesses 
are  favourably  situated. 

In  the  Treatment  of  acute  pyaemia  the  surgeon  is  acting  at  a  con- 
siderable disadvantage,  in  that  the  disease  is  only  recognisable  when 
it  has  obtained  some  hold  upon  the  patient,  since  the  recurrent  rigors, 
by  which  it  is  known,  are  usually  the  evidence  of  a  grave  toxaemia. 

Local  treatment  is  most  important,  and  since  the  disease  is  in  the 
majority  of  cases  due  to  the  detachment  of  infected  emboli  from  a 
vein,  the  ideal  surgical  practice  consists  in  preventing,  if  possible, 
the  further  contamination  of  the  general  blood-stream.  This  can 
sometimes  be  accomplished,  in  the  case  of  a  limb,  by  amputation 
well  above  the  local  lesion  ;  or  if  the  medullary  cavity  of  a  bone  is 
the  source  of  trouble,  it  may  be  possible  to  scrape  out  the  gangrenous 
and  offensive  medullary  tissue,  and  disinfect  the  cavity  with  pure 
carbolic  acid  ;  or  if  it  is  due  to  a  wound  in  the  soft  parts,  it  may  be 
feasible  to  dissect  out  the  implicated  vein  and  surrounding  tissues,  or 
at  any  rate  to  remove  the  disintegrating  clot  after  placing  a  ligature 
upon  the  vessel  between  the  thrombus  and  the  heart,  A  typical  illus- 
tration of  such  treatment  is  that  adopted  for  septic  thrombosis  of  the 
lateral  sinus  complicating  disease  of  the  middle  ear,  where,  after  tying 
the  internal  jugular  in  the  neck,  the  sinus  is  exposed  by  the  trephine 
or  gouge,  opened,  and  all  the  septic  clot  removed,  partly  from  above, 
partly  from  below.  Admirable  results  have  been  thereby  obtained. 
The  abscesses  must  be  dealt  with,  where  practicable,  by  opening  them 
early  and  washing  them  out ;  such  wounds  often  heal  well,  and  joints 
which  have  been  distended  with  pus  may  recover  with  free  mobility. 
Occasionally,  however,  although  rigid  asepsis  has  been  maintained, 
the  suppuration  continues,  and  even  sloughing  of  the  abscess  wall 
may  follow.  If  the  general  condition  can  be  improved,  a  barrier  of 
granulation  tissue  will  form  in  time,  and  repair  be  established. 

Constitutional  treatment  consists  in  supporting  the  patient's 
strength  by  nourishing  diet  and  stimulants,  and  in  taking  precautions 
to  avoid  bedsores  or  any  local  injury.  Salicylate  of  quinine  may  be 
administered,  though  its  value  is  doubtful.  The  antistreptococcic 
serum  (p.  28)  may  also  be  utilized,  and  it  may  do  good  in  cases 
which  have  not  progressed  too  far.  Vaccine  treatment  may  also 
be  tried. 


CHAPTER  V. 

ULCERATION. 

Ulceration  has  been  defined  as  the  '  molecular  or  particulate  death 
of  a  part,'  by  which  is  meant  the  disintegration  of  the  superficial 
tissues,  which  liquefy  and  disappear,  and  usually  without  any 
obvious  slough.  It  differs .  from  gangrene  in  that  the  latter  term  is 
used  to  denote  the  simultaneous  loss  of  vitality  of  a  considerable 
portion  of  tissue.  The  two  processes  are,  however,  often  closely 
associated — in  fact,  both  signify  tissue  necrosis ;  in  the  former  the 
dead  particles  are  not  always  visible  to  the  naked  eye,  whereas  in 
the  latter  the  necrotic  portions,  if  superficial,  can  always  be  seen. 
Three  main  classes  of  ulcers  are  met  with  in  surgical  practice  : 

I.  Ulcers  due  to  traumatism  or  to  nojt- specific  pyogenic  bacteria,  e.g.,  the 
spreading,  healing,  chronic,  etc. 

II.  Ulcers  due  to  specific  bacteria,  e.g.,  soft  chancre,  lupoid,  tuber- 
culous, syphilitic,  etc. 

III.  Malignant  ulcers,  e.g.,  rodent,  epitheliomatous,  scirrhous,  and 
f ungating. 

Causation. — Ulceration  is  due  to  the  application  of  an  irritant  to  the 
surface  of  such  an  intensity  and  for  such  a  period  as  to  lead  to 
local  inflammation,  resulting  in  the  destruction  of  the  tissue  affected. 
Any  form  of  irritant,  whether  chemical,  thermal,  mechanical,  or 
infective,  may  accomplish  this  end,  and  all  the  factors  predisposing  to 
inflammation  will  hasten  its  occurrence.  Thus,  faulty  nutrition, 
whether  from  anaemia  or  from  long-standing  congestion,  is  par- 
ticularly liable  to  further  the  ulcerative  process.  Moreover,  when 
any  part  becomes  anaesthetic,  or  is  cut  off  from  its  trophic  centres, 
the  continued  presence  of  an  irritant  may  not  be  appreciated,  and 
hence  destructive  inflammation  occurs,  e.g.,  corneal  ulcer  following 
section  of  the  fifth  nerve,  or  perforating  ulcer  of  the  foot  in  tabes. 
In  malignant  disease  the  projection  of  the  mass  of  the  growth  may 
expose  it  unduly  to  irritation ;  but  the  chief  cause  of  ulceration  is 
the  replacement  of  the  deeper  layers  of  the  skin  or  mucous  membrane 
by  the  cells  of  the  neoplasm,  so  that  when  the  superficial  epithelium 
wears  off  or  is  lost,  it  cannot  be  reproduced. 


91 


92  A  MANUAL  OF  SURGERY 


I.  Ulcers  due  to  Traumatism  or  to  Non-specific  Pyogenic  Bacteria. 

Clinical  History. — Every  ulcer  of  this  class  tends  sooner  or  later 
to  recovery,  and  so  may  be  said  to  pass  through  three  stages,  viz., 
(i)  that  of  ulceration  proper,  or  extension ;  (2)  a  stage  of  transition, 
or  preparation  for  healing,  which  may  be  short  or  long,  according  to 
whether  the  ulcer  is  running  a  rapid  or  a  slow  course,  and  persists 
until  the  surface  is  covered  with  granulations ;  and  (3)  the  stage  of 
healing  or  repair.  It  must  be  clearly  understood  that  the  first  stage 
alone  represents  the  true  ulcerative  process  ;  when  this  ceases,  the 
ulcer  proper  disappears,  and  merely  a  superficial  loss  of  substance, 
the  result  of  the  preceding  ulceration,  remains.  If  every  simple 
ulcer  passes  through  these  three  stages,  then  every  variety  of  simple . 
tdcer  must  necessarily  be  in  one  of  the  three  stages,  and  hence  may  be 
described  as  a  modification  of  a  typical  condition  representing  the 
stage  to  which  it  belongs.  Naturally,  in  a  large  ulcer  the  three 
stages  may  co-exist,  or  a  healing  ulcer  may  from  intrinsic  or  extrinsic 
causes  relapse  again  to  the  stage  of  tissue  destruction. 

Stage  I.  :  Ulceration  Proper,  or  Extension. — The  special  charac- 
teristic of  this  stage  is  that  destructive  changes  are  progressing  with 
greater  or  less  rapidity,  and  hence  the  ulcers  may  be  described  as 
inflamed,  spreading,  or  sloughing. 

Naked-eye  Appearances. — Surface,  covered  with  ashy  gray  or  dirty 
yellow  material,  partly  slough,  partly  lymph,  partly  breaking-down 
tissue  ;  no  granulations  are  present ;  the  tendency  to  slough  is  most 
marked  when  the  organisms  are  particularly  virulent,  or  if  the 
resistance  of  the  tissues  is  much  diminished  ;  discharge,  considerable 
in  amount,  thin,  sanious,  and  often  irritating  and  offensive,  rarely 
purulent ;  margins,  thickened  and  inflamed,  and  the  surrounding 
tissues  often  cedematous  and  infiltrated  ;  edge,  sharply  cut  and  well 
defined  ;  the  base  of  the  ulcer  is  thickened  and  fixed  to  the  underlying 
structures. 

Microscopically,  all  the  phenomena  of  inflammation  may  be 
observed  progressing  to  thrombosis  and  tissue  necrosis,  so  that  in 
approaching  the  surface  from  the  healthy  tissues  one  would  pass 
through  zones  of  active  hyperaemia,  of  retarded  blood-flow  with 
infiltration  of  leucocytes  and  plasma,  of  stasis  and  thrombosis,  whilst 
the  tissues  are  in  a  state  of  coagulation-necrosis. 

Treatment  of  First  Stage. — This  resolves  itself  into  removing  the 
cause,  protecting  the  surface  from  all  sources  of  mechanical  irrita- 
tion, and  purifying  it  from  all  septic  contamination.  The  inflamed 
part  must  be  kept  at  rest,  and  if  necessary  raised  from  a  dependent 
position  [i.e.,  the  leg  must  not  be  allowed  to  hang  down),  whilst  the 
sore  is  dressed  with  moist  and  warm  antiseptic  applications,  such 
as  a  boracic  poultice.  When  the  parts  are  very  offensive,  a  charcoal 
and  linseed-meal  poultice  may  be  first  employed.  The  state  of  the 
bowels  and  constitution  must  be  attended  to,  and  probably  a  mild 
purgative  will  be  needed. 


ULCERATION  93 

Stage  II. :  The  Transition  Period  comprises  all  the  changes  which 
occur  from  the  termination  of  the  ulcerative  process  proper  to  the 
time  when  healing  is  fully  established  by  the  wound  becoming 
covered  with  granulations.  In  short,  it  may  be  described  as  the 
stage  oi  preparation  for  healing. 

Naked-eye  Appearances. — When  the  destructive  process  has  ceased, 
and  the  septic  element  has  been  eliminated,  the  surface  of  the  ulcer 
begins  to  clean,  and  becomes,  as  it- were,  glazed  over;  sloughs  are 
either  removed  in  the  dressing  or  absorbed.  The  discharge  becomes 
less  abundant  and  more  serous  in  character,  and  the  angry  red  blush 
is  replaced  by  a  rosy  hyperaemia.  The  infiltretion  of  the  base  also 
diminishes,  so  that  the  tissues  around  are  less  fixed  and  more  supple. 
The  film  on  the  surface  becomes  more  and  more  defined,  and  in  the 
course  of  time,  shorter  or  longer,  according  to  circumstances,  little 
red  spots  make  their  appearance  here  and  there;  these  gradually 
increase  in  number  and  size,  and  coalesce,  until  the  whole  surface  is 
covered  by  what  has  now  become  granulation  tissue.  The  processes 
occurring  in  this  stage  are  :  [a)  the  removal  of  the  sloughs ;  (h)  the 
covering  of  the  surface  with  a  cellulo-plastic  exudation ;  and  (c)  the 
vascularization  of  this  newly-formed  material,  and  its  conversion 
into  granulation  tissue. 

Microscopic  Appearances. — When  the  action  of  the  irritant  has 
ceased,  the  migration  of  the  leucocytes  lessens,  and  the  destruction 
of  tissue  comes  to  an  end.  The  surface  of  the  ulcer  is  now  covered 
with  a  layer  of  small  round  cells  resembling  lymphocytes  in  appear- 
ance, plasma  cells  (p.  44),  and  cells  formed  by  the  proliferation  of 
the  neighbouring  connective-tisstie  elements,  the  superficial  ones 
being  intermixed  with  fibrin  in  such  a'^way  that  the  cells  lie  in  the 
interstices  of  the  ffKrillae  ;  this  constitutes  the  film  mentioned  above. 
The  vessels  in  the  area,  where  merely  stasis  has  occurred,  become 
patent,  and  the  circulation  in  the  neighbourhood  of  the  ulcer  is  thus 
restored.  The  vascularization  of  this  superficial  film  is  next  under- 
taken, according  to  the  process  described  in  Chapter  IX.  The 
wound  thus  becomes  covered  with  granulation  tissue,  and  with  its 
formation  the  processes  included  in  the  second  stage  come  to  an  end. 

All  the  forms  of  chronic  ulcer  which  are  neither  spreading  nor  actively 
healing  may  be  included  in  this  transitional  stage,  viz.,  the  indolent  or 
callous  ulcer,  the  irritable,  the  varicose,  etc. 

The  Indolent  or  Callous  Ulcer  occurs  most  frequently  on  the  legs 
of  women  about  the  middle  period  of  life.  The  size  varies  greatly, 
but  it  is  sometimes  so  extensive  as  to  involve  the  whole  circum- 
ference of  the  limb.  It  may  also  follow  large  burns  on  any  part  of 
the  body ;  healing  proceeds  to  a  certain  extent,  and  then  stops  from 
the  fact  that  the  contraction  of  the  cicatricial  tissue  already  formed 
interferes  with  the  vitality  of  the  part  still  unhealed  by  compressing 
the  vessels,  and  so  cutting  off  the  granulations  from  their  source  of 
nutriment.  The  surface  is  usually  smooth  and  glistening,  and  of  a 
dirty  yellow  colour,  with  perhaps  a  few  badly-formed  granulations ; 
the  edges  are  hard  and  sharply  cut,  and  elevated  considerably  above 


04  A  MANUAL  OF  SURGERY 

tne  surface,  whilst  the  skin  around  may  be  heaped  up  over  the  edge, 
and  either  covered  with  sodden  cuticle  or  congested.  The  skin  of 
the  limb  is  often  deeply  pigmented  from  chronic  congestion,  the 
pigmentation  starting  in  the  separate  papillae  as  maculae,  which 
gradually  coalesce.  The  discharge  is  purulent  or  serous,  and  may  be 
so  abundant  and  irritating  as  to  cause  eczema  of  the  parts  around, 
and  thus  give  rise  to  one  form  of  eczematotis  ulcer.  The  base  is  adhe- 
rent to  the  underlying  tissues,  fasciae,  etc.  ;  and  this  constitutes  one 
of  the  main  difficulties  in  healing,  as  contraction  is  thus  prevented. 
If  the  ulcer  is  situated  over  a  bone,  such  as  the  tibia,  chronic  perio- 
stitis results,  and  a  subperiosteal  node  is  formed,  corresponding 
exactly  to  the  size  and  situation  of  the  ulcer,  forming  a  mushroom- 
shaped  projection,  and  possibly  going  on  to  necrosis  or  to  diffuse 
osteo-periostitis  of  the  whole  bone.  Such  ulcers  are  sometimes  very 
painful  from  pressure  on  cutaneous  nerves,  or  from  a  localized  cellu- 
litis,  associated,  perhaps,  with  inflammation  of  veins  and  lymphatics. 
Thrombosis  not  infrequently  occurs  in  both  sets  of  vessels,  leading 
to  chronic  oedema  of  the  foot,  often  of  a  very  solid,  brawny  type,  and 
the  limb  may  even  pass  into  a  condition  of  pseud-elephantiasis. 

The  so-called  Irritable  Ulcer  is  usually  met  with  in  this  stage. 
Its  chief  peculiarities  are  the  position,  generally  in  the  neighbour- 
hood of  the  ankle,  and  the  pain  which  accompanies  it.  The  surface 
of  a  healing  or  chronic  ulcer  cari  usually  be  touched  without  the 
patient  complaining ;  but  in  this  variety  the  pain  is  excessive, 
especially  at  night.  It  was  pointed  out  by  the  late  Mr.  Hilton  that, 
if  a  probe  is  run  lightly  over  the  surface  of  such  a  sore,  one  or  more 
spots  will  be  indicated  as  the  chief  seats  of  the  pain,  the  rest  being 
insensitive.  In  all  probability,  nerve  filaments  are  there  exposed,  as 
the  pain  has  a  very  marked  burning  or  shooting  character. 

The  Varicose  Ulcer  occurs  in  the  leg  of  a  patient  who  is  the 
subject  of  aggravated  varicose  veins,  especially  when  the  smaller 
venules  are  involved.  The  skin  becomes  passively  congested,  and 
its  nutrition  is  consequently  impaired.;  any  injury  or  abrasion,  which 
would  readily  heal  in  a  sound  limb,  is  likely  under  such  circumstances 
to  give  rise  to  a  chronic  sore.  Again,  it  may  be  preceded  by  eczema 
resulting  from  the  irritation  of  dirt  or  the  friction  of  hard  trousers, 
whilst  occasionally  it  may  be  due  to  the  yielding  of  the  thinned  skin 
which  forms  the  only  covering  of  a  much  dilated  vein,  an  accident 
often  leading  to  severe  haemorrhage.  The  characters  of  a  varicose 
ulcer  in  the  main  correspond  to  those  of  the  indolent  variety,  but 
when  due  to  rupture  are  quite  small ;  it  is  usually  found  on  the 
inner  and  lower  portion  of  the  leg,  whilst  syphilitic  sores  are 
more  often  placed  nearer  the  knee  and  on  the  outer  side. 

Treatment  in  this  stage  differs  according  to  the  conditions  present. 
If  it  is  merely  a  passing  phase  in  the  progress  of  an  ulcer  tending 
rapidly  to  repair,  the  same  course  of  treatment  should  be  adopted  as 
in  the  earlier  period,  viz.,  rest  and  protection  from  irritation.  It 
may  be  advisable  to  shield  the  surface  from  contact  with  dressings 
by  the  intervention  of  a  small  portion  of  purified  *  protective ' — i.e.. 


ULCERATION 


95 


oiled  silk  coated  with  dextrin — so  that  the  reparative  material  may 
not  be  damaged  during  their  removal. 

The  Chronic  Ulcer  needs  much  care  in  its  treatment,  and  some 
cases  require  operative  interference.  Rest  in  a  more  or  less  elevated 
position  is  absolutely  essential  in  order  to  relieve  the  congested 
condition  of  the  limb ;  whilst  if  the  surface  is  foul,  a  charcoal 
poultice  may  be  beneficial,  or  the  sore  may  be  dusted  over  with 
iodoform,  and  boracic  fomentations  applied.  This  may  be  preceded 
in  some  cases  by  touching  the  surface  with  solid  nitrate  of  silver,  or 
with  a  solution  of  chloride  of  zinc  (40  grains  to  i  ounce). 

Pressure  has  been  found  of  considerable  service  in  the  treatment 
of  these  ulcers  ;  an  ordinary  bandage,  reaching  from  the  toes  to  the 
knee,  will  suffice  in  some  cases,  a  suitable  dressing  of  boric  acid 
ointment,  with  perhaps  some  resin  ointment  added  to  make  it  more 
stimulating,  being  applied  beneath  it.  Martins  indiarubber  bandage 
is  more  useful  when  the  veins  are  much  enlarged. 

The  method  of  dealing  with  chronic  ulcers  suggested  by  Professor 
Unna,  of  Hamburg,  has  given  excellent  results.  It  consists  in  the 
use  of  an  adhesive  plaster,  made  up  as  follows  :  Gelatin,  5  parts  ; 
oxide  of  zinc,  5  parts;  boric  acid,  i  part;  glycerine,  8  parts;  water, 
6  parts  ;  to  this  ichthyol  (5  per  cent.)  may  be  added  with  advantage. 
The  Hmb  is  first  washed  thoroughly  with  soap  and  water,  and 
purified  with  carbolic  or  subUmate  lotion.  It  is  then  wrapped  round 
with  a  single  layer  of  sterile  gauze,  and  the  paste,  liquefied  by 
placing  it  in  a  galhpot  in  a  saucepan  of  boiling  water,  is  applied 
over  it  with  a  paint  or  paste  brush.  Another  layer  of  gauze  is 
placed  over  the  paste  arid  a  thin  bandage  over  all,  and  the  whole 
allowed  to  dry.  Where  there  is  extensive  varix,  the  paste  should 
extend  from  the  ankle  to  the  knee,  and  may  sometimes  include  the 
foot.  If  there  is  much  discharge,  the  ulcer  should  not  be  covered, 
and  the  dressing  should  be  reapplied  daily ;  but  after  it  has  dimin- 
ished in  amount,  the  paste  may  be  carried  right  over  the  sore,  and 
the  whole  application  left  in  position  for  a  week,  or  even  longer. 

When  the  edges  are  very  indurated  and  thickened,  and  all  action 
is  at  a  standstill,  Syme's  suggestion  may  be  followed,  viz.,  to  bhster 
the  whole  surface,  as  well  as  the  surrounding  skin.  A  more  satis- 
factory method,  but  requiring  an  anaesthetic,  is  to  scrape  the  surface 
with  a  sharp  spoon,  and  then  to  rub  in  a  strong  solution  of  chloride 
of  zinc.  As  soon  as  healthy  action  is  established,  skin-grafting  may 
be  employed,  if  necessary  ;  it  is  useless  to  undertake  this,  however, 
unless  the  patient  can  promise  to  rest  for  a  prolonged  period,  and 
even  then  elastic  support  will  be  subsequently  required.  In  bad 
cases  where  a  considerable  portion  of  the  circumference  of  the  limb 
is  involved,  when  the  ulcer  is  very  callous  and  its  base  attached  to 
the  tibia,  causing  severe  pain  at  night  from  chronic,  periostitis,  and 
especially  when  the  patient  is  unable  to  rest  up,  amputation  may  be 
the  best  treatment.  Faraboeuf's  amputation  at  the  site  of  election 
can  often  be  undertaken  with  advantage. 

Where  varicose  veins  exist,  treatment  is  of  little  avail  unless  these 


96  A  MANUAL  OF  SURGERY 

are  efficiently  dealt  with  either  by  operation  or  by  some  suitable 
support,  such  as  Unna's  paste.  It  is  often  undesirable  to  attack  the 
veins  locally  owing  to  the  septic  condition  of  the  ulcer,  which  must  be 
dealt  with  by  rest  and  fomentations.  Operation  consists  either  in 
removal  of  the  dilated  veins  at  a  higher  level,  or  in  Trendelenburg's 
operation  {q.v.)  in  suitable  cases. 

The  Irritable  Ulcer  may  be  treated  by  discovering  the  painful  spots, 
and  incising  the  tissues  just  above  them  with  a  knife,  so  as  to  divide 
the  exposed  nerves  ;  but  thorough  scraping  under  an  anaesthetic  is 
preferable. 

The  Eczematous  Ulcer  must  be  dealt  with  differently  from  the 
others,  or  the  eczema  will  be  aggravated.  Soothing  applications 
are  needed,  such  as  lead  lotion,  and  when  once  the  acute  stage  has 
passed,  tarry  preparations  (liq.  carbonis  detergens,  i  ounce  to  i  pint 
of  lotio  plumbi),  or  an  ichthyol  ointment  (5-10  per  cent.),  may  be 
beneficially  employed.  A  mixture  of  benzoate  of  zinc  and  boric  acid 
ointments  is  a  very  useful  application,  or  Unna's  paste  with  ichthyol 
may  be  utilized. 

Stage  III.  :  Repair  having  now  been  fully  established,  we  have  to 
deal  with,  not  a  healthy  ulcer,  for  such  a  condition  cannot  exist,  but 
a  healthy  granulating  wound,  the  result  of  ulceration,  or,  as  we  call 
it,  to  avoid  confusion,  a  'healing  ulcer.' 
/  A  Healing  Ulcer  is  characterized  by  the  following  conditions  : 
/  Surface,  smooth  and  even,  shelving  gradually  from  the  skin,  and 
covered  with  healthy  granulations ;  these  present  a  florid  red  appear- 
ance, are  painless,  and  bleed,  but  not  readily,  on  being  touched. 
The  discharge  varies  according  to  the  plan  of  treatment  adopted  :  if 
the  surface  is  kept  at  rest  and  free  from  all  irritants,  either  septic  or 
antiseptic,  the  discharge  is  merely  serous  ;  but  should  the  wound 
become  septic,  or  be  dressed  with  irritating  antiseptics,  ordinary  pus 
is  formed.  The  surrounding  skin  is  soft,  flexible,  and  free  from 
inflammatory  congestion,  and  the  base  is  similarly  free  from  fixity. 
The  margins  present  a  healing  edge,  Avhich  has  been  described  as 
manifesting  three  coloured  zones  :  within  is  a  red  area  consisting 
of  granulation  tissue,  covered  by  a  single  layer  of  epithelial  cells, 
which  cannot  be  seen  except  in  a  good  light ;  next  comes  a  thin 
dusky  purple  or  blue  line,  where  the  granulations  are  covered  by 
a  few  layers  of  epithelium,  and  the  circulation  is  becoming  retarded 
owing  to  cicatricial  development ;  whilst  outside  is  a  white  zone  due 
to  the  heaping  up  of  sodden  cuticle  upon  the  healthy  or  healed 
part. 

The  method  of  repair  in  such  a  wound  consists  in  a  change  of 
the  deeper  layer  of  granulations  into  fibro-cicatricial  tissue,  which 
gradually  contracts  and  is  finally  covered  with  epithelium.  For  full 
description  see  Chapter  IX. 

If  emolhent  applications  are  used  too  long,  the  granulations 
become  pale,  protuberant,  and  cedematous,  and  the  healing  process 
is  temporarily  checked.  A  depressed  general  condition  of  the 
patient,  or  a  varicose  condition  of  the  veins,  may  also  account  for 


ULCERA  TION 


97 


this,  and  the  term  a  weak  ulcer  is  appHed  to  it,  whilst  the  prominent 
flabby  granulations  are  popularly  known  as  proud  flesh. 

Treatment. — The  part  must  be  kept  at  rest,  and  if  the  leg  is  the 
seat  of  the  trouble,  it  should  not  be  allowed  to  hang  down.  The 
wound  must  be  protected  from  injury  by  a  dressing  which  can  be 
removed  without  damaging  the  surface.  A  piece  of  sterile  protective, 
the  exact  size  of  the  lesion,  may  be  placed  over  it,  and  covered  with 
sterile  gauze,  or  the  wound  may  be  dressed  with  a  simple  ointment 
{e.g.,  ung.  acidi  borici,  diluted  with  an  equal  part  of  vaseline)  spread 
on  sterile  butter-cloth  or  lint.  If  the  granulations  become  too 
prominent,  they  may  be  lightly  touched  with  nitrate  of  silver,  or  a 
stimulating  lotion  applied,  such  as  that  known  as  lotio  rubra 
(R.  Zinci  sulphatis,  gr.  ii.  ;  tinct.  lavandulae  co.,  spir.  rosmarini, 
aa  ni^xx. ;  acidi  borici,  gr.  x.  ;  aquam  destill.  ad  gi.). 

Large  ulcers  require  assistance  in  order  to  obtain  expeditious 
healing,  otherwise  a  time  comes  when  the  contraction  of  the 
cicatricial  tissue  interferes  with  the  nutrition  of  the  granulations, 
and  retards  the  healing  process.  To  obviate  this  difficulty,  skin- 
grafting  is  frequently  utilized. 

Skin-grafting,  or  the  transplantation  of  more  or  less  of  the  thickness 
of  the  skin  from  a  healthy  to  a  healing  part,  was  introduced  by 
Reverdin  in  1869,  and  has  since  been  much  elaborated.  The 
following  are  the  chief  methods  employed  : 

1.  Transplantation  of  small  pieces  of  the  cuticle  and  cutis, 
Reverdin's  original  plan.  A  small  portion  of  the  cutaneous  tissue 
is  pinched  up  with  or  without  forceps,  and  removed  by  a  pair  of 
sharp  curved  scissors.  •  It  should  include  the  cuticle  and  a  portion 
of  the  cutis  vera,  so  that  a  drop  or  two  of  blood  will  slowly  ooze 
from  the  denuded  surface.  The  graft  is  gently  placed  cutis  down- 
wards on  the  surface  of  the  granulations  and  covered  with  protective, 
purified  in  boric  acid.  Many  of  these  may  be  applied  at  the  same 
time,  and  the  whole  wound  carefully  dressed  and  protected.  If  there 
is  much  discharge,  the  grafts  will  not  '  take '  ;  but  if  the  surface  is 
healthy,  there  should  be  no  difficulty  in  getting  them  to  grow. 
Usually  they  disappear  for  a  day  or  two,  from  the  cuticle  becoming 
softened  or  disintegrated  ;  but  soon  the  epithelium  of  the  cutis 
spreads,  and  makes  itself  visible  as  a  distinct  centre  of  repair. 

2.  Transplantation  of  large  portions  of  cuticle  as  suggested  by 
Thiersch.  This  method  consists  in  removing  wide  strips  of  cuticle 
with  a  razor,  and  implanting  them  on  a  fresh  wound  or  on  a  raw 
surface  previously  denuded  of  all  granulations  by  scraping.  All 
haemorrhage  must  be  stayed  by  pressure,  a  layer  of  protective  being, 
however,  interposed,  so  that  when  the  gauze  or  swabs  are  removed 
the  bleeding  shall  not  recur.  The  strips  of  cuticle  are  then  cut,  care 
being  taken  to  make  them  as  thin  as  possible ;  the  papillae  are 
always  encroached  on,  however,  and  hence  some  amount  of  blood 
escapes,  in  which  the  grafts  are  allowed  to  remain  soaking  until 
required  for  use.  No  subcutaneous  tissue  must  be  included  in  the 
graft.     When  it  is  thought  that  sufficient  material  has  been  obtained, 

7 


98  A  MANUAL  OF  SURGERY 

the  wound  is  uncovered,  and  the  grafts  are  gently  transferred,  being 
applied  in  such  a  way  that  they  overlap  each  other  and  also  the 
margins  of  the  defect.  There  is  always  some  tendency  for  the  edges 
of  the  graft  to  turn  in,  and  this  must  be  prevented.  They  are  then 
covered  with  protective,  or  preferably  with  perforated  tin  or  thin 
silver-foil,  and  the  whole  dressed  antiseptically.  There  is  usually 
no  need  to  look  at  the  wound  for  some  days.  The  outer  sides  of  the 
thigh  and  arm  are  the  best  places  from  which  to  take  grafts. 

3.  The  whole  thickness  of  the  skin  is  used  in  some  instances 
{Wolfe  graft).  The  graft  is  cut  rather  larger  than  is  necessary,  to 
allow  of  shrinkage,  and  all  subcutaneous  tissue  and  fat  removed 
therefrom.  It  is  applied  to  the  raw  surface  of  the  wound  after 
scraping  away  all  granulations,  and  stitched  into  position.  It  may 
also  be  applied  to  the  raw  surface  of  an  operation  wound. 


II,  Ulcers  due  to  Specific  Bacteria. 

The  different  forms  of  infective  ulcers  met  with  in  surgical 
practice  will  be  described  under  the  appropriate  headings  in  different 
parts  of  the  book.     It  will  suffice  here  to  mention  them  : 

Soft  Chancre  (p.  140). — This  may  be  taken  as  a  type  of  all 
infective  ulcers,  clearly  showing  the  stages  of  infection,  incubation, 
ulceration,  and  repair. 

Ulcers  due  to  Syphilis. 

(a)  The  primary  sore  (p.  145). 

(b)  Secondary   ulcers,    mainly   of    mucous    membranes,    but 

sometimes  involving  the  skin  (p.;  149). 

(c)  Intermediate,  rupial,  or  ecthymatous  sores  (p.  152), 

(d)  Tertiary   ulcers    from    the    disintegration    of    gummata 

(P-  154)-  .  ... 

Phagedenic  ulceration  (p.  147)  is  usually  associated  with  syphilis. 

Ulcers  due  to  Tubercle : 

{a)  The     lupoid     ulcer,    due     to    a    cutaneous    tuberculosis 
(Chapter  XVI.),  or 

(b)  The  tuberculous  ulcer,  arising  as  a  rule  from  the  bursting 

of  a  subcutaneous  or  submucous    tuberculous    abscess 

(P-  173)- 

(c)  Various  other  tuberculous  ulcerative  lesions  of  the  skin 

are  described  by  dermatologists  under  the  title  '  scrofulo- 
dermia,'  whilst  Bazin's  disease  (or  erythema  induratum) 
is  possibly  tuberculous  in  origin. 

III.  Malignant  Ulcers. 

These  are  due,  as  has  already  been  pointed  out,  not  to  any 
inflammatory  process,  but  to  the  actual  replacement  of  the  skin  by 
the  growth,  so  that  loss  of  substance  necessarily  ensues.  They  will 
be  described  in  Chapter  VIII. 


CHAPTER  VI. 

GANGRENE. 

By  gangrene,  or  necrosis,  is  meant  the  simultaneous  loss  of  vitality 
of  a  considerable  area  of  tissue.  If  the  process  is  limited  to  the  soft 
parts  of  the  body,  it  is  often  termed  sloughing  or  sphacelation,  and  the 
dead  mass  a  slough  or  sphacelus  ;  if  a  tangible  portion  of  bone  dies,  the 
necrosed  mass  is  called  a  sequestrum  ;  while  the  term  gangrene  is  more 
especially  applied  to  a  necrotic  process  affecting  simultaneously  the 
nard  and  soft  tissues  of  a  limb. 

General  Hititory  of  a  Case  of  Gangrene. 

Signs  of  Death. — Death  of  a  limited  portion  of  the  body  can  be 
recognised  prior  to  the  supervention  of  evident  post-mortem  changes 
within  it  by  five  characteristic  signs: 

1.  Loss  of  pulsation  in  the  vessels. 

2.  Loss  of  heat,  since  no  warm  blood  is  brought  to  it. 

3.  Loss  of  sensation,  although  much  pain  may  be  experienced 
whilst  death  is  occurring,  and  such  may  be  referred  to  the  dead  part 
through  irritation  of  the  nerves  above. 

4.  Loss  of  function  of  the  gangrenous  mass,  which,  if  it  is  a  limb, 
lies  flaccid  and  motionless. 

5.  Change  of  colour,  the  character  of  which  depends  on  the 
amount  of  blood  present  at  the  time  of  death  ;  if  the  part  is  full 
of  blood  it  becomes  purple  and  mottled ;  if  anaemic,  a  waxy  or  cream 
colour  results. 

These  five  signs  may  be  in  measure  present  when  the  vitality  of  a 
limb  is  seriously  depressed,  as  by  ligature  of  the  main  vessel  or  by 
its  embolic  obstruction  ;  but  if  they  continue  for  any  length  of  time, 
death  is  certain  to  ensue,  and  they  will  then  be  rendered  more 
obvious  by  the  phenomena  about  to  be  described.  Sometimes  it  is 
a  little  difficult  to  determine  whether  a  part  is  dead,  especially  when 
it  is  engorged  with  venous  blood  and  the  arterial  pulsation  has 
ceased ;  if  living,  it  will  usually  be  found  that  pressure  causes  some 
modification  of  the  colour,  and  that  the  discoloration  returns  when 
the  pressure  is  removed. 

Changes  occurring  in  the  Dead  Tissues. — The  character  of  these 
depends  mainly  on  the  condition  of  affairs  at  the  time  of  death,  and 
whether  or  not  putrefaction  supervenes. 

99 


lOO  A  MANUAL  OF  SURGEB.Y 

1.  Dry  Gangrene  (  =  death  +  mummification)  can  only  occur  when 
the  tissue  involved  is,  previous  to  its  death,  more  or  less  drained  of 
its  fluids,  so  that  it  readily  shrivels  up  and  loses  its  moisture.  The 
usual  cause  is  chronic  arterial  obstruction,  as  brought  about  by 
atheroma  or  calcification  of  the  terminal  arteries,  to  which  a  sudden 
or  gradual  complete  occlusion  of  the  main  trunk  is  often  superadded. 
The  dead  part  becomes  hard,  dry  and  wrinkled,  and  is  of  a  dark 
brown  or  black  colour  from  the  diffusion  of  the  disintegrated  haemo- 
globin (Fig.  1 6).  The  more  fleshy  parts  [e.g.,  above  the  ankle)  rarely 
undergo  complete  mummification,  and  are  often  considerably 
inflamed,  and,  if  sepsis  be  admitted,  horribly  offensive. 

2.  Moist  Gangrene  arises  when  a  part  of  the  body  full  of  fluid  dies, 
and  is  especially  associated  with  conditions  which  involve  venous 
obstruction  as  well  as  a  sudden  arterial  block,  or  with  acute  arterial 
thrombosis  in  a  previously  sound  limb,  e.g.,  in  traumatic  gangrene 
due  to  pressure  upon,  or  rupture  of,  the  main  trunk.  The  loss  of 
the  vis-a-tergo  derived   from   the  heart's  impulse  causes  a  negative 


Fig.   i6. — Senile  Dry  Gangreki:, 

pressure  in  the  capillaries,  which  become  filled  by  regurgitation 
from  the  veins.  Obviously,  such  a  condition  is  well  suited  for  the 
development  of  the  organisms,  which  always  exist  in  numbers  on 
the  skin,  and  unless  the  most  vigorous  efforts  are  made  to  render  it 
aseptic  before  or  immediately  after  death,  moist  gangrene  is  certain 
to  be  associated  with  putrefaction ;  but  it  must  be  clearly  under- 
stood that  the  latter  is  no  essential  part  of  the  gangrenous  process. 

Aseptic  Moist  Gangrene  is  characterized  by  the  dead  tissues  be- 
coming more  or  less  discoloured,  either  purple  or  any  shade  from 
black  to  yellow,  green  or  white.  It  remains  of  much  the  same  size 
and  consistency  as  at  the  time  of  death  so  long  as  it  is  kept  from 
contamination,  and  is  then  simply  and  quietly  cast  off  from  the 
surrounding  tissues  without  any  obvious  inflammatory  disturbance, 
although  a  certain  amount  of  toxaemia  may  result  from  the  absorption 
of  various  products  from  the  dead  tissues. 

Septic  or  Putrid  Moist  Gangrene  (Fig.  17)  is  necessarily  associated 
with  a  rapid  breaking-up  and  disintegration  of  the  mass,  which 
becomes  black,  green,  or  yellow.     The  cuticle  is  raised    from   the 


GANGRENE  lai 

cutis  vera  by  blebs  containing  stinking  serum,  or  even  bubbles  of 
gas,  and  these  can  be  readily  pressed  along  under  the  epidermis  for 
some  distance.  The  tissues  of  the  limb  are  soft  and  lacerable,  and 
on  grasping  it  emphysematous  crackling  is  usually  noted. 

The  Later  History  of  a  gangrenous  mass  depends  entirely  on  its 
asepticity  or  not,  and  on  its  bulk. 

(a)  If  the  necrotic  area  is  small  in  size  and  aseptic,  it  may,  under 
favourable  circumstances,  be  entirely  absorbed  in  the  same  way  as  is 
a  catgut  ligature.  Such  is  often  observed  after  sloughing  of  small 
portions  of  amputation  flaps ;  if  the  part  is  kept  dry  and  aseptic,  it 
is  gradually  removed,  and  when  the  process  is  completed,  a  small 
dark  scab  will  fall  or  be  picked  off,  and  a  cicatrix  be  found  beneath 
it.  In  a  similar  way  dead  bone  may  be  absorbed,  if  the  sequestrum 
is  not  too  large  or  too  dense,  and  if  it  is  in  close  proximity  to  healthy 


/ 

/■ 


^M 


FiG.   17. — Septic  Moist  Gangrene  of  Leg  from  Penetrating  Wound  of 
Femoral  Artery. 

vascular  tissue.  The  dead  portion  is  first  invaded  by  small  round  cells, 
presumably  leucocytes,  derived  from  the  lymphatic  spaces  or  vessels 
of  the  immediately  contiguous  living  tissues,  and  infiltrated  by  them 
and  the  accompanying  blood  plasma.  By  the  activity  of  these  cells 
this  infiltrated  portion  is  gradually  removed  and  replaced  by  granula- 
tion tissue  (for  the  origin  of  which,  see  Chapter  IX.),  which  in  turn 
is  converted  into  a  cicatrix,  and  covered  with  cuticle  in  the  usual  way. 
(b)  If  the  mass,  though  aseptic,  is  of  such  a  size,  or  consists  of 
such  tissues,  as  to  prevent  its  total  absorption,  or  if  the  vital  activity 
of  the  patient  is  lowered,  a  modification  of  the  same  process  results 
in  partial  absorption  of  the  dead  material,  whilst  the  remainder  is  cast  off 
and  separated  by  a  simple  process  of  ancsmic  ulceration.  The  dead  part 
immediately  contiguous  to  the  living  is  removed  and  replaced  by 
granulation  tissue,  and  this  change  continues  advancing  into  the 
mass  until  the  layer  of  granulations  which  has  penetrated  furthest  is 
at  such  a  distance  from  its  nutritive  basis  as  to  be  unable  to  derive 
from  it  sufificient  pabulum,  owing  to  the  contraction  of  the  cicatricial 
tissue  which  is  forming  behind  ;  and  then  a  simple  ulcerative  process 


*°2  A  MANUAL  OF  SURGERY 

from  defective  nutrition  causes  a  line  of  cleavage  to  form  between 
the  living  and  dead,  by  means  of  which  the  latter  is  separated  from 
the  body.  The  size  of  the  portion  thus  cast  off  is  distinctly  less  than 
that  of  the  original  necrotic  mass.  Whilst  this  is  occurring,  there  is 
no  local  inflammatory  reaction,  and  but  little  resulting  constitutional 
disturbance.  It  is  slow  in  progress,  but  there  are  none  of  the  risks 
attaching  to  the  more  rapid  septic  proceeding.  Of  course,  the 
denser  and  harder  the  tissues,  the  longer  they  take  in  separating, 
and  hence  when  a  whole  limb  is  involved  it  is  possible  for  the  soft 
parts  to  have  separated,  and  the  wound  caused  thereby  to  have 
cicatrized  before  much  impression  has  been  made  on  the  bones. 
Considerable  retraction  ensues,  giving  rise  to  a  '  conical  stump  '  from 
the  apex  of  which  the  bone  protrudes. 

(c)  If  the  gangrenous  portion  is  septic,  its  separation  is  accom- 
plished by  an  inflammatory  act  taking  place  in,  and  at  the  expense 
of,  the  surrounding  living  tissues.  The  extent  of  the  gangrene  is 
primarily  indicated  by  a  line  of  demarcation,  due  to  the  change  in 
colour  occurring  in  the  dead  part,  the  living  tissues  retaining  their 
normal  hue.  The  irritation  of  the  chemical  products  formed  in  the 
necrosed  mass  causes  inflammation  in  the  surrounding  structures, 
resulting  in  hypersemia  and  subsequent  exudation  of  plasma  and 
leucocytes  ;  the  tissue  of  the  part  is  replaced  by  a  cell  infiltration, 
which  in  turn  breaks  down  into  pus,  whilst  a  layer  of  granulation 
tissue  forms  at  the  limit  of  the  living  portion,  and  thus  the  final  line 
of  separation  is  produced.  Clinically,  one  notices  in  this  latter  stage 
a  bright  red  line  of  hyperaemia  at  the  extremity  of  the  living  tissues, 
which  gradually  spreads  and  deepens  until  about  the  eighth  or  tenth 
day,  when,  if  the  cuticle  is  intact,  the  living  and  dead  parts  are 
separated  by  a  narrow  white  or  yellow  line,  which  is  proved,  on 
pricking  the  epidermis,  to  be  due  to  the  presence  of  a  layer  of  pus ; 
as  the  pus  escapes,  a  shallow  groove  is  seen  running  between  a 
granulating  surface  on  the  side  of  the  living  tissues  and  the  gan- 
grenous mass.  This  process,  gradually  extending  through  the  whole 
thickness  of  the  limb,  is  accompanied  by  the  local  signs  of  inflam- 
mation and  by  fever,  the  degree  of  the  latter  depending  on  the 
amount  of  toxic  material  absorbed.  The  inflammation,  moreover,  is 
not  always  limited  to  the  line  of  separation,  but  may  spread  upwards 
along  the  lymphatics  or  veins,  or  in  the  fascial  and  muscular  planes, 
until,  perhaps,  the  whole  limb  is  involved  in  an  extensive  suppurative 
process. 

The  Constitutional  Symptoms  of  gangrene  may  be  described  under 
two  distinct  headings : 

{a)  Those  general  conditions  which  predispose  to  the  occurrence 
of  gangrene,  and  which  are  mainly  of  a  debilitating  character, 
affecting  either  the  composition  of  the  blood  or  the  vitality  of  the 
limbs.  General  diseases,  such  as  diabetes  and  albuminuria,  may  be 
present,  as  also  the  constitutional  results  of  a  vicious  life,  whilst 
local  evidences  of  malnutrition  often  manifest  themselves  before  the 
onset  of  gangrene. 


GANGRENE  lo^ 

{h)  Those  conditions  depending  on  the  presence  and  connection 
with  the  body  of  the  dead  tissue.  Various  forms  of  septic  poisoning 
result,  usually  causing  fever,  asthenic  in  type  and  variable  in  amount. 
Pain,  moreover,  is  frequently  a  prominent  feature  in  some  forms  of 
gangrene,  and  the  patient  is  liable  to  become  exhausted  from  this 
cause,  even  though  he  is  protected  by  the  surgeon's  care  from  the 
dangers  of  sepsis. 

The  Treatment  of  gangrene  naturally  divides  itself  into  the  local 
and  general.  We  shall  not  discuss  the  question  of  Local  treatment 
at  this  place,  leaving  it  to  be  dealt  with  under  the  appropriate 
headings  hereafter.  As  to  G-eneral  treatment,  but  little  need  be  said 
beyond  that  the  strength  of  the  patient  must  be  maintained  by 
plenty  of  easily  assimilable  food,  sufficient  stimulant,  and  tonics. 
Pain  and  sleeplessness  must  be  combated  by  the  administration  of  a 
suitable  amount  of  opium  or  morphia,  if  the  kidneys  are  healthy. 
Diabetes  and  albuminuria  need  dietetic  and  therapeutic  measures  in 
order  to  limit,  if  possible,  the  excretion  of  sugar  and  albumen. 

Varieties  of  Gangrene. 

The  following  classification  is  one  which,  though  admittedly 
imperfect,  does  in  a  measure  group  together  allied  types  of  the 
affection,  and  will  serve  as  a  useful  one  for  practical  purposes  : 

I.  Symptomatic  Gangrene,  or  that  predisposed  to  by  preceding 
vascular  or  general  conditions,  where  a  trauma,  if  present  at  all,  is 
of  very  slight  significance. 

(a)  Gangrene  from  embolus.  , 

(b)  Senile  gangrene.     - 

{c)  Gangrene  from  arterial  thrombosis  (non-senile)..^ 
{d)  Diabetic  gangrene. 
{e)  Raynaud's  disease. 
(/)  Gangrene  due  to  ergot. 

II.  Traumatic  Gangrene,  which  may  be  due  to  direct  or  indirect 
injury,  and  where  the  damage  done  to  the  vessels  or  tissues  by  the 
trauma  is  the  immediate  cause  of  the  loss  of  vitality.  Two  varieties 
may  be  described,  viz  : 

(fl)  The  indirect,  where  the  lesion  involves  the  vessels  of 
the  limb  at  some  distance  above  the  spot  where  the 
gangrene  occurs. 

(b)  The  direct,  where  the  gangrenous  process  is  Hmited  to  the 

part  injured. 
III.  Infective  Gangrene,    which    arises    from    the    activity    and 
influence  of  micro-organisms. 

(fl)  Acute  inflammatory  or  spreading  traumatic  gangrene. 
{h)  Wound  phagedena  and  hospital  gangrene. 

(c)  Necrosis  of  bone  (most  cases). 
{d)  Noma  and  cancrum  oris. 

\e)  Carbuncle  and  boil. 


I04  A  MANUAL  OF  SURGERY 

IV.  Gangrene  from  Thermal  Causes — frost-bite  and  burns. 
Each  of  these  varieties  must  now  claim  separate  and  individual 
attention. 

I.  Symptomatic  G-angrene. 

(a)  Embclic  Gangrene.  (For  general  details  as  to  emboli,  see 
Chapter  XIII.)  When  the  main  artery  of  a  limb  becomes  blocked 
6y  a  simple  embolus,  the  condition  is  exactly  similar  to  that  which 
obtains  after  ligature,  and  under  ordinary  circumstances  should  not 
lead  to  gangrene ;  but  if  either  the  general  or  local  vitality  is  much 
reduced,  the  occlusion  of  the  main  trunk  may  be  sufficient  to 
determine  the  death  of  more  or  less  of  the  limb.  Thus  it  may  occur: 
(i.)  Where  the  embolus  consists  of  a  fibrinous  vegetation  detached 
from  one  of  the  cardiac  valves  in  a  case  of  endocarditis  following 


Fig.  i8, — Gangrene  of  Foot  after  Embolic  Obstruction  of 
Popliteal  Artery. 

rheumatic  or  other  fevers.  The  general  nutrition  has  been  depressed 
by  the  preceding  fever,  the  heart's  action  is  weak,  and  the  circulation 
possibly  impeded  by  the  valvular  lesion,  so  that  the  occlusion  of 
a  main  trunk,  even  in  a  young  person,  is  often  sufficient  to  determine 
gangrene,  (ii.)  It  also  follows  when  a  detached  atheromatous  plate 
blocks  the  main  vessel  of  a  limb  previously  rendered  anaemic  by 
arterial  degeneration,  an  occurrence  not  unusual  in  elderly  people. 

Emboli  are  most  commonly  arrested  at  the  sites  of  division  of  the 
main  trunks  (Fig.  19,  A),  or  where  the  calibre  is  suddenly  diminished 
by  the  origin  of  a  large  branch,  the  embolus  often  saddling  over  the 
bifurcation,  and  thus,  as  it  increases  in  size  by  the  subsequent  deposit 
thereon  of  fibrin,  efifectually  closing  both  branches  (Fig.  19,  B).  In 
the  lower  limb  it  occurs  at  the  division  of  the  femoral  or  popliteal ; 
in  the  upper,  at  the  origin  of  the  superior  profunda,  or  where  the 
brachial  divides. 


GANGRENE 


los 


The  chief  early  Symptom  is  sudden  severe  pain  experienced  both 
at  the  point  of  impaction  and  also  down  the  limb  along  the  course 
of  the  vessel.  Pulsation  below  the  block  ceases,  the  limb  becomes 
useless  and  devoid  of  sensation,  and  its  temperature  rapidly  falls. 
If  the  vessels  are  healthy,  stagnation  of  blood  in  the  veins  is  an 
early  result,  the  terminal  portion  of  the  limb  becoming  congested 
and  cedematous,  and  finally  passing  into  a  condition  of  moist  gan- 
grene. If,  however,  the  terminal  arteries  are  calcified  or  atheromatous, 
so  that  the  limb  is  in  a  state  of  chronic  anaemia,  dry  gangrene  is 
likely  to  follow.  The  process  starts  peripherally,  and  spreads 
gradually  upwards  until  it  reaches  a  level  where  there  is  sufficient 
circulation  to  maintain  the  life  of  the  part.  Such  usually  obtains 
in  the  neighbourhood  of  a  joint,  since  there  is  always  a  more  free 
anastomosis  here  than  in  the  interarticular  portions  of  the  limb  ; 
thus,  in  the  leg  the  gangrene  is  arrested  either  immediately  above  the 


A  B 

Fig.  19. — Diagrams  of  Embolus  saddling  the  Bifurcation  of 
AN  Artery. 

In  A  the  embolus  is  seen,  and  the  commencement  of  a  thrombus  on  it,  but  not 
yet  obstructing  the  vessel  :  in  B  both  branches  of  the  trunk  are  blocked  by 
the  growth  of  the  clot. 

ankle  or  below  the  knee.  The  subsequent  history  depends  upon 
whether  or  not  the  dead  tissue  is  allowed  to  become  septic,  and 
requires  no  special  notice. 

Treatment. — The  all-important  requisite  is  to  prevent  the  advent 
of  sepsis,  even  before  any  absolute  signs  of  death  are  manifest. 
The  nails  should  be  cut,  and  the  whole  limb  thoroughly  purified 
(Chapter  X.),  special  attention  being  directed  to  the  intervals 
between  the  toes  and  the  semilunar  folds  of  the  nails.  It  should 
then  be  wrapped  in  a  dry  sterilized  dressing,  with  plenty  of  wool, 
and  bandaged.  The  limb  is  kept  slightly  raised  so  as  to  assist  the 
venous  return  without  interfering  with  the  arterial  supply,  and  by  this 
means  gangrene  may  be  prevented.  Vigorous  massage  so  as  to 
break  up  the  clot  and  drive  it  on  into  the  peripheral  vessels  has  been 
advocated.  A  few  instances  are  also  on  record  of  the  artery  being 
opened,  and  attempts  made  to  extract  or  tunnel  the  clot ;  the  results 
have  not  been  very  favourable.      If,  however,  gangrene  ensues,  the 


io6  A  MANUAL  OF  SURGERY 

same  measures  as  to  the  maintenance  of  asepsis  must  be  con- 
tinued until  a  natural  line  of  separation  forms.  In  old  people  with 
dry  gangrene  the  question  of  amputation  is  decided  by  rules  similar 
to  those  for  the  senile  type  :  but  in  young  people  amputation  through 
the  living  tissues  a  little  above  the  line  of  separation  is  all  that  is 
required,  and  the  period  for  this  must  be  determined  by  the  local  and 
general  conditions.  If  the  parts  are  aseptic,  the  amputation  may  be 
delayed  ;  but  if  spreading  septic  inflammation  exists,  one  may  have 
to  remove  the  limb  higher  up  than  would  be  otherwise  necessary, 
and  this  even  before  any  line  of  separation  has  formed. 

(b)  Senile  Gangrene  occurs  in  elderly  people,  and  is  the  result  of 
imperfect  nutrition  of  the  tissues.  The  toes  are  most  frequently 
affected,  but  it  is  also  seen  in  the  hand,  and  may  attack  the  nose, 
ears,  or  even  the  tongue. 

Causes. — These  are  to  be  found  mainly  in  the  condition  of  the 
circulatory  organs,  (a)  Calcareous  degeneration  of  the  smaller  arteries 
of  the  limb  or  part  is  always  present,  as  also  possibly  atheroma  of 
the  larger  trunks.  The  vessels  become  pipe-like  and  inelastic  in  conse- 
quence, and  incapable  of  accommodating  themselves  to  the  requisite 
variations  in  the  blood-supply.  Hence  a  fixed  minimal  amount  of 
blood  enters  the  limb,  which  passes  into  a  chronic  state  of  anaemia 
and  malnutrition,  w^hilst  the  tunica  intima  is  often  so  rough  as  to 
predispose  to  thrombosis  with  or  w^ithout  injury,  (b)  A  weak  heart 
is  generally  present,  leading  to  low  pulse  tension,  and  increased 
difficulty  in  propelling  the  blood  through  the  rigid  and  narrowed 
vessels  ;  and  (c)  the  condition  of  the  blood  may  be  impoverished  by  albu- 
minuria or  glycosuria.  When  such  predisposing  factors  are  present, 
anything  that  results  in  (d)  thrombosis  either  in  the  main  trunks  or  in  the 
peripheral  arterioles  or  capillaries  is  likely  to  determine  the  onset  of 
gangrene.  Thrombosis  of  the  main  vessels  may  be  due  to  a  blow  or 
strain  which  often  passes  unnoticed,  or  more  frequently  arises  from 
a  gradual  deposit  of  fibrin  on  the  already  roughened  walls.  If  the 
obstruction  originates  in  the  smaller  trunks  or  capillaries,  it  is 
generally  brought  about  by  inflammation  following  some  slight 
injury,  such  as  striking  the  ball  of  the  great  toe  against  the  table,  or 
even  cutting  a  corn.  Exposure  to  cold  may  also  act  as  an  exciting 
agent.  In  either  case  the  clotting  extends  for  some  distance,  and 
the  height  to  which  the  gangrene  spreads  will  vary  accordingly. 

Symptoms. — Evidences  of  malnutrition  of  the  limb  have  probably 
been  present  for  some  time  in  the  form  of  cramp  and  pain  in  the 
muscles,  which  become  fatigued  rapidly,  or  of  sensations  of  pins  and 
needles  or  numbness.  The  pulsation  in  the  tibials  may  be  so  slight 
as  to  be  scarcely  perceptible,  and  the  whole  limb  is  shrivelled  and 
feels  cold  and  heavy.  The  skin  is  often  passively  congested,  and 
hence  prone  to  low  forms  of  ulceration  .or  eczema.  When  the 
gangrene  commences  as  a  result  of  some  peripheral  lesion,  an  area 
of  painful  redness  is  first  noticed,  perhaps  running  on  to  ulceration, 
and  in  the  centre  of  this  patch  a  slough  forms,  which  becomes  dry 
and  black ;   the   process   gradually  spreads    from   this   focus   with 


GANGRENE 


107 


more  or  less  inflammation,  so  that  it  is  sometimes  known  as  in- 
iflammatory  senile  gangrene.  If,  however,  it  results  from  thrombosis 
of  the  main  vessels,  death  occurs  without  the  supervention  of  local 
inflammatory  phenomena,  the  toes  merely  shrivelling  up  and  dying 
{non-inflammatory  senile  gangrene).  The  inner  side  of  the  great-toe  is 
perhaps  the  commonest  situation  for  the  mischief  to  start,  and  thence 
it  spreads  from  one  toe  to  another,  and  also  along  the  instep  and  up 
the  aakle  to  the  leg.  Pain  is  always  a  marked  feature,  whilst  the 
extent  of  the  gangrene  is  dependent  partly  on  the  amount  of  general 
and  local  vitality,  and  partly  on  the  asepticity  or  not  of  the  sur- 
rounding tissues.  As  the  disease  spreads,  the  patient  becomes 
exhausted  by  the  long-continued  pain  and  want  of  sleep  ;  and  septic 
fever,  bedsores,  or  the  intervention  of  some  cardiac,  pulmonary,  or 
renal  complication,  may  also  hasten  a  fatal  termination. 

Treatment  is  governed  by  the  observation  that  after  any  attempt 
to  amputate  through  neighbouring  living  parts  the  gangrenous  process 
is  certain  to  commence  again  in  the  flaps  ;  if  merely  cutting  a  corn 
suffices  to  originate  the  malady,  much  more  will  so  severe  an  injury 
as  an  amputation.  It  is  therefore  necessary  to  amputate  well  away 
from  the  dead  mass  at  a  point  where  the  blood-supply  is  sufficient  to 
nourish  the  flaps,  and  yet  not  so  near  the  trunk  as  to  threaten  life 
seriously  through  shock.  This  must  be  undertaken  early,  especially 
when  pain  is  severe,  or  if  a  spreading  cellulitis  is  present.  In  order 
to  determine  the  most  favourable  site,  the  main  artery  should  be 
carefully  examined,  and  if  feasible  no  operation  is  performed  at  a  level 
where  it  appears  to  be  occluded.  The  condition  of  the  limb  will  also 
influence  the  surgeon's  decision  ;  if  thin,  attenuated,  and  shrivelled, 
it  v/ill  be  wise  to  amputate  high  ;  but  if  the  limb  is  fairly  well 
nourished  and  with  plenty  of  adipose  tissue,  the  operation  may  be 
performed  somewhat  lower.  It  should  inflict  as  little  damage  as 
possible  on  the  parts,  the  flaps  being  nearly  equal  in  length  and 
sufficiently  thick  to  include  plenty  of  muscle.  Where  the  mischief 
is  limited  to  the  foot,  it  is  usually  advisable  to  amputate  through  the 
lower  third  of  the  thigh,  or  at  any  rate  in  the  neighbourhood  of  the 
knee-joint,  though  not  through  the  joint  itself,  as  the  flaps  in  that 
operation  are  always  rather  flimsy.  If  for  any  reason  amputation  is 
contra-indicated,  the  limb  is  kept  aseptic  (if  possible),  wrapped  up 
warmly,  and  elevated.  The  general  health  is  maintained  by  suitable 
nourishment,  tonics,  and  stimulants,  and  pain  alleviated  by  opium. 
In  spite  of  every  care,  however,  the  patient  is  often  unequal  to  the 
task  of  ridding  the  body  of  the  dead  mass,  and  death  finally  occurs 
from  exhaustion  or  blood-poisoning. 

{c)  Gangrene  from  Arterial  Thrombosis  (non-senile)  is  not  a  common 
occurrence.  It  arises  as  a  result  of  the  affection  known  as  endarteritis 
obliterans,  and  also  develops  in  the  later  stages  of  typhoid  fever  and 
other  conditions  of  severe  toxaemia  as  an  outcome  of  arterial  throm- 
bosis, caused  partly  by  the  increased  coagulability  of  the  blood, 
partly  by  a  localized  endarteritis,  lighted  up  by  the  circulating 
toxins.     The  femoral  artery  is  most  usually  blocked,  but  occasionally 


io8  A  MANUAL  OF  SURGERY 

the  trouble  will  spread  up  to  the  aorta  and  involve  both  legs  in  the 
gangrenous  process.  Unless  the  vein  is  also  involved,  the  gangrene 
is  usually  of  the  dry  type.  It  is  wise  to  wait  until  a  line  of  demarca- 
tion has  formed,  and  then  amputate  well  above. 

A  similar  condition  is  met  with  chiefly  in  Russian  and  Polish  Je  vvs 
who  are  heavy  cigarette  smokers,  resulting  from  an  affection  which 
has  been  designated  thrombo-angiitis  obliterans  (Leo  Buerger),  in 
which  extensive  thrombosis  occurs  first  in  the  arteries  and  later  in 
the  veins  of  the  leg.  In  the  earlier  stages  various  sensory  and 
trophic  changes  are  noticed,  and  in  the  later  gangrene,  usually  of  the 
dry  type,  occurs.  It  has  been  suggested  that  in  early  cases  arterio- 
venous anastomosis  between  the  femoral  artery  and  vein  might  be 
useful. 

A  limited  gangrene  of  the  tips  of  one  or  more  fingers  of  a  dry  type 
may  occur  as  a  consequence  of  the  pressure  on  the  subclavian 
vessels  of  a  cervical  rib. 


Fig.  20. — Diabetic  Cellulitis  and  Gangrene  of  Foot  and  Leg. 

(d)  Diabetic  Gangrene  is  mainly  due  to  the  abnormal  condition  of 
the  blood  in  diabetes,  thereby  reducing  the  power  of  the  tissues  to 
resist  bacterial  invasion  ;  but  it  is  also  in  measure  the  result  of  a 
sclerosing  endarteritis  and  peripheral  neuritis.  It  is  not  commonly 
met  with  in  the  subjects  of  acute  diabetes,  nor  in  people  under  forty 
years  of  age.  It  results  usually  from  some  slight  traumatic  or 
infective  injury,  and  often  commences  on  the  under  side  or  at  the 
extremity  of  one  of  the  toes  as  a  bleb,  surrounded  by  a  dusky  purple 
areola.  When  the  bleb  is  opened  or  bursts,  the  central  portion  of 
the  underlying  tissue  is  found  to  be  necrotic,  and  from  this  focus  the 
gangrene  spreads.  If  the  part  is  kept  aseptic,  and  especially  in 
limbs  with  some  degree  of  endarteritis,  the  dead  part  may  shrivel 
and  dry  up,  especially  when  suitable  dietetic  restrictions  are  enforced; 
but  if  such  local  and  general  precautions  are  not  observed,  extensive 
suppurative  infiltration  of  the  soft  parts  may  follow  (Fig.  20), 
even  though  the  necrotic  process  itself  be  of  sHght  extent,  and  from 
this  the  patient  may  succumb,  the  fatal  issue  being  due  partly  to 
diabetes,  partly  to  toxsemia,  and  being  often  preceded  by  coma. 


GANGUENE  109 

Treatment. — In  the  less  severe  cases,  limited  to  one  or  more  toes, 
it  will  often  suffice  to  keep  the  part  warm  and  aseptic,  until  it  is 
separated  by  natural  processes,  or  at  any  rate  the  surgeon  merely 
completes  the  work  by  dividing  or  dissecting  out  bones.  Naturally, 
the  elimination  of  sugar  must  be  checked,  if  possible,  by  suitable 
diet  and  the  administration  of  codeia.  In  more  extensive  trouble 
the  character  of  the  treatment  turns  largely  on  the  amount  of 
vascular  disease  and  the  degree  of  the  accompanying  inflammation. 
If  the  vessels  are  tolerably  healthy,  amputation  not  very  much  above 
the  upper  limit  of  the  gangrene  is  justifiable  ;  but  if  the  main  trunks 
are  probably  affected,  a  high  amputation  will  be  required,  if  the 
patient's  general  condition  permits,  although  there  is  some  risk  that 
diabetic  coma  may  supervene.  When  extensive  suppuration  is 
present,  it  is  sometimes  wise  to  lay  the  parts  open  for  awhile  and 
drain  away  the  inflammatory  exudations  before  considering  the 
question  of  radical  treatment.  The  choice  of  the  anaesthetic  will 
also  require  careful  consideration  ;  and  spinal  analgesia  should  be 
employed  when  the  lower  extremity  is  involved. 

{e)  Raynaud's  Disease,  or  Spontaneous  Symmetrical  Gangrene,  is  a 
condition  usually  met  with  in  anaemic  or  neurotic  young  women 
between  the  ages  of  fifteen  and  thirty.  It  is  due  to  vaso-motor 
spasm,  dependent  on  some  deep  unrecognised  lesion  of  the  spinal 
cord,  or  in  some  cases  to  a  peripheral  neuritis.  Three  stages  are 
usually  described  :  (i.)  local  syncope  or  anaemia,  due  to  arterial 
spasm,  and  characterized  by  pallor  and  painfulness  of  the  part  ; 
(ii.)  local  asphyxia  or  congestion,  the  affected  tissues  being  blue  and 
cyanosed  from  venous  regurgitation  ;  and  (iii.)  necrosis,  the  part 
becoming  dry  and  black.  The  onset  is  often  sudden,  and  the  disease 
may  last  for  a  variable  time,  from  days  to  months.  If  gangrene 
supervenes,  the  latter  is  the  limit  more  often  reached ;  but  it  by  no 
means  necessarily  follows  that  tissue  necrosis  occurs  in  every  case. 
The  disease  is  usually  symmetrical,  and  affects  the  fingers  rather 
than  the  toes,  but  superficial  patches  may  occur  on  any  part  of  the 
body  ;  the  process  is  non-febrile  and  often  very  painful.  Paroxysmal 
haemoglobinuria  has  been  observed,  and  is  supposed  to  be  due  to 
vaso-motor  disturbance  of  the  kidneys.  Ankylosis  of  the  smaller 
interphalangeal  joints  and  localized  patches  of  anaesthesia,  associated 
with  neuralgic  pain,  are  sometimes  present,  resulting  from  peripheral 
neuritis.  The  condition  often  resembles  the  later  stages  of  a  chilblain, 
but  is  distinguished  by  its  more  dusky  colour,  the  greater  pain,  the 
absence  of  itching,  and  the  fact  that  the  process  is  not  limited  to 
exposed  or  terminal  parts,  or  to  cold  weather. 

The  Treatment  in  the  early  stages  is  directed  to  the  prevention  of 
gangrene.  Iron,  quinine,  and  other  suitable  tonics  are  administered, 
and  menstrual  irregularities  are  attended  to.  Friction  with  stimu- 
lating embrocations,  warm  douches,  and  protection  from  cold  and 
injury,  may  be  employed  locally,  but  probably  the  best  results  will 
follow  the  use  of  electricity.  The  constant  current  is  employed,  and 
preferably  in  the   shape  of  the  electric  bath,   local  or  general  as 


no  A  MANUAL   OF  SURGERY 

required,  and  repeated  either  once  or  several  times  a  day.  When 
actual  gangrene  is  present,  the  dead  tissue  should  be  kept  aseptic, 
when  sooner  or  later  it  will  be  absorbed  or  separated. 

(/)  Gangrene  from  Ergot  is  a  rare  phenomenon,  but  it  has  been 
known  to  occur  when  diseased  rye  has  been  used  in  the  manufacture 
of  bread.  The  resulting  gangrene  may  vary  in  extent  from  the  loss 
of  one  or  two  fingers  or  toes  to  the  sacrifice  of  the  greater  portion  of 
one  or  more  limbs. 

II.  Traumatic  Gangrene. 

By  traumatic  gangrene  is  meant  the  loss  of  vitality  of  some  part 
of  the  body  as  the  consequence  of  an  injury,  whether  applied  to  the 
main  bloodvessels  (indirect  traumatic  gangrene),  or  directly  to  the 
tissues  (direct  traumatic  gangrene). 

(a)  Indirect  Traumatic  Gangrene  arises  from  a  considerable  variety 
of  lesions,  and  the  course  and  clinical  history  are  similarly  variable. 

(i.)  Ligature  of  the  main  artery  does  not  produce  gangrene  in  a 
healthy  limb ;  but  should  it  be  in  a  state  of  chronic  malnutrition  and 
anaemia  from  preceding  arterial  disease,  death  of  a  certain  portion 
may  ensue,  the  case  running  a  similar  course  to  one  of  gangrene  due 
to  embolus.  It  is  usually  of  the  dry  type,  and  limited  to  one  or  two 
toes,  or  to  a  patch  of  the  superficial  tissues  ;  but  if  it  rea.ches  the  more 
fleshy  portions,  the  moist  variety  supervenes. 

Treatment  consists  in  keeping  the  parts  warm  and  aseptic  until 
a  definite  line  of  separation  forms,  and  then  in  assisting  the  natural 
processes  at  this  spot  by  dividing  tendons  and  bones.  If,  however, 
a  considerable  area  of  the  limb  loses  its  vitality,  and  especially  if 
the  dead  tissue  is  moist  and  septic,  an  early  high  amputation  is 
required. 

(ii.)  Arterial  thrombosis  from  injury  only  causes  gangrene  under 
special  circumstances,  the  course  and  treatment  being  similar  to  that 
resulting  from  an  embolus. 

(iii.)  Obstruction  to  both  main  artery  and  vein  is  an  almost  certain 
precursor  of  gangrene,  if  it  occurs  suddenly.  Cases  are  on  record  in 
which  both  vessels  have  been  ligatured,  or  even  portions  of  them 
removed  without  such  a  result,  as  in  dealing  with  cancerous  deposits 
in  the  axilla  or  in  the  extirpation  of  aneurisms  ;  but  in  both  these 
instances  obstruction  to  the  circulation  must  have  previously  existed, 
necessitating  the  opening  up  of  collateral  anastomotic  branches.  In 
a  normal  limb  the  simultaneous  occlusion  of  both  afferent  and 
efferent  trunks,  as  by  inclusion  in  a  ligature,  is  almost  certain  to 
determine  tissue  necrosis.  It  may  also  be  caused  by  the  strangulation 
of  organs,  either  within  the  body,  as  in  a  strangulated  hernia,  or 
outside  of  it,  as  when  a  ligature  is  tied  round  the  base  of  the  penis, 
or  a  bandage  applied  too  tightly  round  a  fractured  limb.  It  may 
even  result  from  the  swelling  of  a  limb  under  a  bandage  which  has 
been  originally  applied  with  no  undue  tension. 

Gangrene  may  also  follow  the  rupture  of  a  main  artery  and 
compression  of  the  accompanying  vein  by  the  extravasated  blood, 


GANGRENE  II, 

an  occurrence  perhaps  most  frequently  seen  after  fraciurcs  and  dis- 
locations ;  it  is  then  always  of  the  moist  type.     (See  Chapter  XIX.)   . 

Treatment  varies  considerably  in  these  cases.  If  the  parts  are 
hopelessly  injured,  amputation  should  be  performed  at  once,  so  as  to 
prevent  the  risk  of  sepsis.  In  some  fractures  and  dislocations  with 
vascular  lesions,  it  may  be  possible  to  save  the  limb  by  cutting  down, 
turning  out  clots,  and  securing  the  injured  vessels,  whilst  the  bony 
lesion  is  dealt  with  in  a  suitable  manner.  The  limb  should  after- 
wards be  elevated  slightly,  and  the  peripheral  segment  kept  warm 
and  aseptic.  Should  gangrene  supervene,  amputation  will  be 
required,  its  situation  depending  on  the  character  of  the  local  lesion  ; 
if  it  is  not  of  a  serious  nature — e.g. ,  a  clean  fracture  or  simple  dis- 
location— it  is  wise  to  wait  for  a  line  of  demarcation  ;  but  if  com- 
minution of  bone  or  other  grave  local  trouble  is  present,  one  would 
amputate  above  the  injury. 

{b)  Direct  Traumatic  Gangrene,  or  that  resulting  from  the  im- 
mediate effect  of  injury  to  the  parts,  is  similarly  due  to  a  variety  of 
lesions. 

(i.)  Severe  crushes  or  blows  are  a  common  cause  of  this  type  of 
gangrene ;  thus  a  limb  may  become  mangled  between  the  wheels  of 
machinery,  or  by  heavy  weights  falling  on  it,  or  by  the  passage  of 
vehicles  over  it.  Not  only  are  the  parts  crushed,  severely  contused, 
or  even  '  pulped,'  but  the  bloodvessels  may  be  torn,  and  the  pressure 
of  extravasated  blood  contributes  to  the  result.  The  gangrene  is  of 
the  moist  type,  and  is  more  likely  to  supervene  in  patients  whose 
vitality  is  diminished.  Thus,  a  crush  of  the  foot  in  an  elderly 
person  is  often  followed  by  it,  when  in  a  young  and  healthy  adult  it 
could  be  prevented. 

Treatment. — If  the  part  is  hopelessly  damaged,  operation  should 
not  be  delayed,  on  account  of  the  dangers  of  sepsis  ;  and  therefore 
immediate  amputation  is  recommended.  The  question  of  shock  and 
its  influence  in  determining  operation  is  discussed  elsewhere.  When 
there  seems  a  reasonable  chance  of  saving  the  limb,  it  is  cleansed 
and  purified  under  the  strictest  antiseptic  precautions  ;  should 
gangrene  supervene,  it  may  be  removed  later. 

(ii.)  Prolonged  pressure  is  also  capable  of  producing  gangrene, 
Gangrene  from  splint  pressure  is  either  almost  unavoidable,  or  the 
result  of  carelessness.  When  the  fragments  are  much  displaced 
after  a  fracture,  considerable  pressure  may  be  required  to  retain 
them  in  good  position,  and  then  in  spite  of  every  precaution  necrosis 
may  ensue.  Pain  of  a  neuralgic  type  is  usually  complained  of  for  a 
few  days,  but  even  that  is  not  necessarily  severe  enough  to  attract 
much  attention ;  when  the  limb  is  freed  later  on,  the  dead  portion  of 
the  skin  is  white,  anaemic,  and  insensitive.  The  necrotic  process 
may  extend  to  some  depth,  and  hence  the  greatest  care  must  be 
taken  to  keep  the  dead  tissues  aseptic,  thereby  avoiding  grave  local 
and  constitutional  disturbance. 

Bedsores  are  likely  to  occur  in  patients  who  are  kept  for  a  long 
time  in  the  recumbent  posture,  or  in  any  one  particular  position. 


U2  A  MANUAL  OF  SURGERY 

IT  he  parts  most  exposed  to  pressure  become  red  and  congested,  and 
finally  ulceration  or  actual  gangrene  supervenes.  Bedsores  are  not 
usually  extensive  or  deep ;  but  if  the  patient  is  debilitated,  and 
especially  if  a  condition  of  lowered  sensation  is  present,  due  to  im- 
pairment of  the  nerve-supply,  as  in  paraplegia,  the  process  may 
extend  rapidly,  destroying  fascias,  laying  open  muscular  sheaths,  and 
even  leading  to  necrosis  or  caries  of  bone  (acute  bedsore).  The  spinal 
canal  itself  has  been  opened  in  this  way,  and  death  from  septic 
meningitis  has  resulted.  To  prevent  the  occurrence  of  such  sores, 
the  most  scrupulous  attention  must  be  given  to  the  parts  exposed  to 
pressure.  The  nurse  should  see  that  the  draw-sheet  and  bed-linen 
are  placed  smoothly  and  without  creases,  and  that  no  contamination 
by  urine  or  faeces  is  allowed ;  if  the  patient  is  perspiring  freely,  the 
sheet  should  be  frequently  changed,  so  as  to  prevent  decomposition 
of  the  sweat.  The  skin  of  the  back  is  daily  examined,  washed  with 
some  unirritating  soap,  and  rubbed  with  a  soothing,  strengthening, 
and  hardening  application,  such  as  spirit  of  wine,  methylated  spirit, 
or  perhaps,  better  still,  a  mixture  of  brandy  and  white  of  egg.  It  is 
then  dusted  over  with  a  mild  antiseptic  powder,  such  as  boric  acid. 
If  the  skin  becomes  red,  it  should  be  painted  with  collodion,  or  with 
a  mixture  of  equal  parts  of  tincture  of  catechu  and  liquor  plumbi 
subacetatis,  which  when  dry  leaves  a  powdery  film  on  the  surface, 
and  protected  from  pressure  by  means  of  a  circular  hollow  water- 
pillow.  Paraplegic  patients  or  old  people  should  be  placed  at  once 
on  a  water-bed,  which  must  be  sufficiently,  but  not  excessively,  dis- 
tended. If  there  is  too  little  water,  the  weight  of  the  body  displaces 
it  to  one  side,  and  no  good  results  ;  whilst  if  there  is  too  much,  the 
bed  becomes  hard  and  resistant,  and  fails  in  the  object  for  which  it 
was  employed.  When  an  open  sore  forms,  it  must  be  kept  aseptic, 
and  dressed  either  with  diluted  boric  acid  ointment,  or  in  the  more 
sluggish  cases  with  resin  and  boric  acid  ointments  mixed.  Friar's 
balsam,  mixed  with  castor-oil  (i  part  of  the  balsam  to  7  of  the  oil), 
is  useful  in  this  condition. 

(iii.)  The  action  of  corrosive  or  caustic  chemicals  is  followed  by  a 
localized  traumatic  necrosis,  the  degree  of  which  varies  with  the 
amount  and  character  of  the  irritant  present,  and  the  duration  of  its 
action.  All  that  is  needed  is  to  keep  the  parts  aseptic,  and  allow 
them  to  be  absorbed  or  separated  by  natural  processes. 

A  curious  form  of  gangrene  occasionally  follows  the  application 
of  a  carbolic  acid  compress,  even  when  weak  solutions  are  employed. 
The  fingers  are  the  parts  usually  affected,  and  the  gangrene  does  not 
seem  to  be  due  to  tight  bandaging,  or  to  the  presence  of  a  water- 
proof covering.  Possibly  the  carbolic  acid  determined  prolonged 
arterial  spasm,  and  the  anaemia  was  followed  by  local  necrosis. 


GANGRENE  113 

III.  Specific  or  Infective  Gangrene. 

(a)  Acute  Spreading,  Acute  Emphysematous,  or  Spreading  Traumatic 
Gangrene. — This  disease  is  one  of  the  most  rapidly  fatal  and  serious 
met  with  in  surgery. 

Causes. — (i.)  The  individual  attacked  is  often  predisposed  as  a  result 
of  vicious  or  careless  living,  heavy  drinking,  or  simple  malnutrition  ; 
but  even  healthy  individuals  may  be  attacked  if  the  virus  is  active. 
It  is  sometimes  seen  in  diabetics,  but  an  apparent  glycosuria  occa- 
sionally develops  in  the  course  of  the  disease. 

(ii.)  The  causative  lesion  is  usually  severe,  such  as  a  compound 
fracture  or  dislocation,  especially  if  the  soft  parts  are  much  contused 
or  very  dirty.  Less  frequently  it  consists  of  a  small  and  insignificant 
prick,  scratch,  or  abrasion,  through  which  a  virulent  organism  gains 
access  to  the  tissues.  In  this  way  post-mortem  porters,  nurses,  or 
pathological  demonstrators  may  become  infected. 

(iii.)  An  organism  frequently  present  is  the  Bacillus  cedematis 
maligni,  which  is  identical  with  the  Vihrion  septiqiie  of  Pasteur  and 
the  French  writers.  It  is  a  rod-shaped  organism,  which  closely 
resembles  that  of  anthrax,  but  has  a  greater  tendency  to  grow  into 
long  threads.  It  is  actively  motile,  and  forms  oval  spores,  which 
may  be  placed  at  the  centre  or  at  the  end  of  the  rod.  It  does  not 
stain  by  Gram's  method.  Cultures  only  develop  under  anaerobic 
conditions ;  and  if  the  culture  medium  contains  glucose,  a  large 
amount  of  foul-smelling  gas  is  produced.  Mice  and  guinea-pigs  die 
within  twenty-four  hours  of  inoculation  ;  locally  a  spreading  oedema 
is  produced,  the  connective-tissue  spaces  being  filled  with  fluid  con- 
taining bacilli,  and  perhaps  gas.  Bacilli  are  also  found  in  the 
exudations  which  occur  in  the  serous  cavities,  in  the  connective  tissues 
of  important  organs,  and  in  the  blood  for  some  time  after  death. 
The  B.  aerogenes  capsulatus  may  also  cause  acute  spreading  gangrene. 
It  is  an  anaerobe  with  a  similar  power  of  fermenting  sugar,  but  it 
diifers  from  the  bacillus  of  malignant  oedema  in  that  it  is  non-motile, 
rarely  forms  spores,  and  retains  Gram's  stain.  It  usually  possesses 
a  well-defined  capsule,  from  which  its  name  is  derived  ;  this,  however, 
is  not  invariable.  Careful  investigation  of  fifty-eight  cases*  of 
spreading  gangrene  demonstrated  that  in  only  fourteen  cases  was  the 
infection  pure,  and  that  with  an  anaerobic  organism  ;  in  forty-four 
cases  the  infection  was  mixed,  various  septic  organisms  being  present 
in  addition  to  the  gas-producing  microbe,  which  was  more  frequently 
the  B.  aerogenes  capsulatus  than  the  B.  cedematis  maligni.  A  special 
feature  of  infection  with  the  former  is  the  large  amount  of  gas 
produced,  not  only  in  the  tissues,  but  also  post-mortem  in  the 
vessels,  and  notably  in  the  liver,  from  which  it  can  easily  be 
squeezed,  constituting  the  '  foaming  liver  '  of  some  writers. 

The  Symptoms  are  those  of  a  hyperacute  cellulitis,  accompanied 

*  See  Corner  and  Singer  on  '  Emphysematous  Gangrene,'  Trans.  Path.  Soc. 
Lotid.,  vol.  Iii.,  1901,  p.  42;  Welch's  '  Shattuck  Lecture,'  Philadelphia  Med. 
Journ.,  August  4,  igoo. 


ti4  A  MANUAL  OF  SURGERY 

by  general  septicaemia.  The  wound  early  takes  on  an  unhealthy 
action,  the  surface  becoming  covered  with  sloughs,  and  a  thin  serous 
or  sero-sanguineous  discharge  escaping.  The  inflammatory  process 
rapidly  spreads  along  the  connective-tissue  planes  of  the  limb,  which 
becomes  swollen,  painful,  and  brawny.  At  first  it  is  of  a  dusky 
purplish  colour,  but  soon  the  signs  of  actual  gangrene  supervene, 
and  the  necrotic  tissues  become  crepitant  and  emphysematous,  partly 
from  simple  putrefaction,  partly  from  the  gaseous  developments 
associated  with  the  growth  of  the  specific  organism.  Occasionally 
the  emphysema  spreads  widely  and  rapidly,  with  at  first  no  other 
local  evidence  of  mischief;  sloughing  will,  however,  follow  if  the 
patient  live  long  enough.  Evidences  of  profound  toxic  disturbance, 
such  as  hyperpyrexia  and  delirium,  soon  manifest  themselves  ;  but 
not  uncommonly  fever  may  be  entirely  absent,  the  temperature  being- 
subnormal  and  coma  present.  The  outlook  is  exceedingly  grave, 
death  usually  ensuing  in  from  five  to  seven  days  from  the  onset. 

Treatment. — In  the  early  stages  it  may  be  possible  to  save  both 
life  and  limb  by  incising  freely  the  infected  tissues,  and  immersirig 
them  in  a  continuous  warm  antiseptic  bath.  The  fact  that  the 
causative  organisms  are  anaerobic  suggests  the  plentiful  use  of  such 
oxidizing  agents  as  peroxide  of  hydrogen,  Sanitas,  or  Condy's  Fluid. 
At  the  same  time  the  general  health  must  be  attended  to  by  giving 
•plenty  of  fluid  nourishment,  together  with  diffusible  stimulants,  such 
as  ether  and  ammonia.  If,  in  spite  of  this,  the  disease  shows  signs 
of  rapid  progress,  a  high  amputation,  even  through  the  shoulder  or 
hip-joint,  is  the  only  hope  of  saving  life.  Perhaps  it  may  be  wise  to 
leave  the  wound  widely  open  for  a  day  or  two,  so  as  to  permit  of  the 
free  discharge  of  secretions. 

(b)  Wound  Phagedena  and  Hospital  Gangrene  were  seen  often 
enough  in  the  pre-antiseptic  era,  but  are  now  practically  unknown. 
They  consisted  in  a  rapidly  spreading  ulceration  or  gangrene,  which 
attacked  operation  wounds  a  few  days  after  their  infliction,  and  as  a 
rule  led  to  rapid  death. 

(c)  Necrosis  of  Bone  is  almost  always  due  to  the  development  of 
organisms,  and  may  be  either  acute  or  chronic.  In  the  former,  the 
inflammatory  reaction  is  so  severe  that  the  vessels  are  strangled 
within  the  bony  alveoli ;  in  the  latter,  it  is  largely  due  to  an 
obliterative  endarteritis,  which  accompanies  the  various  specific 
processes.     (See  Chapter  XX.) 

(d)  Cancrum  Oris  and  Noma. — Cancrum  oris  is  an  infective  gan- 
grenous stomatitis,  affecting  young  children  living  in  squaMd  sur- 
roundings in  over-populated  districts  of  large  cities.  The  patients 
are  always  in  a  low  state  of  health,  and  frequently  convalescing 
from  one  of  the  exanthemata,  particularly  measles.  Various  special 
organisms  have  been  described  from  time  to  time  as  responsible  for 
cancrum  oris  ;  but  it  appears  that  any  of  the  many  forms  found  in 
the  mouth  may  be  present,  and  probably  the  Streptococcus  pyogenes 
acting  in  conjunction  with  various  saprophytic  bacilli  is  the  most 
important.     The  process  starts  in  an  abrasion  of  the  mucous  mem- 


GANGRENE  115 

brane,  which,  being  infected  from  a  diseased  or  dirty  tooth,  becomes 
inflamed  and  gangrenous.  A  foul  ashy-gray  pultaceous  slough  forms 
on  the  inside  of  one  of  the  cheeks,  and  from  this  a  most  offensive 
discharge  is  poured  into  the  mouth  and  swallowed,  the  breath  in 
consequence  becoming  intensely  foetid.  The  gangrene  gradually 
spreads  both  superficially  and  deeply ;  the  cheek  becomes  swollen, 
shiny,  and  tense,  and,  should  the  process  extend  through  its  whole 
substance,  a  black  slough  appears  on  its  outer  aspect.  In  bad  cases, 
the  adjacent  bones  of  the  face  may  be  affected  and  die,  and  the 
tongue,  palate,  and  even  the  fauces,  may  also  be  involved. 

The  general  phenomena  are  those  of  a  severe  toxaemia,  since  not 
only  are  the  toxic  products  swallowed,  but  they  are  also  absorbed  by 
the  lymphatics,  and  may  be  inhaled,  in  the  latter  case  giving  rise  to 
septic  pneumonia.  Moreover,  the  patient  runs  a  considerable  risk 
of  developing  pyaemia,  from  implication  of  the  facial  or  other  veins 
in  the  necrotic  process,  whilst  infective  septicaemia  may  also  super- 
vene. Rigors  and  high  fever  may  occur  early  in  the  case,  but  death 
is  usually  preceded  by  symptoms  of  collapse  and  coma  with  a 
subnormal  temperature. 

The  Treatment  must  be  prompt  and  energetic  if  the  child's  life  is  - 
to  be  saved.  The  patient  should  be  anaesthetized,  and  all  the  pulta- 
ceous slough  removed  by  cutting  or  scraping,  until  healthy  bleeding 
tissue  is  reached.  The  denuded  surface  is  then  freely  rubbed  over  with 
pure  carbolic  or  strong  nitric  acid.  In  using  such  agents,  the  throat 
must  be  carefully  protected,  and  the  excess  of  acid  in  the  case  of  the 
former  dissolved  by  spirit,  and  in  the  latter  neutralized  by  bicarbo- 
nate of  soda.  If  the  bones  of  the  face  are  involved,  they  must  be 
removed,  as  also  any  offending  teeth.  Afterwards  the  mouth  is  to 
be  washed  out  frequently  with  antiseptic  lotions,  such  as  a  solution 
of  peroxide  of  hydrogen  (i  in  10),  sanitas  (i  in  10),  boroglyceride 
(i  in  20),  or  permanganate  of  potash.  The  child  must  be  given 
plenty  of  suitable  fluid  nourishment,  and  a  mixture  containing 
chlorate  of  potash,  dilute  hydrochloric  acid,  and  infusion  of  cinchona, 
may  be  administered  for  a  few  days,  and  then  iron  and  quinine.  In 
the  most  severe  cases,  the  whole  thickness  of  the  cheek  may  be 
encroached  on  ;  loss  of  substance  must  be  made  good  by  subsequent 
plastic  work.  Necessarily,  the  cicatrization  following  this  destructive 
process  results  in  a  good  deal  of  permanent  impairment  to  the 
movements  of  the  jaw. 

Noma  is  the  name  given  to  a  similar  process  occurring  about  the 
genital  organs  of  children,  especially  the  vulva.  The  Treatment 
is  practically  the  same,  except  that  here  it  is  possible  to  immerse 
the  patient  in  a  warm  bath,  thereby  diluting  the  toxic  products, 
and  possibly  preventing  the  necessity  for  having  recourse  to  more 
serious  surgical  procedures. 

(e)  For  Carbuncle  and  Boil,  see  Chapter  XVI. 


Il6  A  MANUAL  OF  SURGERY 

IV.  Gangrene  from  Thermal  Causes. 

1.  Frost-bite. — This  condition  is  not  often  seen  in  this  country, 
but  is  by  no  means  uncommon  in  regions  where  the  winter  is  colder, 
and  is  induced  more  readily  if  a  high  wind  is  blowing,  the  heat  of 
the  body  being  thereby  more  quickly  dispersed.  Children  and  old 
people  are  more  likely  to  be  attacked,  as  their  vital  powers  are  less 
marked  than  in  adults.     It  originates  in  one  of  two  ways  : 

(fl)  From  the  direct  efect  of  cold  on  the  tissues,  which  become  shrunken, 
hard,  and  of  a  dull  waxy  appearance.  No  pain  is  experienced  in 
the  freezing  process,  so  that  onlookers  are  more  likely  to  recognise 
the  condition  than  the  individual  himself.  The  extremities  of  the 
body,  where  the  circulation  is  a  little  sluggish,  and  exposed  parts, 
such  as  the  nose  and  ears,  are  chiefly  liable  to  be  attacked. 
Gradually  the  part  shrivels,  turns  black,  and  is  either  absorbed  or 
separated  by  a  process  of  ulceration  with  or  without  suppuration. 
A  feature  of  gangrene  from  frost-bite  is  the  more  extensive  implication 
of  the  superficial  tissues  on  account  of  their  greater  exposure. 

(b)  From  the  subsequent  inflammation  in  parts  which,  though  frozen, 
are  not  immediately  killed.  The  thawing  of  these  structures  is 
accompanied  by  severe  pain,  and  the  prolonged  anaemia  so  depresses 
the  vitality  of  the  vessel  walls  that. the  re-admission  of  the  circulating 
blood  is  likely  to  be  followed  by  an  acute  inflammation,  which  ter- 
minates in  necrosis  from  compression  of  the  vessels  by  the  rapidly 
formed  exudation.  If  it  escapes  actual  death,  the  part  remains 
red,  congested,  and  painful  for  some  time,  and  superficial  ulcers 
may  even  develop  ;  eventually,  however,  it  recovers. 

Treatment. — The  frozen  parts  must  be  thawed  very  gradually,  and 
the  blood  admitted  into  the  tissues  slowly,  if  inflammatory  gangrene 
is  to  be  avoided.  They  should  be  gently  rubbed  with  snow  or  cold 
water,  and  warmed  by  being  held  in  the  hands  of  the  manipulator, 
whilst  the  patient  should  be  placed  in  a  cool  room,  the  temperature 
of  which  is  slowly  raised.  As  reaction  comes  on,  a  small  amount  of 
warm  drink  may  be  cautiously  given.  Excessive  pain  or  congestive 
oedema  may  be  limited  by  elevation  of  the  part.  If  actual  gangrene 
occurs,  the  dead  tissue  must  be  rendered  and  kept  aseptic,  and  the 
case  carefully  watched  until  a  definite  line  of  separation  has  formed. 

Indians,  lumbermen,  prospectors,  etc.,  in  North-West  Canada, 
where  frostbites  are  common,  have  found  that  oil  of  turpentine  is  the 
best  application  in  all  stages.  The  parts  are  kept  soaked  with  the 
fluid,  and  the  results  are  reported  as  phenomenal. 

2.  Burns  and  Scalds. — These  may  be  considered  as  a  special  variety 
of  wound,  not  necessarily  ending  in  gangrene,  brought  about  by  the 
action  of  heat ;  burns,  either  by  the  close  proximity  to,  or  direct 
contact  with,  flame  or  heated  solid  bodies ;  scalds,  by  the  action  of 
boiling  water,  superheated  steam,  or  other  hot  fluids  or  gases,  the 
difference  in  the  effects  being  comparable  to  the  distinction  between 
roasting  and  boiling.  Naturally,  fluids  such  as  oil,  which  boil  at  a 
higher  temperature  than  water,  produce  increasingly  severe  results. 


GANGRENE 


117 


Six  different  degrees  of  burn  were  described  by  Dupuytren,  and 
his  classification  may  still  be  retained  with  advantage.  The  first 
degree  consists  merely  in  a  scorch  or  superficial  congestion  of  the 
skin,  without  destruction  of  tissue ;  the  part  may,  however,  remain 
red,  painful,  and  prone  to  ulceration  for  a  time.  Should  the  scorch 
be  often  repeated,  as  by  people  constantly  warming  their  legs  before 
the  fire,  the  skin  becomes  chronically  pigmented  and  indurated 
(erythema  ah  igne).  In  the  second  degree  the  cuticle  is  raised  from  the 
cutis,  and  a  bleb  or  blister  results.  When  this  bursts,  and  the 
cuticle  is  removed,  the  cutis  vera,  red  and  painful,  is  exposed  below. 
In  the  third  degree  the  cuticle  is  destroyed,  as  is  also  part  of  the  cutis 
vera,  but  the  tips  of  the  interpapillary  processes,  including  the 
exquisitely  sensitive  nerve  terminals,  are  laid  bare  and  left  intact ; 
consequently  this  is  a  most  painful  form  of  burn.  The  deeper 
structures  of  the  skin — viz.,  the  sweat  and  sebaceous  glands,  and 
the  hair  follicles — remain  untouched,  so  that,  although  the  surface 
during  the  healing  process  becomes  covered  with  granulations,  the 
integument  is  very  rapidly  replaced,  since  there  are  so  many 
epithelial  elements  from  which  it  can  grow.  The  cuticle  is  able 
to  form  not  from  the  edge  only,  as  must  occur  wherever  the  whole 
of  the  cutaneous  envelope  is  destroyed,  but  also  from  innumerable 
foci  scattered  over  the  wound  surface.  The  resulting  scar,  though 
often  white  and  visible,  undergoes  no  contraction :  it  is  supple  and 
elastic  from  containing  all  the  elements  of  the  true  skin.  In  the 
fourth  degree  the  whole  thickness  of  the  integument  is  destroyed,  as 
well  as  part  of  the  subcutaneous  tissues.  In  the  fifth  the  muscles 
are  also  encroached  upon,  whilst  in  the  sixth  the  whole  limb  is 
charred  and  disorganized.  In  the  last  three  forms  healing  can  only 
occur  by  removal  of  sloughs  and  the  formation  of  a  cicatrix,  which 
by  its  contraction  may  lead  to  deformity. 

The  Local  History  of  a  burn  may  be  described  in  three  stages, 
corresponding  to  the  three  stages  through  which  an  ulcer  or  a 
lacerated  wound  passes:  (i)  The  stage  of  destruction  or  burning, 
the  various  degrees  of  which  have  been  just  alluded  to ;  (2)  the 
stage  of  inflammation  and  sloughing,  whereby  the  dead  tissue  is 
removed,  and  the  wound  converted  into  a  healthy  granulating  sore  ; 
(3)  the  stage  of  repair.  There  are  no  special  characteristics  of  these 
processes  which  call  for  particular  note,  except  that  they  are  usually 
of  a  septic  nature,  unless  the  burn  is  a  small  one.  The  skin  is 
generally  dirty  (from  a  surgical  standpoint)  at  the  time  of  the  accident; 
it  may  be  infected  from  the  clothes  which  are  being  worn,  and 
immediate  attention  may  be  impossible.  Moreover,  the  extent  of 
the  lesion  and  the  terrible  pain  associated  with  it  often  render 
complete  sterilization  impracticable. 

The  General  or  Constitutional  Conditions  which  correspond  to 
these  three  stages  require  a  little  fuller  notice. 

I.  In  the  early  stages  shock  is  usually  present,  and  its  intensity 
depends  as  much  on  the  extent  of  the  burn  as  on  its  depth,  so  that 
total  charring  of  a  limb  may  cause  less  depression  of  the  system  than 


Ii8  A  MANUAL  OF  SURGERY 

an  extensive  superficial  scorch,  especially  if  the  latter  involves  the 
abdomen  or  the  head  and  neck.  It  frequently  passes  into  a  condition 
of  collapse,  due  in  measure  to  the  absorption  of  toxic  products  from 
the  burnt  tissues. 

2.  Subsequently  a  period  of  inflammatory  fever,  usually  of  septic 
origin,  follows,  and  may  last  four  to  fourteen  days.  The  viscera 
become  congested,  particularly  the  gastro-intestinal  canal,  liver, 
lungs,  and  brain,  and  various  complications  may  result  there 
from. 

One  of  the  most  interesting  sequelae,  though  at  the  present  day  it 
is  admittedly  uncommon,  is  Ulceration  of  the  Duodenum.  The  ulcer  is 
of  the  usual  duodenal  type,  and  occurs  close  to  the  orifice  of  the  bile- 
duct.  It  probably  results  from  the  elimination  by  the  liver  of  some 
irritating  substance  derived  from  septic  changes  in  the  burnt  tissues 
which  is  capable  of  inducing  thrombosis,  or  of  producing  ulceration 
in  the  structures  in  close  contiguity  to  the  entrance  of  the  bile-duct. 
In  one  case  under  observation,  a  post-mortem  examination  revealed 
a  patch  of  well-marked  ecchymosis  in  the  duodenal  mucosa  exactly 
opposite  the  orifice  of  the  bile-duct.  Obviously  it  was  the  early 
stage  of  this  condition,  and  would  have  gone  on  to  ulceration  had 
the  patient  lived.     For  clinical  phenomena,  see  Chapter  XXXIV. 

3.  When  healthy  repair  is  occurring  locally,  and  the  parts  are  kept 
aseptic,  no  abnormal  constitutional  condition  should  be  present, 
although  there  may  be  a  certain  amount  of  asthenia  or  anaemia. 
Where,  however,  the  wounds  are  septic  and  suppurating  freely,  this 
tendency  will  be  much  more  marked,  and  the  patient  may  even 
develop  hectic  fever  and  amyloid  changes  in  the  viscera,  and  finally 
die  of  exhaustion. 

Causes  of  Death  from  Burns. — If  an  individual  is  burnt  to  death, 
the  fatal  event  is  usually  occasioned  by  asphyxia  from  the  smoke 
and  noxious  fumes  of  the  fire  ;  shock  and  syncope  from  fright  may 
perhaps  be  adjuvants,  especially  if  the  heart  is  weak  or  diseased. 
Within  the  first  few  days  death  results  from  shock  or  collapse  from 
toxaemia;  in  the  second  stage,  from  sepsis,  internal  complications, 
ulceration  of  the  duodenum,  etc. ;  in  the  third  stage,  from  exhaustion 
or  intercurrent  maladies.  The  prognosis  in  children  is  always  more 
unfavourable  than  in  adults. 

Treatment. — In  superficial  scorches  without  vesication,  all  that  is 
needed  is  to  protect  the  affected  parts,  e.g.,  by  dusting  them  over 
with  boric  acid  powder  mixed  with  starch,  or  by  painting  them  with 
collodion.  Blisters  should  be  washed  antiseptically  and  then  punc- 
tured, so  as  to  allow  the  contained  serum  to  escape ;  the  separated 
epidermis  should  not  be  cut  away,  but  should  be  pressed  down, 
dusted  with  boric  acid  powder,  and  covered  with  aseptic  wool. 
Picric  acid  may  be  used  when  the  cutis  vera  has  not  been  entirely 
destroyed,  and  the  burnt  area  is  not  too  extensive  ;  the  vesicles  are 
punctured,  and  then  a  piece  of  lint,  soaked  in  a  solution  of  picric 
acid  (5  grains  to  i  ounce  of  sterilized  water),  is  applied  to  the  burnt 
surface,  and  over  this  a  pad  of  sterilized  wool.     Thus  a  dry  dressing 


GANGRENE  119 

is  produced,  which  may  be  left  in  situ  for  some  days,  when  it  is 
reapplied.     The  results  are  sometimes  most  satisfactory. 

Where  the  burn  includes  deeper  structures,  the  clothes  must  be 
removed  with  as  little  dragging  as  possible,  being  cut  away  if 
necessary;  the  damaged  tissues  are  then  bathed  with  some  anti- 
septic, such  as  sublimate  lotion  (i  in  2,000),  and  covered  up  as 
rapidly  as  possible  with  lint  soaked  in  eucalyptus-oil  or  weak 
carbolized  oil  (i  in  40).  In  some  cases,  where  the  skin  and  surface 
are  exceedingly  dirty,  it  is  well  to  anaesthetize  the  patient,  cut  away 
parts  which  must  obviously  slough,  and  purify  thoroughly  the  wound, 
which  is  covered  with  protective  and  dressed  with  cyanide  gauze  or 
some  such  material.  In  very  extensive  burns  caution  must  be 
exercised  in  the  use  of  poisonous  antiseptics,  such  as  carbolic  acid  or 
corrosive  sublimate,  or  serious  toxic  effects  may  be  produced. 

If  the  patient  is  in  a  state  of  shock,  he  should  be  put  to  bed  and 
covered  with  warm  blankets  or  rugs,  v/hilst  perhaps  a  little  warm 
stimulating  fluid  is  administered,  and  a  dose  of  morphia  given  hypo- 
dermically ;  in  bad  cases  an  intravenous  injection  of  hot  saline 
solution  is  advisable,  and  it  may  often  be  repeated  with  advantage. 
In  the  case  of  children  with  very  extensive  burns,  it  is  sometimes 
useful  to  put  them  into  a  hot  bath,  to  which  some  eucalyptus-oil,  if 
obtainable,  or  Condy's  fluid,  has  been  added  ;  the  clothes  are  then 
removed  or  cut  away,  and  the  patient  allowed  to  remain  for  some 
time,  or  until  the  shock  has  subsided,  in  the  warm  water,  which 
should  be  replenished,  if  necessary.  It  may  be  desirable  to  repeat 
the  immersion  at  every  dressing.  The  wounds  are  then  dressed, 
and  the  little  patient  removed  to  bed,  where  special  attention  must 
be  directed  towards  maintaining  the  bodily  heat,  as,  e.g.,  by  placing 
electric  lights  under  the  blankets  which  cover  a  cradle  placed  over 
the  patient. 

When  a  limb  has  been  hopelessly  charred  or  burnt  to  the  bone, 
it  is  useless  to  retain  it,  and  early  amputation  through  the  nearest 
healthy  tissues  should  be  undertaken. 

During  the  stage  of  inflammation  and  sloughing  the  only  requisite 
is  to  keep  the  parts  as  free  from  sepsis  as  possible,  assisting  the 
natural  processes  of  repair  by  warm  moist  applications,  and  snipping 
away  sloughs  as  they  loosen.  Subsequently  the  wounds  are  treated 
on  general  principles.  The  granulations  often  become  prominent, 
and  stimulating  applications,  such  as  touching  them  with  nitrate  of 
silver,  may  be  necessary.  In  large  wounds,  healing  should  be 
assisted  by  skin-grafting,  according  to  Thiersch's  method,  in  order 
to  prevent  the  wound  becoming  chronic.  A  similar  proceeding 
should  be  undertaken  in  burns  which  involve  the  flexures  of  joints, 
so  as  to  avoid  subsequent  contractions. 


CHAPTER  VII. 
SPECIFIC  INFECTIVE  DISEASES. 

Erysipelas.* 

Erysipelas  is  a  contagious  infective  disease  due  to  the  development 
of  the  Streptococcus  pyogenes  in  the  smaller  lymphatics  of  the  skin  and 
occasionally  of  mucous  niembranes,  with  a  decided  tendency  to 
spread  and  to  recovery  without  loss  of  tissue,  the  constitutional 
symptoms  being  due  to  the  absorption  of  toxins  developed  locally. 
Occasionally  the  subcutaneous  connective  tissue  is  also  involved, 
constituting  the  variety  known  as  cellulo-ctitaneotis  erysipelas. 

There  has  been  considerable  discussion  as  to  whether  there  is  any 
difference  between  the  erysipelas  micrqije  and  the  ordinary  Strepto- 
coccus pyogenes  found  in  spreading  suppuration,  l?ut  it  is  now  generally 
admitted  that  they  are  identical.  The  explanation  of  the  differences 
in  the  clinical  history  and  infectiousness  between  erysipelas  and 
other  conditions  due  to  the  development  of  5.  pyogenes  is  probably 
to  be  found  in  the  method  of  invasion  and  in  the  differing  virulence 
of  various  strains  of  the  organism.  It  is  well  known  that  a  culture 
which  is  practically  non-pathogenic  can  have  its  virulence  exalted 
by  repeated  passage  through  animals  to  such  a  degree  that  an  ex- 
ceedingly minute  dose — perhaps  a  single  coccus — proves  fatal.  On 
the  other  hand,  cultivation  in  vitro  leads  to  attenuation  of  the 
organism  to  a  marked  degree. 

The  Causes  of  erysipelas  may  be  briefly  stated  as  follows  :  (i.)  The 
existence  of  an  abrasion  or  wound  in  most  cases,  and  particularly  of 
an  unprotected  septic  wound.  Thus,  it  is  not  uncommon  to  find  it 
associated  with  neglected  scalp  wounds  or  with  those  communi- 
cating with  the  mouth.  In  the  so-called  idiopathic  erysipelas  the 
wound  may  be  very  minute,  such  as  a  prick  or  scratch,  or  there  may 
be  no  obvious  wound  at  all,  infection  occurring  through  a  hair 
follicle  in  healthy  skin,  (ii.)  A  weak,  depressed  state  of  the  constitu- 
tion, as  from  alcoholism,  deficient  or  bad  food,  vicious  living,  diabetes, 

*  It  is  becoming  more  than  ever  doubtful  whether  erysipelas  is  to  be  looked  on 
as  a  specific  infection.  Careful  bacteriological  examination  is  indicating  that  other 
pyogenic  organisms  than  the  streptococcus  may  be  responsible  for  its  appearance, 
and  it  is  probable  that  hereafter  we  may  have  to  relegate  it  to  the  chapter  dealing 
with  non-specific  infections. 

I20 


SPECIFIC  INFECTIVE  DISEASES  I2i 

albuminuria,  etc.  Some  people,  moreover,  seem  naturally  predis- 
posed to  the  disease,  particularly  plethoric  and  gouty  individuals,  and 
one  attack  renders  the  subject  more  liable  to  recurrence  after  a  short 
period  of  immunity.  (iii.)  Bad  hygienic  surroundings  are  a  most 
important  additional  factor  in  its  production,  especially  overcrowd- 
ing in  hospitals  and  defective  ventilation.  But  these  are  all  merely 
predisposing  conditions ;  the  only  exciting  and  absolute  cause  is — 
(iv.)  infection  with  the  particular  micro-organism. 

The  Symptoms  of  the  disease  are  usually  ushered  in  by  a  slight 
chill,  scarcely  amounting  to  a  rigor,  and  by  a  period  of  headache 
and  malaise  for  about  twenty-four  hours  with  some  degree  of  pyrexia. 
These  symptoms  are  followed  by  the  development  of  the  rash, 
spreading  either  from  the  margin  of  the  wound,  or  showing  itself  in 
apparently  unbroken  skin  in  the  so-called  idiopathic  variety.  If 
there  is  a  wound,  it  usually  presents  a  yellowish,  unhealthy-looking 
surface,  with  very  little  evidence  of  repair.  If  the  erysipelatous  virus 
is  unmixed  with  other  organisms,  the  healing  process  may  continue 
until  the  rash  appears  on  about  the  fourth  or  fifth  day,  when  the  young 
cicatrix  will  break  open  again,  exposing  a  dry  and  sluggish  surface 
with  a  thickened  margin ;  it  may  occur,  however,  at  an  earlier  date. 
The  rash  is  generally  of  a  characteristic  vivid  rosy-red  colour,  dis- 
appearing on  pressure,  and  accompanied  by  a  sensation  of  stiffness  or 
burning,  scarcely  amounting  to  pain,  except  when  dense  structures, 
such  as  the  scalp,  are  involved,  and  then  the  pain  may  be  severe. 
Swelling  is  not  marked,  except  in  lax  areolar  tissues,  such  as  in 
the  scrotum  or  eyelids  ;  the  oedema  may  then  attain  considerable 
proportions.  The  rash  continues  to  advance  more  or  less  rapidly, 
with  a  continuous  slightly  raised  margin,  and  as  it  spreads  to  new 
regions  it  fades  away  from  those  already  involved,  leaving  a  slight 
brownish  stain  and  a  fine  branny  desquamation.  In  some  cases  it  does 
not  spread  regularly,  but  appears  to  leap  over  an  interval,  and  then 
the  intervening  lymphatics  are  found  to  be  thickened.  Vesicles  and 
bullae  form  superficially,  containing  serum,  which  speedily  becomes 
turbid,  but  suppuration  is  uncommon,  except  in  lax  cedematous 
tissue,  such  as  the  eyelids.  Occasionally,  from  the  severity  of  the 
inflammation  or  the  low  state  of  vitality  of  the  tissues,  the  skin  may 
become  gangrenous  and  slough,  especially  about  the  umbilicus  and 
genitals  of  young  children.  Neighbouring  lymphatic  glands  are 
always  enlarged  and  painful,  and  this  may  even  be  noted  at  a  period 
when  the  rash  has  not  appeared.  Periphlebitis  may  also  be  caused, 
leading  to  pyaemic  complications.  Fever  is  present  as  long  as  the 
rash  persists,  and  merely  shows  slight  diurnal  variations.  It  is  not 
uncommon  for  the  temperature  to  rise  to  104°  F.,  but  anything  above 
that  is  of  grave  significance.  At  first  the  fever  is  of  a  sthenic  type, 
the  pulse  full,  and  the  delirium  noisy  and  active  ;  but  later  on  the 
pulse  becomes  quick  and  weak,  accompanied  by  low,  muttering 
delirium  and  great  prostration  of  the  vital  powers.  Delirium  is 
usually  a  well-marked  feature  in  erysipelas  of  the  scalp,  but  this  is 
due  to  the  general  rather  than  to  any  local  condition,  unless  meningitis 


122  A  MANUAL  OF  SURGERY 

supervenes.     The  duration  of  the  attack  is  most  variable,  lasting,  as 
a  rule,  from  one  to  three  weeks,  but  relapses  are  not  uncommon. 

The  so-called  Idiopathic  Erysipelas  mainly  affects  the  head,  and 
occurs  in  predisposed  individuals,  often  recurring  about  the  same 
time  of  the  year ;  pain  and  delirium  are  prominent  symptoms,  and 
the  subcutaneous  tissues  of  the  face  become  so  swollen  that  the 
features  are  almost  unrecognisable.  Large  blebs  form,  and  abscesses 
are  not  uncommon  about  the  eyelids. 

Cellulo- cutaneous  Erysipelas  is  due  to  infection  of  the  subcutaneous 
tissues  as  well  as  of  the  skin  with  the  specific  virus,  and  results  in 
suppuration  and  sloughing  both  of  the  skin  and  subjacent  cellular 
tissue.  To  the  ordinary  phenomena  of  erysipelas  are  added  a  diffuse 
infiltration  of  the  subcutaneous  tissues,  brawny  at  first  in  type,  but 
subsequently  softening  and  becoming  boggy,  the  skin  finally  giving 
way,  and  allowing  exit  to  the  pus  and  sloughs.  The  general 
symptoms  are  correspondingly  severe,  and  pyaemia  may  supervene. 
As  distinguishing  features  from  ordinary  erysipelas,  it  is  stated  that 
the  margin  of  the  redness  is  less  defined,  and  that  the  lymphatic 
glands  are  less  enlarged. 

Erysipelas  of  the  Fauces  causes  a  diffuse  inflammation  of  the 
mucous  membrane  of  the  fauces,  often  spreading  to  the  glottis  and 
larynx,  and  arising  either  by  extension  from  without,  or  in  association 
with  some  external  manifestation  of  the  disease  elsewhere.  The 
fauces  and  soft  palate  become  of  a  dusky  scarlet  colour,  and  are 
much  swollen.  The  voice  is  either  husky  or  absolutely  disappears, 
whilst  severe  spasmodic  dyspnoea  may  arise  from  oedema  of  the 
glottis.  The  parts  are  very  prone  to  ulcerate  or  slough,  and  the 
glands  at  the  angle  of  the  jaw  are  enlarged.  Fever  is  usually,  though 
not  invariably,  present,  and  great  depression  of  the  vital  powers. 

Erysipelas  of  the  Scrotum,  or,  as  it  is  sometimes  termed,  acute 
inflammatory  oedema,  is  characterized  by  the  part  becoming  greatly 
distended  by  serum,  but  without  any  marked  redness.  Suppuration 
and  sloughing  are  not  unlikely  to  follow.  It  thus  somewhat 
simulates  the  appearance  produced  by  extravasation  of  urine,  but  is 
distinguished  from  it  by  the  facts  that  micturition  is  usually  not 
interfered  with,  and  that  the  swelling  is  not  Hmited  in  the  same  way 
as  in  the  latter  affection. 

Diagnosis. — There  is  not  much  difficulty  in  recognising  a  case  of 
erysipelas,  if  the  distinguishing  features  of  the  rash  are  remembered, 
viz.,  its  method  of  extension  by  a  broad,  sharply-defined,  slightly 
raised  and  infiltrated  red  margin,  and  its  almost  invariable  association 
with  superficial  vesicles,  perhaps  visible  only  on  examination  with  a 
lens,  or  with  obvious  pustules  or  bullae.  A  septic  wound  with  pent-up 
discharge  closely  simulates  erysipelas ;  but  the  redness  has  not  such 
an  accurately  defined  margin  and  does  not  spread  beyond  the  im- 
mediate neighbourhood  of  the  wound ;  cutaneous  vesicles  are  not 
usual  in  ordinary  sepsis,  whilst  lymphatic  enlargement  is  uncommon. 
A  patch  of  cellulitis  will  also  be  distinguished  by  the  same  features. 
Diffuse  erythema  nodosum  is  recognised  by  the  slight  degree  of  the 


SPECIFIC  INFECTIVE  DISEASES  123 

febrile  disturbance,  and  the  presence  of  outlying  patches  of  redness, 
which,  moreover,  are  not  so  clearly  limited.  There  is  always  con- 
siderable pain  in  this  affection,  which  often  involves  both  legs,  and 
usually  occurs  in  young  women  of  a  rheumatic  temperament.  The 
so-called  erythema  solare  follows  exposure  to  the  sun's  rays,  especially 
when  reflected  from  water,  of  parts  of  the  body  which  are,  as  a  rule, 
protected ;  though  usually  of  slight  importance,  it  may  sometimes 
give  rise  to  so  much  pain,  oedema,  and  constitutional  disturbance  as 
to  simulate  erysipelas.  It  is  readily  distinguished  by  the  facts  that 
it  is  limited  to  the  parts  exposed  and  has  no  tendency  to  spread.  In 
acute  eczema  nibrum  the  presence  of  a  honey-like  exudation  is  quite 
characteristic. 

Pathological  Anatomy. — If  a  person  dies  of  erysipelas,  one  merely 
finds  the  general  signs  common  to  all  septic  cases  detailed  elsewhere 
(p.  83).  The  rash  will  have  faded,  but  on  microscopic  section  of  the 
skin  colonies  of  cocci  arranged  in  chains  will  be  found  invading  the 
lymphatics  just  beyond  the  spreading  margin,  whilst  in  the  parts 
which  the  inflammation  has  recently  attacked  there  will  be  a  con- 
siderable excess  of  leucocytes,  presumably  connected  with  the 
destruction  and  removal  of  the  cocci.  The  lymph  glands  will  also 
be  found  enlarged  and  congested. 

Prognosis. — Erysipelas  is  not  peculiarly  dangerous  in  itself  (Osier 
gives  the  death-rate  as  7  per  cent,  in  hospital  patients),  but  may 
become  so  from  the  com.plications  which  attend  it.  The  most  im- 
portant of  these  are  inflammatory  conditions  of  the  brain,  lungs,  and 
other  viscera,  especially  of  the  kidneys.  Pyaemia  and  general  septic 
intoxication  are  also  observed.  Erysipelas  is  usually  attended  with 
danger  to  life  in  old  people,  drunkards,  and  infants,  whose  vital 
powers  become  rapidly  exhausted.  It  is  interesting  and  important 
to  note  that  after  an  attack  has  passed,  wounds,  even  if  previously 
chronic  and  sluggish,  often  manifest  marvellous  reparative  power, 
provided  no  other  complication  is  present.  Chronic  lupoid  and 
syphilitic  ulcers  may  also  rapidly  cicatrize,  and  even  malignant 
sores,  especially  sarcomata,  have  been  known  to  be  cured. 

Treatment. — Erysipelas  is  a  notifiable  disease  under  the  Infectious 
Diseases  Acts,  1889  and  1899,  and  the  patient  must  be  isolated  or 
removed  if  possible  from  a  surgical  ward.  If  unfortunately  this  is 
impracticable,  the  patient  must  be  placed  as  far  away  from  others  as 
possible,  and  especially  from  those  with  open  wounds,  which  from 
their  position  {e.g.,  the  mouth)  cannot  be  properly  protected  from 
infection.  It  is  wise  under  these  circumstances  to  put  off  all 
operations  that  can  be  safely  postponed ;  the  bed  should  be 
surrounded  with  sheets  kept  moist  with  carboHc  lotion,  and  the  floor 
around  sprinkled  with  the  same.  Special  nurses  and  dressers 
must  be  told  off  to  attend  to  the  case,  which  should  never  be 
dressed  with  ungloved  hands. 

Local  Treatment.^When  one  considers  the  bacterial  origin  of  the 
affection,  it  is  evident  that,  except  in  the  mildest  cases,  the  old- 
fashioned  plan  of  merely  protecting  the  part  from  the  air,   as  by 


.124  A  MANUAL  OF  SURGERY 

painting  it  with  collodion,  or  covering  it  with  a  thick  layer  of  starch 
or  flour,  mixed  perhaps  with  boric  acid,  was  .very  inefficient,  whilst 
it  is  equally  obvious  that  the  local  application  of  cold  is  absolutely 
harmful,  inasmuch  as  it  still  further  depresses  the  vitality  of  the  part. 
Where  tension  and  pain  are  severe,  fomentations  containing  opium 
or  belladonna  (e.g.f  i  ounce  of  laudanum  to  i  pint  of  lotio  plumbi) 
may  be  applied,  or  the  parts  should  be  scarified  and  antiseptic  com- 
presses applied — e.g.,  gauze  soaked  in  carbolic  acid  (i  in  40)  or  in 
sublimate  solution  (i  in  2,000).  Perhaps  the  best  local  applications 
are  ichthyol  or  thiol,  the  latter  being  an  artificial  sulphur  compound 
much  resembling  ichthyol,  but  without  the  objectionable  smell.  A 
20  to  40  per  cent,  aqueous  solution  is  painted  over  the  affected  area, 
possibly  after  scarification,  as  well  as  over  the  neighbouring  healthy 
skin,  several  times  a  day  until  the  fever  disappears;  such  treatment 
:is  stated  to  be  usually  successful  in  checking  the  disease  in  two  or 
three  days,  whilst  the  stickiness  of  the  preparation  hinders  the 
diffusion  of  the  virus. 

Anything  that  tends  to  produce  a  local  accumulation  of  leucocytes 
in  the  skin  beyond  the  spreading  edge  should  be  beneficial  in  checking 
its  advance,  and  therefore  good  may  be  derived  by  painting  around 
the  rash  with  strong  solutions  of  nitrate  of  silver  (gr.  xxx.-lx. 
ad  §i.)  or  with  lin.  iodi,  granting  that  it  is  done  sufficiently  far  off  to 
be  on  healthy  skin.  The  most  efficient  plan  based  on  this  idea  is 
Kraske's,  in  which  the  skin  is  scarified  all  round  at  a  distance  of  an 
inch  or  two  from  the  spreading  margin,  the  knife  going  just  deeply 
enough  to  draw  blood;  antiseptic  compresses  are  then  applied. 
•  Antistreptococcic  serum  (p.  28)  should  be  einployed  as  early  as 
possible,  ten  or  fifteen  c.c.  of  the  polyvalent  serum  being  given  sub- 
cutaneously  as  a  dose,  and  repeated  once  or  twice  a  day.  The 
results,  however,  have  not  been  as  satisfactory  as  v/as  originally 
expected. 

Constitutional  Treatment  must  be  of  a  tonic  and  supporting 
character.  Good  food,  easy  of  assimilation,  stimulants  and  quinine, 
should  be  freely  administered,  whilst  the  tincture  of  the  perchloride 
of  iron  in  ^-drachm  doses,  repeated  three  or  four  times  a  day,  is  still 
looked  on  by  many  as  a  specific.  The  latter  drug  must  be  combined 
with  salines  or  purgatives,  so  as  to  avoid  constipation. 

In  cellulo-cutaneous  erysipelas  early  and  free  incisions  must  be  made 
to  relieve  tension,  and,  if  possible,  anticipate  suppuration.  The 
tissues,  when  incised,  look  gelatinous  from  the  cedema  present,  and 
much  fluid  of  a  sero-purulent  type  will  escape.  Antiseptic  fomenta- 
tions should  be  employed  after  the  incisions  have  been  made,  until 
granulations  have  developed. 

In  erysipelas  of  the  fauces  the  parts  must  be  painted  over  once  a  day 
with  liquor  argenti  nitratis  (10  grains  to  i  ounce),  or  sprayed  more 
frequently  with  antiseptic  lotions,  such  as  liq.  hydrarg.  perchlor. 
(i  in  2,000),  or  liq.  sodse  chlorinatas  (i  part  to  15  parts  of  water),  or 
sanitas,  whilst  antiseptic  tabloids  or  pastilles — e.g.,  of  formamint — 
should  be  frequently  sucked.     Tracheotomy  may  be  needed  if  the 


PLATE   II. 


Fig.  21. — Typhoid  bacilli,  showing  flagella.  Van  Ermengen's  stain.  Fig.  22. — 
Tubercle  bacilli  in  sputiun.  Carbol-fuchsin  and  methylene  blue.  Fig.  23. — Tetanus 
bacilli,  some  showing  spores :  from  a  culture.  Stained  by  carbol-fuchsin  and 
methylene  blue.  Fig.  24. — Anthrax  bacilli  in  blood.  Gram  and  eosin.  Fig.  25. — 
Leprosy  bacilli,  in  cells  from  the  spleen.  Carbol-fuchsin  and  methylene  blue. 
Fig.  26. — Bacillus  coli  in  urine,  with  a  few  pus  cells.     Methylene  blue. 

{To  face  page  124. 


SPECIFIC  INFECTIVE  DISEASES  125 

glottis  is  involved.  Diffusible  stimulants  and  plenty  of  nourish- 
ment are  urgently  necessary  to  combat  the  depressing  effects  of  this 
disease. 

Tetanus. 

Tetanus  is  a  local  infective  disease,  due  to  the  Bacillus  tetani,  and 
the  characteristic  symptoms  are  of  a  toxaemic  nature.  The  first  clue 
to  the  infective  nature  of  this  disease  was  obtained  from  the  observa- 
tion that,  if  portions  of  soil  or  garden  mould  were  placed  under  the 
skin  of  animals,  they  died  in  a  short  time  with  tetanic  symptoms, 
and  in  the  pus  and  walls  of  the  resulting  abscess  characteristic 
bacilli  were  observed.  Experimenting  in  the  same  way,  it  has  been 
found  that  the  bacilli  or  their  spores  are  very  widely  disseminated, 
and,  indeed,  are  present  in  almost  every  sample  of  garden  or  field 
soil ;  they  have  been  found  in  the  grime  on  a  working  man's  hand 
and  on  dirty  surgical  instruments.  Great  difficulty  was  experienced 
in  iEolating  the  bacillus,  but  at  last  Nicolaier  and  Kitasato  succeeded, 
by  heating  the  pus  from  an  infected  wound  to  a  temperature  of  80°  C. 
for  an  hour,  thereby  destroying  all  the  pyogenic  and  septic  microbes. 
It  occurs  in  the  form  of  delicate  straight  rods,  which  sometimes  grow 
into  long  threads.  It  is  a  strict  anaerobe,  ceasing  to  grow  if  the 
smallest  trace  of  oxygen  is  present,  and  is  usually  cultivated  in  an 
atmosphere  of  hydrogen  or  nitrogen  ;  no  gas  is  produced  by  its 
growth.  It  forms  characteristic  spores  which  are  nearly  spherical 
in  shape  and  situated  at  the  extreme  end  of  the  bacillus,  giving  it  the 
appearance  of  a  drumstick  (Plate  II.,  Fig.  23)  ;  these  appear  both  in 
the  pus  of  the  wound  and  in  cultures.  It  stains  by  Gram's  method 
and  possesses  numerous  flagella.  The  bacilli  themselves  are  not 
powerful  parasites,  and  when  separated  completely  from  their  toxins 
often  fail  to  cause  infection  when  injected  into  susceptible  animals ; 
should,  however,  a  minute  trace  of  toxin  be  present,  it  so  depresses 
the  vitality  of  the  surrounding  tissues  that  the  bacilli  continue  to 
grow  and  produce  more  toxin. 

Predisposing  Causes. — i.  Climalic  Influences. — The  disease  is  most 
commonly  seen  in  the  tropics,  where  it  may  be  almost  epidemic, 
probably  owing  to  the  heat  favouring  the  development  and  virulence 
of  the  organisms  in  the  soil ;  hot  seasons  assist  its  activity,  and 
particularly  when  hot  days  are  followed  by  cold  nights. 

2.  Personal  Proclivity. — It  was  formerly  considered  that  negroes 
and  stable  attendants  were  specially  liable  to  this  disease,  owing  to 
some  peculiar  idiosyncrasy  ;  but  such  an  idea  cannot  now  be  main- 
tained. The  causative  organism  is  a  facultative  saprophyte — i.e.,  is 
capable  of  continuing  its  development  apart  from  the  body — and  is 
almost  constantly  found  in  garden  soil,  dust,  or  dirt  of  any  kind. 
Those,  therefore,  who  are  likely  to  be  much  brought  in  contact  with 
the  ground — e.g.,  negroes  and  agricultural  labourers — owe  their 
liability  to  the  disease  to  their  more  constant  exposure  to  infec- 
tion. Horses  are  peculiarly  susceptible  to  tetanus,  and  the  bacilli 
are   usually  present  in    their  fasces ;   hence  stablemen  and   others 


126  A  MANUAL  OF  SURGERY 

brought  into  contact  with  horses  are  attacked  with  comparative 
frequency. 

3.  Bad  Hygiene  is  a  most  important  predisposing  condition. 
Every  hygienic  error  favours  its  appearance,  but  especially  the 
overcrowding  of  sick  and  wounded  people  into  a  limited  space,  and 
especially  if  asepsis  is  impossible. 

Exciting  Causes. — i.  The  existence  of  a  wound,  which  is  usually 
of  a  dirty,  lacerated  or  punctured  character,  and  the  site  of  septic 
contamination.  Any  part  of  the  body  may  be  thus  affected,  but 
perhaps  those  regions,  such  as  the  sole  of  the  foot,  or  the  palm  of  the 
hand,  which  are  likely  to  be  brought  into  contact  with  the  soil,  are 
most  often  involved.  The  depressed  vitality  of  the  tissues  owing  to 
the  bruising  and  tearing,  the  irritation  caused  by  the  growth  of  septic 
organisms,  and  the  absorption  by  the  latter  of  any  oxygen  present, 
thereby  determining  a  condition  of  anaerobiosis,  co-operate  in 
favouring  the  development  of  the  tetanus  bacilli.  Hence  it  is  rare 
for  the  disease  to  affect  wounds  where  asepsis  has  been  maintained 
and  rapid  repair  has  been  effected,  and  it  is  very  uncommon,  though 
possible,  for  it  to  develop  after  blows  or  bruises  with  no  breach  of 
surface.  Gunshot  wounds  due  to  blank  cartridges  are  often  followed 
by  it,  since  the  injury  is  largely  due  to  the  wad,  which  is  made  of 
coarse  horsehair  felt,  and  is  therefore  likely  to  contain  spores  of  the 
bacillus.  Commercial  gelatin,  derived  from  the  hoofs,  etc.,  of  horses, 
often  contains  the  bacilli,  and  the  injection  of  this  substance  in  the 
treatment  of  aneurisms  has  been  followed  by  this  disease. 

2.  Infection  with  the  B.  Tetani. — Tetanus  forms  the  best  example 
in  pathology  of  a  local  infection  with  general  toxaemia.  The  bacilli 
remain  localized  in  the  neighbourhood  of  the  wound,  and  do  not 
enter  the  blood  or  reach  distant  parts  of  the  body.  The  toxins  pro- 
duced locally  act  on  the  cells  of  the  central  nervous  system  in 
a  manner  very  similar  to  strychnine.  There  is,  however,  a  very 
unusual  feature  in  the  mode  of  passage  of  the  toxin  from  the  local 
lesion  to  the  brain  and  cord,  in  that  it  appears  to  travel  in  the  nerves 
themselves,  and  not  in  the  blood,  as  in  other  infections.  One  or  two 
of  the  proofs  that  have  been  advanced  in  support  of  this  theory  may 
be  quoted.  Tetanus  may  be  caused  by  the  injection  of  a  very  small 
dose  of  toxin  directly  into  a  nerve,  whereas  the  animal  may  resist  the 
injection  of  four  or  five  times  this  amount  into  a  muscle ;  and  if  the 
nerve  is  cut  between  the  site  of  inoculation  and  the  central  nervous 
system,  the  spasms  may  be  delayed,  or  even  prevented  altogether. 
This  may  explain  the  beneficial  effects  which  sometimes  followed 
the  now  abandoned  operation  of  nerve  stretching  or  section  in 
tetanus.  Further,  the  toxin  can  be  demonstrated  in  the  nerves 
themselves,  since  they  give  rise  to  tetanus  when  introduced  into  a 
susceptible  animal,  and  it  is  even  possible  to  form  some  idea  as  to 
the  amount  contained  in  different  nerves.  Thus  the  toxin  has  a 
special  affinity  for  the  motor  nerves,  and  large  amounts  have  been 
found  in  the  nerve  to  the  masseter  muscle,  an  interesting  fact  in 
view  of  the  frequent  occurrence  of  trismus. 


SPECIFIC  INFECTIVE  DISEASES  127 

The  post-mortem  anatomical  changes  are  not  characteristic.  The 
muscles  are  often  pale,  or  show  evidences  of  rupture  or  extravasa- 
tion of  blood.  The  peripheral  nerves  extending  from  the  wound 
may  be  red  and  congested  for  some  distance  :  this  may  not  be  due 
to  the  action  of  the  toxin  (which  appears  to  produce  no  demonstrable 
lesions  of  the  nerves  themselves),  but  to  septic  inflammation.  The 
nerve-centres  frequently  present  areas  of  softening  and  perivascular 
cellular  exudation,  with  some  hyperaemia.  Minute  changes  may 
also  be  demonstrated  in  the  nerve-cells. 

Clinical  History. — Acute  Tetanus  usually  manifests  itself  in  this 
country  two  or  three  weeks  after  infection  (but  sometimes  abroad 
as  early  as  a  few  hours  or  days)  by  a  difficulty  in  opening  the 
mouth,  associated  with  a  cramp-like  pain  in  the  muscles  of  mastica- 
tion and  of  the  neck.  This  soon  becomes  so  marked  that  it  may 
be  difficult  even  to  insert  a  paper-knife  between  the  teeth  (trismus, 
or  lock-jaw),  causing  great  difficulty  in  the  administration  of  food  ; 
to  it  is  added  a  fixed  and  rigid  condition  of  the  muscles  of  the  back 
of  the  neck  and  of  the  face,  the  latter  producing  a  curious  grin-hke 
appearance  (risus  saydonicus),  whilst  dysphagia  is  sometimes  caused  by 
spasm  of  the  pharyngeal  muscles.  A  considerable  degree  of  fever 
is  often  manifested,  but  in  some  cases  an  apyrexial  course  is  main- 
tained until  nearly  the  end.  The  spasms  soon  extend  to  the  trunk 
and  extremities,  accompanied  by  cramp-like  pains,  and  when  fully 
established  they  may  be  excessively  painful  and  violent,  and  the 
remissions  between  them  but  partial.  Fortunately  the  disease 
usually  involves  the  respiratory  muscles  late  in  the  attack.  The 
more  severe  spasms  can  be  excited  by  any  form  of  stimulus,  such  as 
the  slamming  of  a  door,  a  draught  of  cold  air,  or  some  voluntary 
movement,  and  are  always  of  a  tonic  [i.e.,  continuous)  character.  The 
body  is  contorted  in  various  directions,  and  respiration  may  be  much 
impeded  by  the  fixation  of  the  thorax.  Occasionally  the  body  is 
arched  backwards  (opisthotonos)  by  the  contraction  of  the  muscles  of 
the  back,  the  recti  abdominis  being  firm  and  tense — '  as  hard  as 
boards';  sometimes  it  is  doubled  forwards  [emprosthotonos),  and  in 
rare  cases  laterally  (pkurosthotonos).  The  muscles  may  contract  so 
violently  as  to  be  ruptured,  whilst  teeth  have  been  broken  and  the 
tongue  has  been  almost  bitten  off.  The  intellectual  faculties  usually 
remain  clear  to  the  end,  which  is  generally  due  to  exhaustion  from 
a  repetition  of  the  convulsions,  or  more  rarely  to  asphyxia  induced 
by  a  prolonged  fixation  of  the  respiratory  muscles.  Before  death 
the  temperature  sometimes  runs  up  to  108°,  or  even,  in  one  case,  to 
112°  F.,  and  it  often  continues  to  rise  for  a  degree  or  two  after 
death ;  such  hyperpyrexia  is  mainly  due  to  the  continuous  muscular 
contractions.  The  surface  of  the  body  is  bathed  in  sweat,  and  the 
urine  occasionally  albuminous.  Death  may  occur  in  twenty-four 
hours  from  the  onset  of  the  disease,  or  not  for  four  or  five  days. 

Chronic  Tetanus  usually  begins  later  after  infection,  is  less  severe 
in  its  symptoms,  and  more  likely  to  be  recovered  from.  The  course 
is  usually  afebrile,  and  the  spasmodic  contractions  may  be  limited  to 


128  A  MANUAL  OF  SURGERY 

the  wounded  part  of  the  body  whence  the  infection  has  arisen,  or 
may  be  general.  Sometimes  the  patient  Hes  in  bed  with  his  jaw 
partially  fixed,  and  the  muscles  of  his  neck,  back,  and  abdomen 
rigidly  contracted,  but  with  none  of  the  characteristic  convulsions. 

A  special  variety  known  as  cep halo-tetanus,  or  T.  paralyticus 
(German,  hop f -tetanus),  follows  injuries  within  the  area  of  distribution 
of  the  cranial  nerves,  and  especially  those  about  the  supra-orbital 
margin  ;  it  is  characterized  by  the  association  of  trismus  with  facial 
paralysis  on  the  affected  side,  whilst  the  usual  tonic  spasms  occur  in 
other  parts  of  the  body-  Spasm  of  the  muscles  of  deglutition  and 
attacks  of  maniacal  frenzy  are  sometimes  present,  and  hence  the 
name  T.  hydrophobicus  which  has  been  applied  to  it.  The  condition 
is  uncommon,  and  the  prognosis  not  quite  so  grave  as  in  the  acute 
cases. 

The  Diagnosis  of  tetanus  is  rarely  difficult.  In  the  early  stages  it 
must  be  distinguished  from  simple  trismus  arising  from  dental  irrita- 
tion, or  from  inflammatory  ankylosis  of  the  temporo-maxillary  joint. 
This  may  be  readily  accomplished  by  noting  that  rigidity  of  the 
neck  muscles  is  also  present  in  tetanus.  In  the  later  stages 
strychnine-poisoning  leads  to  a  very  similar  group  of  symptoms,  but 
is  recognised  from  it  by  the  contractions  being  more  sudden  and 
violent,  the  relaxation  of  the  muscles  between  the  spasms  complete 
so  that  the  mouth  can  readily  be  opened,  whilst  the  hands  are 
involved  in  the  contractions,  a  rare  sign  in  tetanus,  and  the  muscles  y 
of  mastication  often  escape. 

No  difficulty  should  be  experienced  in  distinguishing  tetanus  from 
hydrophobia,  owing  to  the  very  different  nature  of  the  convulsions  in 
the  latter  case — i.e.,  clonic  and  not  tonic  ;  moreover,  they  affect  the 
muscles  of  respiration  and  deglutition,  whilst  the  history  of  the  case, 
the  early  hallucinations,  and  the  absence  of  tonic  muscular  contrac- 
tions, are  also  characteristic  features. 

Laboratory  methods  are  usually  unnecessary  for  the  diagnosis  of 
the  disease  when  developed,  but  in  case  of  doubt  the  best  method  is 
to  collect  some  of  the  discharge  from  the  deeper  portions  of  the 
wound,  dilute  it  with  broth,  and  divide  it  into  two  parts:  one  of 
these  is  to  be  injected  into  a  mouse  or  guinea-pig,  whilst  the  other 
portion  is  mixed  with  i  c.c.  of  tetanus  antitoxin  and  then  injected. 
If  the  former  animal  develops  tetanic  symptoms,  whilst  the  latter 
escapes,  the  diagnosis  is  assured. 

The  Prognosis  is  unfavourable  in  any  case,  but  the  so-called 
idiopathic  variety  is  less  fatal  than  the  traumatic.  The  longer  the 
case  lasts,  and  the  lower  the  temperature,  the  more  likely  is  the 
patient  to  recover,  whilst  an  acute  onset,  hyperpyrexia,  sleeplessness, 
dehrium,  and  strabismus  are  bad  signs.  The  length  of  the  incuba- 
tion period  is  also  a  most  important  factor ;  for  even  when  antitoxin 
Is  administered,  the  mortality  in  early  cases  {i.e.,  with  an  incuba- 
tion period  of  less  than  ten  days)  is  at  least  20  per  cent,  higher 
than  when  the  appearance  of  the  disease  is  delayed  to  a  later 
period. 


SPECIFIC  INFECTIVE  DISEASES  129 

Treatment. — In  places  where  tetanus  is  known  to  be  rife,  it  is  a 
wise  precaution  to  administer  antitetanic  serum  as  a  preventive  or 
immunizing  agent  in  cases  of  wounds  or  abrasions  that  might  pos- 
sibly be  infected,  especially  if  due  to  street  accidents,  or  if  suspicious 
bacilli  are  found  on  microscopic  examination  of  a  scraping  from  the 
deeper  parts  of  the  wound.     The  dose  need  not  be  large  (1-5  c.c). 

After  the  disease  has  appeared,  the  originating  sore,  if  accessible, 
should  be  freely  excised  and  the  wound  cauterized,  or  the  limb  may 
be  amputated  ;  but  even  then  convulsions  may  persist  for  a  time,  or 
prove  fatal,  from  the  amount  of  toxin  already  in  the  system. 

In  addition  to  these  local  measures,  the  specific  antitetanic  serum, 
prepared  from  the  blood-serum  of  an  immunized  animal  should 
be  injected  (p.  28).  The  serum  is  purely  antitoxic  and  has  no  effect 
upon  the  development  of  the  bacilli,  for  the  destruction  of  which 
local  phagocytosis  or  other  immunizing  action  has  to  be  relied  on. 
Any  toxin  circulating  in  the  blood  is  readily  destroyed  or  neutralized ; 
but  inasmuch  as  the  toxin  travels  by  the  nerves  and  rapidly  unites 
with  the  protoplasm  of  the  nerve-centres,  and  then  cannot  be 
influenced  by  the  antitoxin,  the  results  of  its  use  are  often  disap- 
pointing. The  treatment  should  always  commence  with  a  large 
dose,  and  smaller  amounts  should  then  be  administered  once  or 
twice  a  day,  varying  with  the  severity  of  the  symptoms  ;  20  to 
30  c.c.  may  be  given  as  the  initial  injection,  followed  by  doses  of  10 
to  15  c.c.  twice  a  day.  This  is  introduced  into  the  subcutaneous 
tissues  of  the  abdomen  or  back,  or  in  somewhat  smaller  doses  into 
the  veins  or  subdural  space  after  lumbar  puncture.  Intracerebral 
injections  have  also  been  utilized,  in  the  hope  that  thereby  the  toxin 
absorbed  in  the  nerve-centres  may  be  acted  upon,  and  that 
unaffected  nerve-centres  (especially  the  organic  centres  in  the 
medulla)  may  be  protected.  The  injection  is  made  through  the  dura 
mater  into  the  posterior  portion  of  the  second  frontal  convolution  on 
each  side  ;  2-5  c.c.  of  the  dried  serum  dissolved  in  5  c.c.  of  sterilized 
water  are  injected  very  slowly,  and  this  may  be  repeated  several 
times,  if  an  interval  of  a  few  days  is  allowed  to  elapse  between  each 
injection.  The  point  selected  is  placed  midway  between  the  external 
angular  process  of  the  frontal  bone  and  the  centre  point  of  the  line 
between  the  root  of  the  nose  and  the  external  occipital  protuberance. 
A  small  trephine  may  be  applied  here,  or  simply  a  hole  drilled 
through  the  skull  sufficient  to  allow  of  the  introduction  of  a  syringe, 
which  is  pushed  about  two  inches  deep  into  the  brain.  This  treat- 
ment must  of  course  be  augmented  by  subcutaneous  injections  and 
other  subsidiary  measures.  Another  plan  of  treatment,  suggested 
by  Baccelli,  consists  in  the  hypodermic  injection  of  carbolic  acid  ; 
10  or  15  minims  of  a  2  per  cent,  solution  are  injected  two  or  three 
times  a  day,  and  although  its  action  cannot  be  explained,  yet  the 
percentage  mortality  of  cases  treated  in  this  way  hitherto  reported  is 
certainly  less  than  that  accompanying  the  serum  treatment. 

The  patient  should  be  kept  absolutely  quiet  in  a  darkened  room, 
and    free    from    all    sources   of    irritation.     The    spasms    may   be 

9 


I30  A  MANUAL  OF  SURGERY 

diminished  or  almost  abolished  by  the  injection,  either  subcutane- 
ously  or  by  lumbar  puncture,  of  a  sterilized  solution  of  magnesium 
sulphate,  which  acts  solely  by  reducing  the  excitability  of  the  motor 
cells,  and  has  no  action  on  the  tetano-toxins,  fixed  or  free.  The 
dose  subcutaneously  is  lo  to  20  c.c.  of  a  10  per  cent,  solution  every 
four  hours ;  whilst  intraspinally  2  to  4  c.c.  of  a  25  per  cent,  solution 
can  be  injected  daily  without  ill  effect.  Chloroform  may  be 
administered  with  the  same  object.  Food  should  be  nutritious, 
fluid,  and  unstimulating ;  it  has  been  suggested  to  feed  the  patient 
twice  a  day  by  a  stomach-pump  under  chloroform,  or  by  a  soft 
rubber  catheter  through  the  nose.  Opium,  chloral  hydrate,  bromide 
of  potash,  physostigma,  and  curare,  have  been  vaunted  as  beneficial 
drugs,  but  probably  cases  which  have  recovered  after  their  exhibition 
would  have  done  so  without. 

Hydrophobia. 

Hydrophobia  is  an  acute  general  infective  disease,  transmitted  from  animals  to 
men,  especially  from  rabid  dogs,  wolves,  etc.  It  consists  in  an  affection  of  the 
central  nervous  system,  and  one  of  its  most  marked  features  is  the  long  and 
variable  incubation  period.  It  never  originates  idiopathically  either  in  animals 
or  man,  and  although  the  actual  virus  has  not  yet  been  isolated,  there  can  be  no 
doubt  that  it  is  a  micro-organism.  Infection  usually  follows  a  bite  ;  but  if  the 
teeth  pass  first  through  a  garment,  the  virus  may  be  wiped  off,  and  the  individual 
may  escape.  It  has  also  been  proved  that  if  an  infected  animal  merely  licks  an 
abraded  surface  the  disease  may  be  transmitted,  even  when  the  animal  has  not  at 
the  time  shown  any  of  the  more  typical  signs  of  rabies. 

In  the  Dog,  rabies  manifests  itself  three  to  five  weeks  after  infection,  but  the 
period  varies  considerably ;  the  original  wound  usually  heals  perfectly,  or  there 
may  be  some  inflammatory  thickening  about  it.  Two  chief  varieties  have  been 
described — the  raging  or  maniacal,  and  the  quiet  or  dumb.  Rabies  with  frenzy 
commences  with  a  stage  of  depression,  which  is  manifested  by  snappishness  and 
irritability,  especially  towards  other  animals,  by  restlessness,  and  by  the  dog 
moping  in  dark  corners,  with  a  depraved  appetite,  eating  any  kind  of  rubbish  or 
dirt,  and  even  its  own  excreta.  This  period  lasts  for  two  or  three  days,  and  is 
perhaps  the  most  dangerous,  since  there  is  nothing  very  suggestive  about  the 
symptoms.  It  is  followed  by  a  period  of  frenzy  and  maniacal  fury,  and  this  in 
turn  is  succeeded  by  a  stage  of  paralysis,  going  on  to  death.  During  the  whole 
attack  the  mouth  is  filled  with  ropy  saliva,  which  the  animal  vainly  tries  to 
scratch  away  ;  the  bark  loses  its  ring  and  becomes  hoarse,  and  as  the  disease 
progresses  the  lower  jaw  becomes  paralyzed ;  finally,  after  partial  or  general 
convulsions,  the  animal  dies  five  or  six  days  from  the  onset.  In  the  melancholic  or 
dumb  form  the  animal  succumbs  more  rapidly,  passing  through  the  same  stages  as 
the  above,  with  the  exception  of  the  maniacal  period.  The  disease  lasts  then 
but   wo  or  three  days. 

In  Man  the  incubation  period  is  most  variable,  lasting  from  days  to  months  or 
years,  but  as  a  rule  it  does  not  exceed  six  weeks.  During  this  interval  the  wound 
heals,  although  the  scar  may  remain  tender  and  neuralgic.  The  disease  is 
Ushered  in  by  a  vague  sense  of  terror,  with  illusions  of  the  senses  and  disturbance 
of  the  mind,  lasting  for  about  twenty-four  hours.  Restlessness,  sleeplessness, 
loss  of  appetite,  and  a  repugnance  to  fluids  follow,  with  perhaps  some  slight 
febrile  disturbance.  The  more  characteristic  symptoms  are  inaugurated  by  a 
convulsive  stiffness  of  the  tongue,  neck,  and  especially  of  the  muscles  of  deglutition 
and  respiration,  which  becomes  more  marked  if  any  attempt  is  made  to  swallow. 
These  convulsions  are  clonic  in  character,  and  thus  differ  from  those  of  tetanus ; 
they  become  more  and  more  generalized,  being  brought  on  after  a  time  by 
almost  any  afferent  impulse,  however  slight — such  as  a  blast  of  cold  air,  a  flash 


SPECIFIC  INFECTIVE  DISEASES  131. 

of  light,  a  sudden  noise,  especially  such  as  is  caused  by  the  movements  of  iiuids ; 
swallowing  is  quite  impracticable.  The  mouth  is  usually  filled  with  ropy  mucus, 
which  is  very  difficult  to  remove.  The  respirations  become  catchy,  and  a 
hiccoughing  noise  may  be  produced  by  the  spasm  of  the  diaphragm,  which  is 
sometimes  thought  to  resemble  the  barking  of  a  dog.  Finally,  the  convulsions 
may  entirely  cease,  and  the  patient  dies,  retaining  his  consciousness  to  the  end, 
the  fatal  issue  being  due  to  the  destructive  changes  taking  place  in  the  medulla, 
or  to  exhaustion;  it  may,  however,  occur  earlier,  from  spasm  of  the  glottis.  The 
disease  lasts  about  a  week,  but  may  be  more  rapid,  killing  even  in  two  days. 

The  Post-mortem  Changes  are  mainly  negative.  Evidences  of  acute  inflam- 
mation of  the  lower  part  of  the  medulla,  including  the  centres  for  the  9th,  loth, 
and  nth  nerves,  are  observed  on  microscopic  examination,  the  vessels  being 
thrombosed,  and  the  connective  tissue  infiltrated  with  leucocytes.  The  nerve 
fibres  and  ganglion  cells  may  also  be  found  degenerated.  The  salivary  glands 
are  always  somewhat  enlarged.  The  disease  may  be  diagnosed  in  the  lower 
animals  by  the  recognition  of  the  Negri  bodies  in  the  hippocampus  major  and 
cerebral  cortex.  They  are  minute  cell-like  bodies,  consisting  of  a  large  or  small 
central  mass,  or  of  a  cluster  of  minute  corpuscles,  surrounded  by  a  homogeneous 
hyaline  zone,  around  which  there  is  a  delicate  membrane.  These  are  found  in  nearly 
all  cases  of  the  disease,  and  are  thought  to  represent  a  stage  in  the  life-history  of 
a  protozoal  parasite.  They  can  be  demonstrated  in  a  few  hours,  and  afford  a 
means  of  detecting  the  presence  of  rabies  in  a  dog  without  waiting  for  the  results 
of  inoculation  experiments.     They  have  also  been  found  in  man. 

Preventive  Measures  should  be  adopted  imnudiately  in  all  cases  of  bites  from 
dogs  which  are  either  rabid  or  may  possibly  become  so.  The  circulation  in  the 
limb  should  be  arrested  by  a  string  or  bandage,  bleeding  encouraged,  and  some 
powerful  caustic,  e.g.,  pure  carbolic  acid,  applied  as  soon  as  possible.  A  free 
excision  of  the  part  is,  however,  preferable. 

Pasteur's  Preventive  Treatment  is  based  on  the  discovery  that  the  injection  of 
an  attenuated  virus  in  increasing  doses,  and  in  gradually  increasing  strength, 
protects  an  animal  or  individual  from  the  disease,  and  will  even  catch  up  the 
poison  already  inoculated,  and  save  the  patient  from  its  subsequent  development, 
if  too  long  a  start  has  not  been  given.  The  method  employed  is  as  follows  :  A 
virus  of  constant  and  maximum  intensity  is  first  obtained  by  passing  the  poison 
from  a  dog  through  a  series  of  rabbits,  until  the  animal  dies  with  regularity  on 
the  seventh  day,  all  parts  of  the  cord  being  then  equally  virulent.  The  material 
inoculated  is  obtained  by  mashing  up  a  portion  of  the  spinal  cord  or  medulla  of 
the  diseased  dog  in  sterilized  broth,  and  injecting  it  with  a  hypodermic  syringe 
beneath  the  arachnoid  after  trephining.  AH  that  is  now  needed  is  to  take  a 
series  of  these  virulent  cords,  and  dry  them  by  hanging  in  a  glass  bell-jar  with 
some  caustic  potash  at  the  bottom  for  variable  periods,  the  virus  being  thus 
weakened  in  its  intensity,  until  at  the  end  of  fourteen  days  it  is  completely  destroyed. 
Individuals  are  inoculated  with  portions  of  such  cords,  pounded  up  in  sterilized' 
broth,  beginning  with  the  weakest,  and  gradually  increasing  the  strength  of  the 
injection,  until  a  preparation  of  a  cord  which  has  merely  hung  one  day  is  used. 
Ttiis  method  of  treatment  was  introduced  in  1885,  and  the  results  hitherto  obtained 
have  been  such  as  to  indicate  that  we  have  here  a  most  potent  preventive  agent 
against  hydrophobia,  granted  that  the  disease  has  not  been  allowed  too  long  a 
start.  When  the  disease  has  attacked  an  individual,  only  palliative  treatment 
can  be  adopted.  Every  source  of  irritation  and  disturbance  must  be  removed, 
and  the  patient  kept  absolutely  quiet.  With  a  view  to  diminish  the  spasms, 
chloral  maybe  administered  internally,  or  chloroform  inhaled,  or  cocaine  sprayed 
on  the  fauces.  All  the  nourishment  that  the  patient  can  possibly  take  should  be 
administered,  with  the  addition  of  stimulants. 

Anthrax. 

This  disease  results  from  infection  with  the  Bacillus  anthracis,  which  produces  in 
sheep  and  cattle  the  so-called  '  splenic  fever. '  In  man,  if  the  microbe  is  inoculated 
through  the  skin,  it  produces  a  local  inflammatory  swelling,  known  as  a '  malignant 
pustule,'  or  a  more  diffuse  condition  termed  'anthrax  oedema  ' ;  sometimes  the 


132  A  MANUAL  OF  SURGERY 

latter  follows  the  former.  If  the  virus  is  absorbed  by  the  lungs  or  intestinal 
canal,  it  originates  a  general  inflammatory  dis'order,  known  as  '  woolsorter's 
disease,' or  anthracsemia. 

The  B.  anthracis  (Plate  II.,  Fig,  24)  is  one  of  the  largest  of  the  pathogenic 
organisms,  measuring  5  to  20  ju  in  length,  and  i  to  i  -50  fi  in  breadth.  It  is  found  in 
the  blood  of  diseased  animals  in  the  form  of  rods  or  threads,  composed  of  a  varia.ble 
number  of  individual  elements  (from  two  to  ten).  It  is  aerobic,  immobile,  grows 
best  at  about  blood-heat,  and  liquefies  gelatin.  Well-marked  spores  are  formed 
within  the  bacillus  when  cultivated  artificially  and  in  the  presence  of  oxygen  ;  but 
spore-formation  has  not  been  observed  in  the  living  tissues.  The  bacilli  are 
readily  killed  by  boiling  for  a  few  seconds,  whilst  the  decomposition  of  the  carcass 
in  which  they  are  present  causes  their  death  in  about  a  week.  The  spores,  how- 
ever, are  very  resistant ;  for  whilst  a  i  per  cent,  solution  of  carbolic  acid  kills  the 
bacilli  in  two  minutes,  the  spores  remain  alive  after  a  week's  immersion.  More- 
over, alcohol  and  even  a  5  per  cent,  solution  of  carbolic  acid  have  no  effect  on 
them,  unless  acting  for  a  long  time.  If  a  mouse  is  inoculated,  say,  at  the  root 
of  the  tail  with  a  needle,  the  point  of  which  has  been  dipped  in  the  blood  of  an 
animal  which  died  of  splenic  fever,  it  succumbs  in  less  than  twenty-four  hours, 
and  bacilli  are  found  in  nearly  every  organ  of  the  body. 

Some  animals  are  immune  against  the  attacks  of  anthrax,  especially  the  dog 
and  rat  ;  and  one  of  Pasteur's  most  useful  discoveries  was  that  of  providing 
artificial  immunity  for  cattle  and  sheep  by  inoculating  them  with  an  attenuated 
virus,  obtained  by  exposing  a  cultivation  for  some  time  to  a  high  temperature. 

Symptoms. — Infection  with  this  organism  usually  occurs  amongst  graziers  who 
tend  the  living  animal,  or  butchers  who  deal  with  the  carcass;  it  is  also  met  with 
amongst  workers  in  hides  or  wool. 

Malignant  Pustule  is  usually  seen  on  the  face  or  fore-arm,  and  commences  as 
an  angry  red  pimple  at  the  site  of  inoculation,  which  rapidly  spreads,  with 
much  infiltration  of  the  base,  whilst  the  centre  becomes  covered  with  vesicles, 
the  serum  within  which  becomes  blood-stained  or  dark  brown  in  colour,  and 
contains  the  typical  bacilli.  This  stage  is  associated  with  no  pain,  but  only  with 
great  itching  and  irritation.  As  the  pustule  extends,  the  centre  becomes  gray, 
and  finally  black,  constituting  an  eschax  or  slough,  whilst  around  it  upon  an  area 
of  deep  brawny  congestion  and  oedema  is  a  narrow  ring  of  vesicles.  The  process 
gradually  becomes  more  marked  locally,  whilst  the  lymphatic  glands  and  vessels 
are  also  enlarged  and  involved  in  the  disease.  Generally,  there  is  a  certain 
amount  of  fever  and  malaise,  which  does  not  become  pronounced  until  about 
the  fourth  or  fifth  day.  The  temperature  then  rises  to  102°  or  103°  F.,  the  pulse 
becomes  rapid  and  irregular,  and  gastric  irritability,  vomiting,  and  flatulence 
more  marked.  Should  the  disease  progress  unchecked,  the  surrounding  parts 
are  involved  in  a  rapidly  spreading  oedema;  thus  from  the  face  it  may  extend 
to  the  neck,  chest,  and  back.  The  respirations  become  shallow  and  embarrassed, 
whilst  signs  of  grave  constitutional  mischief,  such  as  delirium  or  coma,  manifest 
themselves,  and  the  unfortunate  individual  rapidly  succumbs,  generally  in  less 
than  a  week  from  the  onset,  but  sometimes  in  thirty  to  forty  hours.  More 
commonly  the  case  runs  a  more  favourable  course,  limiting  itself  to  the  local 
manifestations,  which  gradually  clear  up,  the  slough  separating  and  the  oedema 
disappearing.  Of  course,  should  there  be  more  than  one  focus  of  mischief,  the 
prognosis  is  much  worse. 

Anthrax  oedema  runs  a  rapidly  fatal  course;  it  is  usually  seen  about  the  face 
and  eyelids,  the  skin  becoming  red  and  brawny,  as  in  erysipelas,  and  after  a  time 
covered  with  vesicles,  whilst  finally  gangrenous  patches  appear.  The  lymphatic 
trunks  and  glands  are  also  involved. 

The  condition  maybe  mistaken  in  the  localized  form  for  accidental  vaccination 
or  a  staphylococcic  infection,  but  is  recognised  by  the  presence  of  the  bacilli  in 
the  serum  of  the  vesicles  ;  in  cases  of  doubt  cultures  should  be  made. 

Woolsorter's  Disease  (or  anthracsemia)  is  the  term  applied  to  the  general 
condition  resulting  from  the  development  of  these  bacilli  in  the  body  without  any 
external  lesion.  The  virus  gains  access  to  the  system  by  either  swallowing  or 
inhaling  the  dried  spores.  If  they  enter  the  respiratory  tract,  the  patient 
complains  of  fever  and  malaise  for  a  few  days,  followed  by  the  development  of 


SPECIFIC  INFECTIVE  DISEASES  133 

a  sero-fibrinous  pleuro-pneumonia,  the  exudation  containing  large  numbers  of 
bacilli.  This  runs  a  rapid  course,  with  high  fever,  great  dyspnoea,  impairment 
of  the  circulation,  and  finally  collapse  in  a  great  majority  of  the  cases.  If  the 
bacilli  enter  the  stomach,  they  are  usually  destroyed  by  the  acid  chyme ;  but 
should  any  of  them  or  their  spores  reach  the  intestine,  the  alkaline  contents  form 
a  suitable  breeding-ground,  and  the  walls  of  the  gut  are  soon  attacked  and  the 
disease  becomes  general.  Colic,  cramps,  vomiting,  and  blood-stained  diarrhcea 
are  the  most  marked  features  in  such  a  case.  The  intestinal  type  appears  to  be 
not  quite  so  virulent  and  fatal  as  the  pulmonary,  but  is  decidedly  worse  than  the 
cutaneous. 

Treatment. — In  the  cutaneous  affection,  excision  of  the  necrotic  patch  and  of 
all  the  infiltrated  tissues  around,  and  the  application  of  the  actual  cautery  or 
of  pure  carbolic  acid,  used  to  be  recommended,  though  those  who  have  had 
much  experience  of  the  affection  think  such  treatment  of  little  value,  and  trust 
in  fomentations  for  the  localized  variety. 

Several  sera  (p.  29)  have  been  introduced  for  the  treatment  of  anthrax,  and 
good  results  have  been  obtained,  especially  in  the  localized  forms  of  the  disease. 
Sclavo's  is  most  used  ;  it  is  obtained  by  immunizing  asses  or  goats  with  Pasteur's 
vaccine  (p.  16),  followed  by  injection  of  large  doses  ol  virulent  cultures.  The 
dose  is  20-40  c.c.  (340-680  minims),  repeated  in  twenty-four  hours,  if  necessary;  in 
severe  cases  the  first  dose  may  be  injected  intravenously.  Sobenheim's  serum  is 
prepared  in  a  different  way,  and  also  gives  good  results  ;  the  dose  is  the  same. 
The  use  of  either  serum  may  be  followed  by  fever  and  sweating,  and  improve- 
ment is  often  very  rapid.     They  appear  to  stimulate  phagocytosis. 

Gonorrhoea. 

Gonorrhoea  is  an  infective  process  due  to  the  action  of  a  specific 
micro-organism,  the  Gonococcus  or  Diplococcus  gomrrhcecs  (Plate  I., 
Fig,  6),  and  characterized  (in  its  commonest  form)  by  a  discharge  of 
pus  from  the  urethra.  The  organism  is  a  diplococcus,  and  each 
coccus  of  the  pair  is  usually  kidney-  or  bean-shaped,  and  the  two  lie 
with  their  concave  borders  facing  one  another.  Single  cocci  and 
tetrads  sometimes  occur.  It  is  not  easily  cultivated,  and  haemoglobin 
is  necessary  for  its  growth  ;  the  simplest  method  of  preparing  a 
suitable  culture  medium  is  to  spread  some  sterile  blood  on  the 
surface  of  ordinary  agar.  The  colonies  are  small  and  translucent, 
appearing  like  droplets  of  dew.  Such  cultures  set  up  gonorrhoea 
when  injected  into  the  human  urethra,  thus  proving  the  causal  rela- 
tion of  the  organism  to  the  disease,  as  all  of  Koch's  postulates  are 
fulfilled.  The  lower  animals  are  all  immune.  The  gonococcus  does 
not  stain  by  Gram's  method  ;  this  fact  is  of  great'  importance  in 
diagnosis,  since  most  of  the  diplococci  with  which  it  might  be  con- 
founded retain  the  stain.  It  occurs  in  large  quantities  in  the  pus 
from  a  gonorrhoeal  lesion,  and  in  most  cases  it  is  found  within  the 
polynuclear  leucocytes.  This  is  very  characteristic,  as  also  the  fact 
that,  whilst  most  of  the  cells  are  usually  free  from  organisms, 
those  that  are  invaded  by  cocci  contain  them  in  abundance  (see 
Plate  I.,  Fig  3,  in  which  some  of  the  cells  are  free  from  germs,  but 
in  others  the  diplococci  can  be  seen  clustered  round  the  poly- 
morphous nuclei).  The  pus  also  contains  desquamated  epithelial 
cells,  in  or  on  which  many  cocci  may  often  be  seen. 

The  laboratory  diagnosis  of  gonorrhoea  does  not  usually  involve 
cultural  methods,  but  can  be  made  by  an  examination  of  stained 
pus-films.     The    best  way  is   to  stain    by  Gram's  method,  and  to 


134  A  MANUAL  OF  SURGERY 

counterstain  by  dilute  carbol-fuchsin.  In  this  way  the  gonococci 
will  be  coloured  red,  whilst  most  of  the  other  cocci  with  which  they 
could  be  confounded  are  deep  violet.  The  intracellular  distribution 
of  the  cocci  and  the  freedom  of  most  of  the  pus-cells,  whilst  others, 
are  packed  full  of  organisms,  are  points  of  great  diagnostic  value. 
Sometimes,  however,  most  of  the  gonococci  are  extracellular. 

In  the  male  the  primary  lesion  is  an  acute  catarrhal  inflammation 
of  the  anterior  portion  of  the  urethra,  which  quickly  runs  on  to 
suppuration,  and  is  likely  to  spread  back  towards  the  deeper  portions 
of  the  urethra,  or  even  to  the  prostate,  bladder,  or  epididymis.  These 
lesions  usually  constitute  the  whole  of  the  disease,  but  in  some  cases 
the  gonococci  enter  the  blood-stream  and  aflfect  distant  organs.  The 
joints  are  most  frequently  affected,  but  occasionally  typical  pyaemic 
phenomena  supervene  (gonococcaemia),  with  secondary  abscesses 
and  even  ulcerative  endocarditis. 

The  Symptoms  of  Acute  Gonorrhoeal  Urethritis  (male)  usually  com- 
mence within  a  few  days  of  the  infection,  varying  from  two  to  eight- 
Most  commonly  the  discharge  appears  about  the  third  or  fourth  day, 
being  preceded  by  itching  of  the  meatus  and  a  scalding  pain  on 
passing  urine.  The  lips  of  the  meatus  are  congested  and  swollen, 
and  the  discharge,  which  is  at  first  thin  and  mucoid,  soon  becomes 
thick,  abundant,  and  yellow  in  colour.  This  stage  lasts  for  a  variable 
time,  and  is  sometimes  associated  with  a  good  deal  of  dragging  pain 
in  the  back  and  loins,  together  with  some  constitutional  disturbance 
and  fever.  The  bowels  are  usually  constipated,  and  the  appetite 
impaired.  Occasionally  the  swelling  and  congestion  of  the  mucous 
membrane  are  so  great  as  to  lead  to  retention  of  urine  or  haemorrhage 
from  the  urethra.  The  first  attack  is  always  more  serious  than  subse- 
quent ones,  although  it  is  often  more  amenable  to  treatment.  Gouty 
and  rheumatic  people  are  especially  difficult  to  treat,  and  relapses 
frequently  occur  after  the  discharge  has  apparently  ceased  ;  it  is  said 
that  fair  people  suffer  more  than  those  who  are  dark. 

If  suitable  treatment  is  adopted,  the  discharge  entirely  ceases  at 
the  end  of  two  or  three  weeks  ;  but  if  neglected,  or  sometimes  in 
spite  of  treatment,  the  inflammation  spreads  backwards,  giving  rise 
to  what  is  sometimes  termed  a  Posterior  Urethritis,  since  it  involves 
that  portion  of  the  canal  which  lies  behind  the  deep  constrictor.  It 
usually  becomes  evident  about  the  end  of  the  second  week,  and  is 
characterized  by  frequent  and  painful  micturition,  a  sense  of  pain  and 
heaviness  in  the  perineum,  possibly  a  little  blood  in  the  urine,  and  a 
general  feeling  of  depression.  This  extension  backwards  is  always 
serious,  since  it  is  likely  to  be  followed  by  complications  involving 
the  prostate,  testis,  or  seminal  vesicles,  whilst  it  is  an  extremely 
common  cause  of  Chronic  G-onorrhcea  or  Gleet,  in  which  a  more  or 
less  abundant  discharge  continues  for  some  time  without  any  other 
troublesome  symptom  than  occasional  scalding  on  passing  urine. 
The  discharge  is  often  thin  and  muco-purulent,  and  may  be  so 
slight  as  only  to  be  evident  on  squeezing  the  urethra  after  a  night's 
rest.  •   This  may  last  for  a  long  time,  even  years,  and  it  must  be  re- 


SPECIFIC  INFECTIVE  DISEASES  135 

membered  that  even  in  this  stage  the  disease  can  be  transmitted  to 
women.  Gleet  is  sometimes  due  to  an  ulcerated  or  granular  con- 
dition of  some  portion  of  the  mucous  membrane  ;  the  discharge  is 
then  yellow,  and  the  urethra  is  tender  on  the  passage  of  a  sound ; 
the  presence  of  the  ulcer  or  granular  patch  can  be  recognised  by 
the  urethroscope.  In  other  cases  gleet  arises  from  chronic  prostatitis, 
a  condition  not  uncommonly  associated  with  chronic  enlargement  of 
the  vesiculae  seminales.  The  latter  condition  may  be  recognised  on 
rectal  examination,  whilst,  when  the  prostate  is  involved,  flocculi  of 
mucus  in  the  shape  of  worm-like  threads  may  be  detected  in  the 
urine.  The  discharge  is  then  often  clear  and  transparent,  resembling 
uncooked  white  of  egg  (prostatorrhoea). 

When  the  disease  has  lasted  for  a  considerable  time,  or  after 
repeated  attacks,  a  certain  amount  of  peri-urethral  infiltration  is 
certain  to  follow,  and  a  stricture  of  the  urethra  may  result :  this 
may  also  be  due  to  the  cicatrization  of  the  ulcerated  and  granular 
patches  in  the  urethral  wall,  alluded  to  above. 

Every  purulent  discharge  is  not  necessary  gonorrhoeal,  since  a 
simple  urethritis  may  follow  connection  with  a  woman  who  is  simply 
suffering  from  leucorrhoea,  or  has  scarcely  recovered  from  her 
menstrual  period,  but  with  no  suspicion  of  a  venereal  taint.  In 
these  cases  infection  may  be  due  to  ordinary  pyogenic  cocci,  or 
possibly  to  the  B.  coli  communis,  which  is  known  to  be  not  an  un- 
frequent  cause  of  vulvo- vaginitis.  A  diagnosis  of  simple  urethritis 
may  be  suggested  by  the  history,  but  only  a  microscopical  examina- 
tion of  the  pus,  and  a  demonstration  of  the  absence  of  gonococci, 
can  establish  it  with  certainty.  It  must  be  remembered,  however, 
that  gonococci  are  capable  of  remaining  in  a  latent  or  passive  state 
for  a  very  long  time  in  the  folds  or  crypts  of  a  mucous  membrane, 
and  hence  a  person  who  has  once  suffered  from  it  may  be  capable  of 
transmitting  the  disease,  although  no  obvious  evidence  of  its  exist- 
ence is  present.  Moreover,  a  highly  acid  condition  of  the  urine  in  a 
gouty  patient,  especially  if  loaded  with  uric  acid  crystals,  may  light 
up  into  activity  a  urethritis  which  has  been  quiescent  for  some  time. 

In  the  Treatment  of  the  early  stages  of  acute  gonorrhoea  it  is 
essential  to  keep  the  urine  free  from  acidity  by  the  use  of  alkalies, 
to  maintain  a  free  action  of  the  bowels,  and  to  allay  the  irritability 
of  the  parts  by  sedatives,  such  as  tincture  of  henbane.  The  diet 
should  be  light  and  unstimulating,  and  all  alcoholic  drinks  pro- 
hibited, as  also  strong  tea  and  coffee,  whilst  the  patient  should  be 
recommended  to  take  plenty  of  bland  fluids,  such  as  barley-water, 
or  milk  and  soda-water.  The  scrotum  should  be  supported  in  a 
suspender,  and  the  patient  advised  against  taking  severe  or  pro- 
longed exercise.  No  local  treatment  is  necessary,  although  the  use 
of  hot  hip-baths  may  relieve  the  pain  and  irritation  ;  indeed,  at  this 
period  injections  are  harmful.  The  same  treatment  must  be  adopted 
as  long  as  the  discharge  is  copious,  and  the  scalding  continues.  As 
soon  as  these  symptoms  moderate,  oleo-balsams  in  the  form  of  oil 
of  sandal- wood  (10  minims,  in  capsules,  three  to  six  times  a  day). 


136  A  MANUAL  OF  SURGERY 

copaiba  (lo  minims,  in  capsules  or  mixture,  thrice  daily),  or  cubebs 
(^  to  I  drachm  doses,  wrapped  in  wafer-paper),  may  be  advan- 
tageously employed.  Both  cubebs  and  copaiba,  especially  the 
latter,  are  capable  of  producing  a  bright-red  erythematous  rash 
which  causes  much  irritation,  and  may  be  extensively  diffused  over 
the  body. 

The  value  of  injections  in  the  treatment  of  the  disease  has  been 
much  discussed,  and  is  a  point  on  which  difference  of  opinion  exists. 
On  the  whole,  we  are  inclined  to  think  that  many  of  the  less  severe 
cases  of  acute  gonorrhoea  can  be  successfully  treated  without  them, 
and  that  they  should  not  generally  be  employed  when  marked  local 
irritation  or  scalding  is  present ;  but  when  the  discharge  persists, 
or  the  urethra  has  become  thickened  by  previous  attacks,  and 
especially  in  gleet,  their  use  is  imperative.  To  employ  them  with 
advantage,  the  following  plan  should  be  adopted  : — The  urethra  is 
first  washed  out,  so  as  to  remove  any  discharge  from  it ;  for  this 
purpose  the  normal  act  of  micturition  answers  admirably,  so  that 
the  injection  should  be  used  immediately  after  passing  water.  The 
rounded  nozzle  of  a  small  glass  syringe,  containing  about  half  an 
ounce,  is  inserted  into  the  meatus,  the  lips  of  which  are  compressed 
over  it.  The  fluid  is  thrown  into  the  urethra,  and  held  there  for 
about  twenty  seconds  by  compressing  the  orifice  with  the  finger  and 
thumb,  as  the  syringe  is  withdrawn  ;  then,  on  relaxing  the  pressure, 
the  fluid  escapes.  Other  forms  of  syringe,  on  the  principle  of  the 
indiarubber  bottle,  etc.,  are  recommended,  but  the  glass  is  un- 
questionably the  cleanest.  Of  the  many  injections  employed, 
one  of  the  best  consists  of  a  mixture  of  tincture  of  catechu 
(lo  minims  to  i  ounce  of  water)  and  sulphate  of  zinc  (2  grains 
to  I  ounce) ;  but  solutions  of  permanganate  of  zinc  (^  grain  to 
I  ounce),  or  nitrate  of  silver  {\  grain  to  i  ounce),  or  protargol  (i  per 
cent.)  are  also  very  effective.  The  great  secret  consists  in  using 
the  injection  four  or  five  times  a  day  at  first,  and  afterwards  night 
and  morning,  even  after  all  visible  signs  of  the  discharge  have 
ceased.  The  fluid  should  always  be  at  a  temperature  of  100°  F.,  and 
care  taken  not  to  use  too  strong  a  solution. 

One  is  bound  to  admit,  however,  that  many  genito-urinary 
surgeons  hold  views  very  different  to  these,  and,  indeed,  maintain 
that  gonorrhoea  can  be  aborted,  or,  at  any  rate,  rapidly  brought 
under  control  at  any  stage  by  large  injections  of  a  weak  solution  of 
permanganate  of  potash,  introduced  with  sufficient  force  to  distend 
the  urethra  in  all  its  parts  and  enter  the  bladder  ;  all  the  crypts  and 
lacunae  are  thus  reached  by  the  antiseptic. 

The  Treatment  of  Gleet  is  always  a  matter  of  difficulty.  The 
general  habits  of  the  patient  must  be  attended  to,  as  in  the  acute 
stage,  whilst  the  bowels  must  be  opened,  and  absolute  sexual 
continence  enjoined  to  prevent  the  spread  of  the  infection.  Large 
doses  of  the  iiq.  ferri  perchlor.,  combined  with  a  sufficient  amount  of 
Epsom  salts  to  prevent  constipation,  may  be  given.  Local-treatment 
is  generally  necessary  in  the  shape  of  injections  as  already  described, 


SPECIFIC  INFECTIVE  DISEASES  137 

and  the  passage  of  a  cold  solid  metal  bougie  every  three  or  four 
days  has  sometimes  an  excellent  effect.  Methodical  dilatation  of  the 
urethra  is  also  advised,  with  the  object  of  compressing  all  the  crypts 
and  lacunae,  and  removing  pent-up  secretion.  If  granular  urethritis 
is  present,  the  topical  application  of  nitrate  of  silver  may  be  under- 
taken through  a  urethroscope,  but  requires  the  greatest  care  for  fear 
of  the  subsequent  formation  of  a  stricture ;  chronic  prostatitis  and 
vesiculitis  are  dealt  with  by  counter-irritation  applied  to  the  perineum, 
or  possibly  by  sedatives,  such  as  belladonna,  administered  in  the 
form  of  suppositories.     Vaccine  treatment  is  also  useful  (p.  139). 

Complications  of  Gonorrlioea. — These  may  be  conveniently  arranged 
under  the  following  headings  : 

I.  Complications  due  to  Direct  Extension. — In  the  male,  the  follow- 
ing may  be  described  : 

Balanitis  is  of  frequent  occurrence  in  patients  with  long  foreskins, 
and  is  ordinarily  due  to  pyogenic  organisms,  and  not  to  gonococci. 
As  a  secondary  result,  inflammation  of  the  lymphatics  of  the  penis 
and  inguinal  bubo  may  follow.  Sometimes  this  inflammation  results 
in  a  development  of  red  papillomatous  outgrowths,  known  as  gonor- 
rhceal  warts,  which  are  found  mainly  on  the  glans  penis,  but  occasion- 
ally on  the  preputial  margin  (Chapter  XL.). 

Lacunar  Abscess  arises  from  infection  of  one  or  more  of  the  lacunae 
with  the  gonococcus  or  accompanying  pyogenic  organisms.  A  tense 
painful  swelling  forms  along  the  floor  of  the  urethra,  which  may 
project  into  the  passage  and  discharge  either  into  the  urethra,  or 
externally,  or  both  ;  in  the  latter  case  a  penile  fistula  will  result. 
The  abscess  should  be  opened  as  early  as  possible  from  without, 
so  as  to  prevent  the  latter  occurrence,  which  is  often  very  difficult 
to  treat.  If  a  fistula  forms  within  a  quarter  of  an  inch  or  so  of  the 
meatus^a  common  situation — it  seldom  heals  of  itself,  but  may 
in  some  cases  be  closed  by  an  application  of  the  electric  cautery 
or  a  weak  solution  of  nitrate  of  silver.  If,  however,  it  remains 
intractable,  the  fistula  should  be  laid  open  into  the  meatus. 
When  it  occurs  in  the  body  of  the  penis,  a  plastic  operation 
is  usually  required  ;  it  consists  in  paring  the  edges  and  dissecting 
up  the  skin  on  either  side  so  as  to  bring  it  together  in  the  median 
line. 

Chordae  results  from  inflammatory  infiltration  of  the  corpus 
spongiosum  or  one  of  the  corpora  cavernosa,  so  that  when  the 
penis  becomes  erect,  it  is  bent  downwards  or  to  one  side,  owing  to 
incomplete  distension  of  the  infiltrated  tissue.  This  condition  is 
exceedingly  painful,  and  most  marked  at  night  when  the  patient 
becomes  warm  in  bed.  It  is  best  dealt  with  by  applying  cold  to 
the  part,  and  by  administering  bromide  of  potassium  or  opium  at 
bedtime. 

Inflammation  of  Cowper's  Glands  may  in  some  cases  give  rise  to 
deep  suppuration  in  the  perineum,  with  symptoms  very  similar  to 
those  of  acute  prostatitis.  It  is  dealt  with  in  the  same  way  as  the 
latter  complaint. 


138  A  MANUAL  OF  SURGERY 

Acute  and  Chronic  Prostatitis  (Chapter  XXXIX.). 

Acute  and  Chronic  Vesiculitis  (Chapter  XLI.). 

Epididymitis  arises  by  extension  along  the  vas,  and  will  be  fully 
described  in  Chapter  XLI.  It  rarely  commences  before  the  third 
week,  and  often  not  until  the  fifth  or  sixth,  being  perhaps  caused  by 
the  injudicious  use  of  injections,  or  by  a  blow  or  squeeze,  especially 
if  the  scrotum  is  lax  and  pendulous. 

Acute  Cystitis  (Chapter  XXXIX.). 

II.  Complications  arising  from  Direct  Transmission  of  the  Virus. — 
Gonorrhceal  Proctitis  sometimes  results  in  the  female  from  infection 
by  the  discharge  which  escapes  from  the  vulva,  whilst  in  both  sexes 
it  may  be  due  to  unnatural  practices.  It  is  characterized  by 
tenesmus  and  a  thick  muco-purulent  discharge,  and  is  treated  by 
injecting  lotions  of  acetate  of  lead  and  opium,  or  of  boric  acid. 

Gonorrhceal  Rhinitis  has  also  been  seen  in  a  few  cases.  It  leads 
to  an  abundant  discharge  of  pus,  and  should  be  treated  by  warm 
soothing  injections,  followed  after  a  time  by  dilute  astringents. 

Gonorrhceal  Conjunctivitis  occurs  either  in  adults,  when  it  is  uni- 
lateral to  start  with,  or  in  infants,  when  it  is  bilateral,  and  due  to 
infection  during  transit  through  the  maternal  passages  (ophthalmia 
neonatorum).  It  is  a  remarkable  fact  that,  although  gonorrhoea  is  so 
very  prevalent,  such  a  small  proportion  of  the  patients  suffer  from 
conjunctival  infection ;  it  would  appear,  therefore,  that  not  only 
must  there  be  direct  contact  with  the  gonorrhceal  poison,  but  in 
addition  the  mucous  membrane  must  be  in  a  receptive  state.  In 
the  adult  variety  it  is  ushered  in  by  redness  and  irritability  of  the 
eye,  followed  quickly  by  a  discharge  which  is  at  first  mucous,  but 
soon  becomes  purulent.  The  eyelids  are  red  and  swollen,  the  con- 
junctiva is  thickened  and  oedematous  (chemosis),  and  the  discharge 
liable  to  accumulate  within  the  conjunctival  sac.  If  allowed  to 
progress  unchecked,  ulceration  or  even  necrosis  of  the  cornea  may 
ensue,  and  possibly  general  panophthalmitis.  This  is  pre-eminently 
the  commonest  cause  of  blindness  in  children.  The  first  detail  in 
the  Treatment  consists  in  protecting  the  opposite  eye  by  means  of 
what  is  known  as  Buller's  shield  ;  a  watch-glass  is  fixed  in  a  piece 
of  mackintosh  over  the  eye,  and  kept  in  position  by  plaster.  The 
affected  conjunctiva  must  be  unremittingly  attended  to  at  night  and 
day,  so  as  to  prevent  accumulation  of  discharge  ;  it  is  frequently 
irrigated  with  warm  boric  acid  lotion,  and  every  four  hours  after 
washing  out  with  this,  the  membrane  is  dried  and  gently  irrigated 
with  a  solution  of  nitrate  of  silver  (5  grains  to  i  ounce),  followed  by 
sterilized  salt  solution.  Between  the  applications  lint  wrung  out  of 
iced  boric  acid  lotion  is  kept  over  the  eye.  This  plan  of  treatment 
is  continued  until  the  suppuration  ceases,  and  then  the  silver  salt  is 
omitted,  and  simple  astringents,  such  as  chloride  or  sulphate  of 
zinc,  are  substituted. 

In  infants  the  disease  often  runs  a  rapid  and  severe  course,  and  is 
very  likely  to  lead  to  ulceration  or  sloughing  of  the  cornea,  a  com- 
plication not  uncommonly  followed  by  escape  of  the  lens  and  blind- 


SPECIFIC  INFECTIVE  DISEASES  139 

ness.  Crede's  preventive  treatment  should  always  be  adopted  for 
new-born  children,  viz.,  washing  out  the  conjunctival  sac  with  a 
weak  solution  of  nitrate  of  silver  (2  per  cent.)  or  corrosive  sublimate 
soon  after  birth.  When  suppuration  occurs,  the  treatment  to  be 
adopted  is  practically  identical  with  that  detailed  above,  except  that 
it  is  useless  to  attempt  to  limit  the  trouble  to  one  eye. 

III.  Complications  resulting  from  G-eneral  Absorption. — Gonorrhoeal 
Affections  of  Joints  are  not  uncommon  sequelae,  arising  usually  in 
the  subacute  stage  of  the  disease.  They  occur  either  in  the  form  of 
a  synovitis  with  effusion,  or  as  an  arthritis,  which  may  or  may  not 
suppurate,  but  generally  ends  in  ankylosis.  For  clinical  features  and 
treatment,  see  Chapter  XXII. 

Any  muscular,  tendinous,  ligamentous,  or  aponeurotic  tissues  may 
become  inflamed  and  painful  during  the  course  of  an  attack  of 
gonorrhoea.  Special  mention  must  be  made  of  the  involvement  of 
the  ligaments  supporting  the  arch  of  the  foot,  since,  if  the  cause  is 
not  recognised  and  the  patient  is  still  allowed  to  walk,  the  arch  of 
the  foot  may  be  lost,  and  a  permanent  flat  foot  result. 

Gonorrliceal  Sclerotitis,  or  inflammation  of  the  deep  subconjunctival 
fibrous  tissue,  is  a  rare  affection,  arising  quite  independently  of 
gonorrhoeal  conjunctivitis.  It  is  characterized  by  marked  subcon- 
junctival redness,  the  globe  of  the  eye  becoming  distinctly  tender. 
Local  appHcations  of  atropine  are  required,  and,  if  need  be,  leeches 
to  the  temples. 

The  pathology  of  the  complications  described  in  the  last  two 
paragraphs  is  uncertain.  They  are  probably  due  to  the  presence  in 
the  tissues  of  a  small  number  of  gonococci  of  enfeebled  virulence, 
but  it  is  also  possible  that  they  are  caused  by  toxins  absorbed  from 
the  local  lesion. 

A  true  Gonorrhoeal  Pysemia  (gonococcsemia)  occasionally  develops, 
characterized  by  a  formation  of  secondary  abscesses  in  various  parts 
of  the  body,  containing  only  the  gonococcus.  They  usually  commence 
deeply,  and  at  first  are  somewhat  chronic,  but  subsequently  the 
ordinary  phenomena  of  suppuration  supervene.  They  must  be  laid 
freely  open,  and,  as  a  rule,  heal  satisfactorily,  if  slowly. 

Occasionally  the  cardiac  valves  become  infected  and  inflamed,  and 
an  ulcerative  endocarditis  due  to  gonococci  has  been  observed.  More 
rarely  a  true  septicsemic  invasion  has  destroyed  the  patient  by  a 
generalized  development  of  gonococci  in  the  blood. 

Vaccine  treatment  has  been  applied  to  the  cure  of  gonorrhoea  and 
its  complications,  and  in  many  cases  with  remarkably  beneficial 
results.  It  may  be  used  in  the  acute  stage,  but  is  especially  valuable 
v/hen  the  acute  stage  has  just  subsided,  as  also  in  gleet  and  for 
gonorrhoeal  arthritis,  ocular  affections,  and  other  internal  complica- 
tions. The  vaccine  is  prepared  as  described  on  p.  27 ,  and  the ' 
usual  dose  is  100,000,000  to  500,000,000  dead  gonococci.  In  the 
present  state  of  our  knowledge  it  is  probably  advisable  to  check  the 
injections  by  observations  of  the  opsonic  index. 


I40  A  MANUAL  OF  SURGERY. 

Gonorrhoea  in  Women  is  by  no  means  uncommon,  even  apart  from 
prostitutes,  in  whom  it  is  more  or  less  constant ;  it  is  often  overlooked 
or  unrecognised,  and  is  a  frequent  source  of  uterine  and  pelvic  trouble. 
This  is  probably  due  to  the  fact  that  an  uncured  gleet  in  a  man 
is  not  looked  on  as  a  bar  to  marriage.  Occasionally  the  disease  is 
contracted  from  the  infected  seat  of  a  public  water-closet,  or  from 
the  use  of  infected  towels,  garments,  etc. 

The  primary  lesion  is  usually  either  in  the  urethra  or  in  the  cervical 
endometrium,  or  in  both.  Vulvitis  is  by  no  means  uncommon,  but 
in  the  adult  a  gonorrhceal  vaginitis  is  unusual.  Sometimes  discharges 
from  the  cervix  accumulate  in  the  vagina  and  undergo  septic  changes, 
producing  a  simple  vaginitis  by  the  direct  action  of  the  bacterial  toxins, 
but  the  gonococci  do  not  attack  the  vaginal  mucosa.  In  children  a  true 
vulvo-vaginitis  occurs. 

The  symptoms  in  acute  cases  are  those  of  heat  and  burning  about  the 
genitalia,  combined  with  a  purulent  discharge  and  painful  micturition. 
The  urethra  can  be  seen  and  felt  to  be  swollen,  and  its  orifice  is  red 
and  congested  ;  on  pressing  it,  pus  escapes.  If  the  cervix  is  involved, 
the  uterus  becomes  congested  and  painful ;  severe  backache  is  noticed, 
and  perhaps  some  tenderness  on  hypogastric  pressure,  with  a  blood- 
stained discharge.  In  the  more  chronic  cases  nothing  may  be  noted 
except  that  the  periods  are  painful,  and  that  there  is  a  certain 
amount  of  leucorrhoea,  with  occasional  attacks  of  discomfort  and 
frequency  in  micturition. 

In  all  cases  the  inflammation  is  likely  to  spread,  either  to  the 
bladder,  or  up  the  uterus  to  the  Fallopian  tubes  (salpingitis),  ovaries, 
or  peritoneum.  In  the  latter  case  the  inflammation  is  usually 
localized,  producing  adhesions  around  the  fimbriated  extremities 
of  the  tubes,  and  these  are  often  an  important  cause  of  sterility. 
Occasionally  a  more  generalized  peritonitis  results  (q.v.). 

Treatment  consists  in  the  use  of  frequent  mild  antiseptic  douches 
{e.g.,  lysol,  I  in  2,000),  and  in  measures  directed  towards  the  urethra 
or  cervix.  When  there  is  much  urethral  swelling  and  discharge, 
the  diet  is  regulated  and  alkalies  ordered,  as  for  men ;  balsams  may 
be  useful,  and  even  injections.  In  the  later  stages  the  shortness  of 
the  urethra  permits  topical  applications  of  nitrate  of  silver  to  be 
made  readily,  and  it  is  unusual  for  the  inflammation  to  persist  for 
long.  In  gonorrhoeal  endocervicitis  the  parts  should  be  thoroughly 
cleansed  by  douching,  and  then  a  10  per  cent,  solution  of  nitrate  of 
silver  applied  through  a  speculum. 

Soft  Chancre  (Ulcus  Molle). 

A  Soft  Chancre  is  a  local  infective  disorder,  which  is  rarely  seen 
elsewhere  than  on  the  genital  organs,  and  is  almost  invariably  the 
result  of  impure  connection.  It  is  due  to  a  specific  bacillus,  which 
was  first  described  by  Ducrey.  It  is  an  extremely  slender  rod,  which 
does  not  form  spores  or  stain  by  Gram's  method.  It  frequently 
occurs  in  short  chains.     The  organism  has  been  cultivated,  though 


SPECIFIC  INFECTIVE  DISEASES  141 

with  difficulty,  and  there  appears  to  be  no  doubt  as  to  its  causal 
relation  to  the  disease.  If  artificially  inoculated,  it  runs  a  typical 
course.  The  spot  becomes  a  red  papule  in  twenty-four  hours,  whilst 
in  two  or  three  days  a  vesicle,  surrounded  by  a  zone  of  angry 
hyperaemia,  is  seen.  The  serum  within  the  vesicle  soon  becomes 
turbid,  and  by  the  fourth  or  fifth  day  a  fully-developed  pustule  is 
present ;  as  soon  as  the  cuticle  is  lost,  an  ulcer  forms  with  cleanly- 
cut  edges,  and  a  sharp,  distinct  outline.  The  chancre  gradually 
increases  in  size  up  to  a  certain  limit,  and  then  if  kept  clean  heals  in 
about  three  weeks.  Such  sores  may  be  met  with  on  any  part  of  the 
penis,  but  m.ore  especially  on  the  prepuce  and  glans,  or  on  the 
corona  glandis,  and  are  very  painful  and  tender.  The  secretion  is 
highly  infective,  and  if  inoculated  elsewhere  on  the  patient  produces 
a  typical  sore,  showing  that  the  condition  is  purely  local,  and  that 
no  constitutional  immunity  results  from  its  presence.  The  discharge 
from  a  true  syphilitic  chancre  may  produce  a  localized  pus- 
tule on  auto-inoculation,  but  no  typical  sore.  Frequently  several 
soft  sores  are  present  at  the  same  time,  and  the  discharge 
from  one  chancre  is  very  likely  to  produce  a  similar  affection 
('  satellite  '  chancre)  on  any  cutaneous  or  mucous  surface  brought 
into  contact  with  it  ;  e.g.,  it  may  spread  from  prepuce  to  glans,  or 
vice  versa,  or  from  one  lip  of  the  vulva  to  the  other.  It  is  a  curious 
but  well-authenticated  fact  that  soft  chancres  are  rarely  seen  on  any 
part  of  the  body  other  than  the  genital  organs. 

Various  Modifications  of  the  typical  chancre  are  seen,  usually  re- 
sulting from  neglect  or  carelessness  on  the  part  of  the  patient.  Thus, 
if  a  long  foreskin  is  present,  the  discharge  may  be  retained  behind  it, 
and  extensive  ulceration  occur,  which  may  even  result  in  the  glans 
protruding  through  the  upper  part  of  the  prepuce,  which  drops 
beneath  it.  If  the  fraenum  is  involved,  haemorrhage  may  occur 
from  ulceration  into  a  branch  of  the  artery  found  in  that  structure. 
When  there  is  much  inflammation,  the  base  of  the  sore  becomes  in- 
durated and  infiltrated,  somewhat  resembling  the  Hunterian  chancre. 
Not  unfrequently  syphilitic  infection  occurs  at  the  same  time  as  a 
soft  chancre  is  contracted,  or  subsequently  ;  the  sore  then  runs  a 
longer  course,  does  not  heal,  even  if  kept  clean,  and  afcer  a  time 
the  patient  presents  the  characteristic  signs  of  syphilis. 

In  all  cases  the  neighbouring  Lympliatic  Glands  become  enlarged 
and  tender,  and  the  process  is  very  liable  to  terminate  in  suppuration, 
constituting  a  bubo.  Two  forms  of  this  affection  are  described  : 
(a)  The  simple  or  sympathetic  btibo  results  from  the  absorption  of 
ordinary  pyogenic  organisms  from  the  abraded  surface.  The  pus  in 
this  case,  if  inoculated  elsewhere,  may  produce  a  pustule,  but  not  a 
true  chancre.  The  process  is  usually  limited  to  the  interior  of  the 
lymphatic  glands,  (b)  The  virulent  bubo  is  due  to  the  absorption, 
not  only  of  pyogenic  organisms,  but  also  of  the  specific  virus,  so 
that  the  pus,  if  inoculated,  always  produces  a  typical  soft  sore.  In 
these  cases  suppuration  occurs  not  only  within,  but  even  more 
abundantly  around  the  lymphatic  glands  {periadenitis),  so  that  the 


142  A  MANUAL  OF  SURGERY 

skin  becomes  considerably  undermined,  and  the  wound  produced  by 
opening  the  abscess  may  take  on  the  form  of  a  huge  soft  chancre  in 
the  groin,  in  the  centre  of  which  is  seen  the  lymphatic  gland  only 
slightly  enlarged.  The  process  is  often  slow,  and  a  good  deal  of 
cutaneous  redness  is  present  with  but  little  pus. 

Treatment  consists  in  keeping  the  sore  clean,  dusting  its  surface 
with  iodoform,  and  covering  it  with  lint  dipped  in  lotio  nigra  or 
boric  acid  lotion,  healing  usually  occurring  in  from  ten  to  twenty 
days ;  where  much  balanitis  exists,  it  may  be  necessary  to  slit  up  the 
prepuce,  but  circumcision  should  not  be  undertaken  until  the  sores 
have  healed.  The  application  of  pure  carbolic  or  nitric  acid  may 
destroy  the  organisms  and  hasten  a  cure,  but  they  need  not  be 
employed  as  a  routine  treatment,  since  soft  chancres,  if  kept  clean, 
are  usually  devoid  of  serious  consequences.  If  the  smell  of  iodoform 
is  objected  to,  iodol  or  aristol  may  be  substituted. 

Buboes  are  treated  in  the  early  stages  by  keeping  the  patient  at 
rest  and  applying  fomentations,  when  resolution  sometimes  occurs. 
If  suppuration  ensues,  the  abscess  should  be  incised  vertically,  so  as 
to  allow  free  exit  to  the  pus,  even  when  the  patient  is  sitting,  the 
cavity  being  subsequently  dressed  by  packing  it  with  gauze  impreg- 
nated with  iodoform.  Some  surgeons  recommend  that  enlarged 
glands  of  this  nature  should  be  freely  removed  by  dissection,  but 
such  is  not  often  required.  The  tissues  surrounding  them  are  so 
extensively  infiltrated  that  it  is  sometimes  impossible  to  define  their, 
limits,  and  surrounding  tissues  of  importance  may  be  encroached 
on.  Moreover,  complete  removal  of  the  lymphatic  glands  in  the 
groin  is  sometimes  followed  by  serious  evidences  of  lymphatic 
obstruction  in  the  limb  or  external  genital  organs  (Fig.  109).  Pro- 
longed rest,  free  incisions,  and  scraping  of  abscess  cavities  and 
sinuses,  followed  by  packing  with  iodoform  gauze,  usually  result  in 
a  cure  ;  when  repair  is  slow,  a  visit  to  the  seaside  will  often  be 
beneficial. 

Syphilis. 

It  is  now  fairly  certain  that  the  cause  of  syphilis  is  a  protozoan 
parasite  discovered  by  Siegel  and  Schaudinn  in  1905,  and  termed 
the  Spirochceta  or  Treponema  pallida  (Fig.  27).  Spirochaetes  and 
spirilla  are  common  in  the  mouth,  septic  ulcers,  etc.,  and  this 
organism  can  only  be  distinguished  from  unimportant  forms  by  its 
morphology  and  staining  reactions,  as  it  has  not  yet  been  cultivated ; 
these  are,  however,  sufficient  in  practised  hands  for  its  recognition. 
It  stains  with  difficulty,  a  fact  which  accounts  for  its  having  eluded 
observation  for  so  long.  Morphologically,  it  is  a  very  delicate  spiral 
filament,  having  eight  to  twelve  fairly  regular  whorls  ;  its  ends  are 
sharply  pointed,  and  each  terminates  in  an  exceedingly  delicate 
flagellum.  It  varies  in  length,  but  on  an  average  is  about  equal  in 
length  to  the  diameter  of  a  red  blood-corpuscle,  and  each  whorl 
occupies  about  i  /x.  The  common  S.  refrmgens,  which  is  frequently 
met  with  in  the  mouth,  ulcers,  etc.,  is  larger,  broader,  has  blunter 


SPECIFIC  INFECTIVE  DISEASES  143 

ends,  and  a  smaller  number  of  less  regular  whorls.     Little  is  known 
of  the  life-history  of  the  syphilitic  form. 

The  proof  of  its  specificity  lies  mainly  in  the  fact  that  it  can  be 
found  in  the  great  majority  of  all  cases  of  syphilis — the  proportion 
depending  on  the  care  taken  and  the  skill  of  the  observer — and  that 
it  is  found  in  regions  in  which  accidental  contaminations  could  hardly 
occur,  e.g.,  in  the  lungs,  liver,  spleen,  and  other  viscera  of  still-born 
syphilitic  foetuses  (Fig.  28).  In  acquired  syphilis  it  may  be  demon- 
strated in  the  primary  chancre,  or  in  scrapings  thereof;  in  the 
secondary  stage  it  occurs  in  the  corresponding  glands,  the  skin 
lesions,  or  in  the  fluid  of  blisters  raised  near  them,  in  the  spleen,  and 
has  been  demonstrated  in  the  blood,  though  rarely  ;  in  the  tertiary 


Fig.  27.— Spiroch.eta  Pallida.  Fig    28.— Section   of   Lung   in  Dead 

(  X  1.500.)  AND  Macerated  Syphilitic  FcETUs, 

showing     the    Tissues    crowded 
WITH  Spirochetes,     (x  1,000.) 

(For  the  preparation  and  loan  of  these  two  specimens  we  are  indebted  to 
Dr.  Eardley  Holland.) 

stage  it  has  been  found  in  very  small  numbers  in  gummata,  but  in 
the  majority  of  cases  it  cannot  be  found  in  these  lesions. 

Syphilis  only  occurs  naturally  in  man,  but  it  may  be  inoculated 
into  the  higher  apes,  which  develop  a  disease  comparable  in  most  of 
its  features  to  human  syphilis.  Experiments  on  these  animals  have 
yielded  results  of  some  clinical  interest.  Thus  the  semen  of  a 
syphilitic  man  will  infect  an  ape,  whereas  the  blood  rarely  does  so ; 
gummata  will  sometimes  cause  the  disease  when  inoculated.  More- 
over, generalization  of  the  virus  takes  place  very  quickly,  extir- 
pation of  the  region  inoculated  being  without  effect  if  undertaken 
more  than  eight  hours  after  infection.  It  has  also  been  found 
that  the  local  inunction  of  calomel  ointment  before,  or  even  as  late 
as  one  hour  after,  inoculation  in  animals,  will  completely  prevent 
the  development  of  the  disease. 


144  A  MANUAL  OF  SURGERY 

The  methods  employed  in  the  laboratory  diagnosis  depend  upon  the 
stage  of  the  disease.  In  the  early  stages  the  Treponema  pallidum 
must  be  sought  for  in  the  serum  which  oozes  from  the  surface  of  the 
supposed  chancre  after  careful  cleaning.  Three  methods  are  in  use 
for  this  :  (i)  The  material  may  be  examined  fresh  under  dark  back- 
ground illumination  (ultra-microscope).  This  is  the  best  method, 
the  organisms  being  easily  seen  and  their  characteristic  movements 
recognised.  (2)  Appearances  somewhat  similar  can  be  secured  by 
mixing  the  secretion  with  fluid  Indian  ink,  spreading  it  out  into  a 
film,  and  allowing  it  to  dry  on  a  slide.  Here  also  the  organisms 
appear  colourless  on  a  dark  ground,  but,  of  course,  there  is  no  move- 
ment. This  is  a  simple  and  quick  method.  (3)  There  are  numerous 
staining  methods,  most  being  modifications  of  Romanowski's ;  photo- 
graphic processes  depending  on  the  reduction  of  silver  are  also  used, 
especially  when  the  organisms  have  to  be  sought  for  in  the  tissues. 

In  the  later  stages  the  treponemata  are  scanty  and  difficult  to 
find,  and  recourse  must  be  had  to  the  Wassermann  reaction  This 
depends  on  the  fact  that  in  the  late  primary,  secondary,  and  later 
stages  of  the  disease,  the  blood-serum  usually  contains  a  substance 
which,  when  incubated  with  an  alcoholic  extract  of  heart  or  liver 
(diluted  with  saline  solution),  removes  complement  (p.  23)  from  the 
mixture.  This  is  demonstrated  by  adding  sensitized  red  corpuscles, 
which  are  dissolved  if  complement  is.  present,  but  which  remain 
unaltered  if  it  is  absent. 

Clinical  History. — Syphilis  is  characterized  by  the  appearance  of 
a  primary  sore,  usually  known  as  a  hard  chancre  {local  infection), 
which  is  followed  in  the  course  of  a  few  weeks  by  evidences  of 
general  infection,  referred  mainly  to  the  skin  and  mucous  membranes, 
comprising  the  secondary  stage.  After  a  variable  time,  known  as  the 
intermediate  period,  during  which  symptoms  may  be  absent,  tertiary 
manifestations  (gummata,  etc.)  may  show  themselves  in  any  and 
every  part  of  the  body. 

Mode  of  Infection. — Acquired  syphilis  is  almost  always  due  to 
infection  of  the  genital  organs  arising  from  impure  connection. 
Occasionally  cases  are  met  with  in  which  the  disease  is  transmitted 
by  other  means  {syphilis  msojitium),  and  then  the  primary  lesion  is 
often  located  on  some  other  part  of  the  body  {extragenital  chancres) ; 
thus,  the  lip  may  be  infected  as  a  result  of  drinking  out  of  the  same 
glass  or  smoking  the  same  pipe  as  a  syphilitic  patient,  or  even  by 
kissing.  The  disease  is  not  equally  infectious  in  all  its  stages ;  in 
the  primary  the  discharge  derived  from  the  chancre  will  alone 
convey  the  contagion  ,  in  the  secondary  period  the  virus  is  present 
in  all  pathological  exudations,  as  also  in  the  semen.  Pure  secretions, 
e.g.,  milk  or  urine,  are  free  from  infection,  although  if  mixed  with  a 
serous  exudation  from  abraded  surfaces,  as  so  frequently  occurs  in 
the  case  of  the  saliva,  they  at  once  become  infective.  It  is  uncommon 
for  infection  to  be  conveyed  by  patients  in  the  tertiary  stage. 

One  .attack  of  syphilis  usually  confers  immunity  on  the  patient 
from  further  outbreaks  of  the  disease,  even  if  exposed  to  infection. 


SPECIFIC  INFECTIVE  DISEASES 


145 


This  protection  is  not  always  permanent,  since  well-authenticated 
cases  have  been  observed  of  second  attacks  of  syphilis,  in  which  the 
primary  lesion  was  on  each  occasion  followed  by  distinct  signs  of 
general  infection. 

The  stage  of  Incubation  lasts  for  a  variable  period,  extending  from 
two  to  six  weeks  ;  as  a  rule  evidences  of  induration  of  the  sore  can 
be  detected  about  the  third  week.  Removal  or  destruction  of  the 
local  lesion  has  not  the  slightest  influence  upon  the  progress  of  the 
case,  unless  it  is  undertaken  immediately  after  infection.  During 
the  incubation  period  the  local  sore  may  heal  completely,  if  it  is 
purely  syphilitic,  and  nothing  further  is  noticed  until  the  typical 
induration  manifests  itself.  Not  unfrequently,  however,  pyogenic 
infection  occurs,  or  a  soft  chancre  is  also  present ;  in  the  latter  case 
the  lesion  does  not  heal  satisfactorily,  and  the  base  of  the  ulcer 
becomes  indurated  after  a  time. 


Fig.  29. — Hard  Chancre,  displayed  by  Eversion  of  Prepuce. 


I.  The  Primary  Stage  of  syphilis  is  characterized  by  the  develop- 
ment of  a  primary  sore,  associated  with  enlargement  of  the  neigh- 
bouring lymphatic  glands.  It  is  usually  situated  on  the  base  of  the 
prepuce,  close  to  the  corona  glandis  (Fig.  29),  or  on  the  frgenum ; 
in  the  female  the  inner  aspects  of  the  labia  majora  or  nymphae  are 
the  most  common  sites. 

The  primary  sore  does  not  invariably  present  the  same  appearance, 
although  it  is  typically  characterized  by  a  certain  amount  of  infiltration 
and  induration.  The  following  are  the  chief  forms  in  which  the 
chancre  manifests  itself :  (a)  The  desquamating  papule  is  a  slightly 
elevated  spot,  which  is  irritable,  of  a  dusky  colour,  and  free 
from  ulceration.  It  is  usually  small,  but  hard,  and  its  surface 
covered  with  epithelial  scales.  If  exposed  to  friction  or  to  the  irrita- 
tion of  retained  discharges,  ulceration  is  very  likely  to  take  place, 
and  an  ordinary  Hunterian  chancre  will  then  form.  Unless  this 
occurs,  it  may  run  its  course  unobserved,  and  thus  a  patient  becomes 
syphilitic  without  being  able  to  trace  the  time  or  source  of  infection. 

10 


146 


A  MANUAL  OF  SURGERY 


(b)  The  indurated,  hard,  or  Huntevian  chancre  is  that  most  commonly 
seen  ;  it  results  from  the  irritation  of  a  papule,  or  is  developed  in 
association  with  a  soft  sore.  Should  the  initial  superficial  abrasion 
have  healed,  a  localized  growth  of  almost  cartilaginous  hardness 
forms  in  the  cicatrix,  closely  adherent  to  and  invading  the  cutis ; 
but  if  a  soft  sore  has  first  developed,  the  surface  remains  ulcerated 
more  or  less  deeply  with  a  well-defined  margin,  though  the  base  be- 
comes indurated  (Fig.  30).  In  some  cases  there  may  be  but  little 
elevation  of  the  growth,  and  the  surface  is  free  from  ulceration,  con- 
stituting the  variety  known  as  the  '  parchment  induration '  of  Ricord, 
and  not  unfrequently  seen  on  .the  glans  penis.  Where,  however,  the 
prepuce  or  body  of  the  penis  is  involved,  the  induration  is  more 
diffuse,  owing  to  the  laxity  of  the  connective  tissue.  When  affecting 
the  base  of  the  prepuce,  the  induration  usually  spreads  transversely, 
producing  a  collar-like  mass,  which  on  retraction  of  the  part  rolls 
back  en  bloc  in  a  very  characteristic  manner  (Fig.  29).     Examined 


Fig.  30. — Hard  Chancre  of  Abdominal  Wall  in  Suprapubic  Region. 

microscopically,  the  new  formation  consists  merely  of  a  mass  of 
round  and  spindle  cells  packed  closely  together,  with  a  certain 
amount  of  intercellular  fibrous  tissue ;  giant  cells  are  sometimes 
seen.  The  blood-supply  of  the  part  is  scanty,  a  fact  which  explains 
the  readiness  with  which  ulceration  occurs.  Several  chancres  may 
be  seen  on  the  same  individual  if  the  infection  occurs  at  one  time, 
and  it  is  possible  that  a  patient  could  be  infected  at  two  different 
periods  if  only  a  short  interval  elapsed  between  the  inoculations ; 
but  the  disease  is  not  generally  auto-inoculable,  and  when  once  a 
hard  chancre  has  developed  on  the  under  surface  of  the  prepuce,  the 
glans  does  not  become  infected  from  contact.  Multiple  chancres  are 
always  of  small  size,  and  the  induration  is  less  marked  than  usual. 

A  Urethral  Chancre  is  usually  situated  just  within  the  lips  of  the 
meatus,  constituting  a  sore  with  an  indurated  base.  It  may  be  felt 
as  a  hard  nodule  on  grasping  the  urethra  between  the  fingers,  and 
gives  rise   to  a   thin  serous  discharge,  often  blood-stained.      The 


SPECIFIC  INFECTIVE  DISEASES  147 

orifice  itself  is  sometimes  the  site  of  a  hard  chancre,  which  may 
encircle  it,  and  be  followed  by  a  stricture. 

Extragenital  Chancres  are  most  commonly  observed  on  the  lips, 
finger,  and  nipple.  They  are  often  characterized  by  much  infiltra- 
tion, due  to  sepsis,  and  less  distinct  and  definite  induration  than  in 
the  forms  met  with  on  the  genital  organs ;  hence  the  swelling  is 
more  prominent  and  vascular,  and  if  ulceration  occurs  there  is  a 
greater  amount  of  discharge,  which  forms  a  thick  scab  over  the 
surface.  Neighbouring  lymphatic  glands  are  often  much  enlarged, 
and  surrounded  by  infiltrated  tissue.  This  condition  has  been  mis- 
taken for  epithelioma,  from  which,  however,  it  can  be  distinguished- 
by  the  induration  and  sharp  limitation  of  the  sore,  its  rapid  develop- 
ment, and  the  earlier  enlargement  of  the  glands.  The  course  of  the 
case  is  sometimes  more  severe  than  when  the  primary  lesion  is  in 
the  usual  situation,  a  fact  possibly  explained  by  the  disease  remaining 
unrecognised  till  secondary  symptoms  develop. 

Digital  Chancres  are  usually  seen  in  surgeons  and  accoucheurs, 
and  start  by  the  side  of  the  nail.  An  indolent  sore  appears,  which 
becomes  infiltrated  and  ulcerates,  spreading  under  the  matrix  and 
along  the  semilunar  fold.  There  is  a  good  deal  of  discharge  and 
pain,  and  the  terminal  phalanx  becomes  swollen  and  bulbous.  The 
epicondyloid  and  axillary  glands  are  enlarged  as  the  case  progresses, 
and  the  condition  has  more  than  once  been  mistaken  for  malignant 
disease.  Occasionally,  however,  the  sore  has  been  so  small  and  so 
little  obvious  as  to  be  overlooked. 

Phagedena  is  a  form  of  spreading  ulceration,  rarely  met  with  at  the  present 
time,  except  in  connection  with  venereal  disease  and  seldom  apart  from  syphilis. 
It  always  attacks  unhealthy  and  debilitated  individuals,  and  is  largely  due  to  the 
retention  of  discharges  resulting  from  phimosis.  The  prepuce  and  end  of  the 
organ  become  red,  swollen,  and  infiltrated.  On  dividing  or  retracting  the  fore- 
skin, the  affected  surface  is  found  to  be  sloughy,  and  the  ulceration,  unless 
checked  by  treatment,  rapidly  spreads,  and  may  destroy  glans  and  prepuce,  and 
even  attack  the  body  of  the  penis.  A  similar  condition  is  occasionally  seen  in 
connection  with  an  inguinal  bubo,  and  then  the  integrity  of  the  femoral  vessels  is 
threatened. 

The  Treatment  consists  in  division  of  the  foreskin  if  that  structure  has  not 
been  already  destroyed,  followed  by  prolonged  immersion  of  the  patient  in  a  hut 
hip-bath.  If  the  patient  cannot  be  kept  for  twelve  or  twenty-four  hours  in  a 
warm  bath,  it  will  suffice  to  immerse  him  in  warm  water  for  two  or  three  hours 
every  day.  In  the  intervals  the  wound  should  be  dusted  with  iodoform,  and 
dressed  with  lint  dipped  in  lotio  nigra.  Under  such  circumstances,  the  surface 
of  the  sore  quickly  cleans,  and  becomes  covered  with  healthy  granulations.  The 
later  treatment  is  conducted  as  for  primary  syphilis,  although  the  depressed 
condition  of  the  general  health  may  necessitate  the  administration  of  tonics  and 
even  a  visit  to  the  seaside.  Should  treatment  by  immersion  in  hot  water  be 
for  any  reason  impracticable,  the  old-fashioned  plan  must  be  resorted  to — viz., 
scraping  the  sore,  and  freely  cauterizing  the  base  with  pure  carbolic  or  fuming 
nitric  acid.  Possibly,  where  there  is  much  slough,  this  latter  method  may 
advantageously  precede  immersion  in  a  bath. 

The  Lymphatic  Glands  which  receive  lymph  from  the  region  in 
which  the  sore  is  situated  become  characteristically  enlarged.  They 
move  freely  under  the  skin   and  feel  hard,  like  bullets,  pellets  of 


148  A  MANUAL  OF  SURGERY 

cartilage,  or  almonds  (hence  the  term  'amygdaloid  '  which  has  often 
been  applied  to  them) ;  they  are  usually  quite  painless,  and  there  is 
no  tendency  for  them  to  suppurate  unless  the  original  sore  is  septic, 
or  also  inoculated  with  the  virus  of  a  soft  chancre,  when  an  abscess 
may  develop,  one  or  more  of  the  inguinal  glands  breaking  down ;  on 
opening  it  the  skin  is  often  found  extensively  undermined. 

Occasionally  the  lymphatic  vessels  extending  from  the  sore  to  the 
glands  become  the  seat  of  a  chronic  lymphangitis,  and  may  be  felt 
as  hard  cords  beneath  the  skin.  The  dorsal  lymphatic  of  the  penis 
is  frequently  blocked  in  this  way,  and  gives  rise  to  solid  or  lymphatic 
cedema  of  the  prepuce  and  glans.  Should  the  chancre  suppurate,  an 
abscess  may  form  in  the  course  of  the  lymphatics. 

The  Diagnosis  of  a  syphilitic  from  a  soft  sore  is  not  always  easy. 
Of  course,  where  there  is  no  ulceration,  and  the  typical  induration 
of  the  base  can  be  felt,  no  doubt  need  arise.  But  when  the  primary 
sore  is  septic,  and  an  excavated  ulcer  is  present,  surrounded  by 
infiltrated  and  hyperaemic  tissues,  it  is  difficult  to  be  certain  as  to 
the  nature  of  the  case.  The  inguinal  glands  are  enlarged  in  both 
varieties,  and  the  fact  that  suppuration  occurs  proves  nothing.  Even 
the  existence  of  a  '  satellite '  chancre  from  auto-inoculation  only 
demonstrates  the  presence  of  a  soft  chancre ;  it  does  not  prove  the 
absence  of  syphilis.  The  presence  of  the  typical  spirochaete  in  scrapings 
from  a  chancre,  or  in  juice  removed  by  a  hypodermic  needle  from  an 
enlarged  inguinal  gland  after  massage,  is  conclusive  evidence.  In  a 
few  cases  it  is  necessary  to  wait  for  the  development  of  secondary 
symptoms  before  a  decided  opinion  can  be  given. 

The  Duration  of  the  primary  sore  varies  in  different  cases,  and 
depends  in  a  great  measure  on  whether  treatment  is  commenced  early 
or  late.  If  the  patient  comes  under  observation  during  the  first  six 
weeks,  and  a  mercurial  course  is  at  once  started,  the  chancre  heals, 
and  the  induration  usually  disappears  in  from  six  to  eight  weeks. 
The  glands  in  the  groin,  however,  remain  enlarged  for  some  time. 
The  longer  the  case  is  left  untreated,  the  more  slowly  does  the 
hardness  disappear.  If  no  mercury  is  given,  the  induration  may 
last  for  twelve  months  or  more,  and  then  slowly  passes  off,  although 
it  may  run  a  much  shorter  course.  From  an  uncomplicated  syphilitic 
sore  but  little  scar  results,  although  a  well-marked  cicatrix  may  follow 
a  soft  or  septic  chancre. 

Re-induration  of  the  cicatrix  (relapsing  chancre)  sometimes  occurs  . 
from  too  early  a  cessation  of  the  mercurial  course,  or  from  some 
localized  irritation,  or  from  a   fresh  exposure  to  infection.     It  is 
occasionally  due  to  a  tertiary  or  gummatous  development,  and  will 
then  be  free  from  lymphatic  complications. 

II.  Secondary  Syphilis.  —  In  the  secondary  stage,  the  virus  is 
diffused  generally  throughout  the  body  by  means  of  the  blood,  which 
is  itself  infective.  A  certain  amount  of  constitutional  disturbance 
may  exist,  the  patient  feeling  '  seedy '  and  out  of  sorts,  whilst  in 
some  cases  distinct  pyrexia  and  headache  have  been  noted.  Well- 
marked   anaemia   is   often   present,   and    on   examination    the   red 


SPECIFIC  INFECTIVE  DISEASES 


149 


corpuscles  are  found  to  be  deficient  in  number,  and  defective  in  the 
amount  of  haemoglobin  contained  within  them.  The  chief  secondary 
manifestations  consist  in  the  appearance  of  various  forms  of  rash  on 
the  skin  and  mucous  membranes,  associated  with  a  general  enlarge- 
ment of  the  lymphatic  glands,  sore  throat,  mucous  tubercles  and 
condylomata,  loss  of  hair,  and  other  less  common  phenomena,  and 
these  usually  show  themselves  in  from  seven  to  nine  weeks  from 
the  time  of  inoculation,  although  they  may  be  delayed  to  a  much 
later  date.  Their  intensity  also  varies  considerably,' the  phenomena 
being  sometimes  scarcely  evident,  and  at  others  very  marked.  They 
are  also  influenced  greatly  by  the  period  at  which  the  administration 
of  mercury  commences  ;  the  earlier  the  drug  is  given,  the  less 
obvious  are  the  secondary  phenomena. 

The  Cutaneous  Eruptions  of  secondary  syphilis  are  chiefly  char- 
acterized by  the  fact  that,  although  any  form  of  rash  may  be 
■simulated,  no  specially  distinctive  variety  is  originated.  Moreover, 
in  the  same  individual  the  eruption  is  not  always  of  the  same 
character  throughout,  several  distinct  types  developing  in  different 
parts  of  the  body  [polymorphism).  The  rash  is  usually  more  or  less 
symmetrical,  the  colour  in  the  early  stages  being  a  dusky  red, 
resembling  that  of  raw  ham,  whilst  later  on  it  becomes  of  a  more 
coppery  hue  ;  occasionally,  however,  it  may  be  a  bright  rosy  red. 
Syphilitic  rashes  do  not  completely  fade  on  pressure,  but  leave  a 
brown  stain,  and  give  rise  to  but  little  irritation  or  itching  ;  they 
always  tend  to  progress  from  the  simpler  types,  due  to  hypersemia, 
to  the  more  serious,  in  which  infiltration  and  overgrowth  are 
evident. 

In  the  simplest  form,  merely  a  hyperaemia  is  present,  sometimes 
appearing  as  a  dusky  mottling  of  the  skin  {roseolous  syphilide),  which 
quickly  fades  or  may  persist  whilst  other  types  are  developing. 
Sometimes  distinct  papillae  become  infiltrated  and  hyperaemic 
{papular  syphilide)  ;  at  others,  vesicles  or  pustules  appear  {vesicular 
or  pustular  syphilides)  ;  the  latter  change  is  uncommon,  and  only 
appears  in  bad  cases  or  in  debilitated  patients.  Another  form  of 
eruption  is  the  squamous  syphilide,'  characterized  by  patches  of 
hyperaemia  and  infiltration,  combined  with  superficial  desquamation. 
It  is  usually  bilateral,  and,  unlike  simple  psoriasis,  affects  the  flexor 
rather  than  the  extensor  surfaces.  It  the  later  stages,  distinct 
nodules  or  tubercles  are  produced  in  the  skin,  which  may  even  run 
on  to  ulceration  [tubercular  syphilide). 

As  to  the  situation  of  the  rash,  the  roseola  is  usually  limited  to  the 
abdomen,  whilst  the  other  forms  are  often  scattered  widely  over  the 
trunk  and  extremities,  involving,  however,  the  flexor  more  than  the 
extensor  surfaces  of  the  limbs.  A  somewhat  characteristic  phenom- 
enon is  the  appearance  of  a  papular  rash  on  the  forehead,  sometimes 
known  as  the  corona  Veneris. 

The  Mucous  Memhranes  may  be  affected  in  much  the  same  way 
as  the  skin.  The  fauces  become  red  and  congested,  the  hyperaemic 
area  being  abruptly  limited,  and  semicircular  in  outline ;  symmetrical 


ISO  A  MANUAL  OF  SURGERY 

ulceration  usually  follows,  starting  near  the  anterior  pillars  of  the 
fauces,  and  spreading  to  the  tonsils  and  along  the  soft  palate  to  the 
uvula.  These  ulcers  are  shallow,  have  sharply  cut  edges,  and 
often  present  a  characteristic  grayish  appearance,  constituting  what 
is  known  as  a  '  snail-track '  ulcer.  The  secondary  sore  throat 
rarely  results  in  extensive  loss  of  substance,  and  hence  pharyngeal 
stenosis  is  not  produced.  Smoking  undoubtedly  aggravates  these 
conditions.  Concurrently  with  these  manifestations  in  the  fauces 
bare  patches  from  loss  of  epithelium  may  be  seen  on  the  dorsum  of 
the  tongue,  or  several  small  superficial,  but  very  painful,  ulcers  may 
develop  on  the  inside  of  the  cheeks  or  lips. 

Mucous  tubercles  and  condylomata  are  somewhat  similar  affec- 
tions, though  more  pronounced,  arising  in  the  secondary  stage  in 
connection  with  mucous  membranes  and  those  parts  of  the  skin 
which  are  soft  and  moist.  Miicotis  Tubercles  consist  of  slightly- 
raised  patches  of  enlarged  and  infiltrated  papillae,  white  in  appear- 
ance from  the  superficial  epithelium  becoming  sodden,  and  often 
progressing  to  actual  ulceration.  Examined  microscopically,  the 
papillae  are  found  to  be  definitely  enlarged,  and  the  epithelium 
heaped  up  over  them.  They  are  most  commonly  observed  at  the 
corners  of  the  mouth,  on  the  inner  aspect  of  the  cheeks,  the  side  of 
the  tongue  (often  due  there  to  the  irritation  of  rough  teeth),  or  the 
margin  of  the  anus  ;  in  the  last-named  situation  they  are  usually 
symmetrical,  one  side  being  infected  from  the  other.  They  are  also 
not  at  all  uncommon  between  the  toes,  and  the  ulcers  caused 
thereby  become  exceedingly  offensive  from  septic  contamination. 
Condylomata  are  similarly  the  result  of  overgrowth  of  the  papillae, 
differing  from  mucous  tubercles  merely  in  the  extent  to  which  this 
has  been  carried.  They  consist  of  definite  wart-like  masses,  which 
may  attain  a  great  size,  constituting  a  cauliflower-like  growth. 
They  are  most  commonly  seen  about  the  anus  or  vulva,  in  the 
former  situation  being  often  mistaken  by  the  patient  for  piles  ;  they 
give  rise  to  an  abundant,  highly  infective  discharge.  A  similar 
condition  is  sometimes  met  with  on  the  dorsum  of  the  tongue,  and 
is  then  known  as  '  Hutchinson's  wart' 

The  Lymphatic  Glands  are  usually  enlarged  throughout  the  body 
during  this  period  of  the  disease,  being  felt  as  round,  hard  swellings 
beneath  the  skin.  The  extent  of  the  glandular  complication  is 
possibly  a  measure  of  the  degree  of  virulence  of  the  affection.  The 
condition  of  the  nuchal  and  epicondyloid  glands  should  always  be 
ascertained  in  suspicious  cases,  since,  if  no  obvious  local  cause 
exists  for  their  enlargement,  syphilis  may  be  suspected. 

Syphilitic  Alopecia  — ^The  hair  becomes  dull  and  lustreless,  and 
either  comes  out  in  patches  from  the  scalp,  eyebrows,  beard,  etc.,  or 
there  is  a  general  '  thinning.'  The  follicles,  however,  are  not 
destroyed,  and  after  a  time  the  hair  will  grow  again  as  before. 

Later  secondary  manifestations  consist  of  flying  pains  in  the 
bones  (osteocopic),  iritis,  and  various  nervous  lesions,  whilst 
periosteal  nodes   may  form   on   the   tibiae  and   other   bones,  or   a 


SPECIFIC  INFECTIVE  DISEASES  151 

symmetrical  chronic  effusion  develop  within  the  synovial  membrane 
of  joints. 

Syphilitic  Iritis  is  characterized  by  pain  in  the  eye,  generally 
referred  to  the  supra-orbital  nerve,  together  with  some  interference 
with  vision,  and  possibly  a  little  lachrymation  and  photophobia. 
On  examination  a  bright-red  circular  zone  immediately  surrounds 
the  cornea,  resulting  from  hypersemia  of  the  ciliary  vessels.  "  The 
iris  is  lustreless,  and  its  definition  somewhat  blurred.  Its  colour  is 
changed,  a  blue  iris  becoming  greenish-yellow  from  the  presence  of 
lymph.  The  pupil  is  diminished  in  size,  and  perhaps  irregular  ;  its 
movements  are  always  considerably  hampered,  and  sometimes 
entirely  prevented,  by  the  formation  of  adhesions  either  to  the  back  of 
the  cornea  (anterior  synechias)  or  to  the  lens  capsule  (posterior 
synechise).  Occasionally  small  yellowish  nodules  are  seen  on  its 
surface,  consisting  of  plastic  lymph. 

The  Duration  and  character  of  the  secondary  stage  vary  consider- 
ably. The  sooner  the  patient  is  brought  judiciously  under  the 
influence  of  mercury,  the  less  severe  the  secondary  phenomena, 
whilst  cases  in  which  treatment  has  been  delayed  are  likely  to  be 
more  troublesome.  Hence  the  disease  is  often  of  an  aggravated 
type  when  following  extragenital  chancres,  as  also  in  women,  by 
whom  the  primary  lesion  often  passes  unnoticed.  When  treatment 
is  commenced  within  four  or  five  weeks  of  infection,  the  secondary 
stage  may  be  slight,  and  all  traces  of  its  existence  may  pass  off  in 
two  months  or  less ;  if  mercury  is  not  administered  until  the 
cutaneous  eruption  has  appeared,  this  stage  is  likely  to  last  longer. 
The  condition  of  the  patient's  health  is  an  important  factor,  as  also 
the  previous  habits,  particularly  as  to  temperance,  since  syphilis 
always  follows  a  more  aggravated  course  in  the  weakly  and  the  dis- 
sipated. Even  under  the  best  circumstances,  the  patient  is  liable  to 
relapses  during  the  first  twelve  months,  which  are  usually  due  to 
intermissions  in  the  treatment.  The  rash  which  appears  under 
these  circumstances  is  often  of  a  more  characteristic  type,  the 
papules  being  grouped  into  rounded  or  confluent  figures. 

III.  The  Intermediate  or  late  Secondary  Stage  constitutes  a  link 
between  the  symptoms  already  described  and  the  tertiary  phenomena ; 
no  distinct  limits  to  this  period  can  be  defined,  nor  need  it  appear  at 
all  if  the  patient's  general  health  is  good,  and  the  treatment  has 
been  carried  out  regularly.  Some  of  the  secondary  manifestations, 
especially  those  of  the  bones  and  joints,  may  persist  through  this 
period,  whilst  even  if  they  have  disappeared,  the  patient  is  liable  to 
suffer  from  '  reminders '  in  the  shape  of  various  cutaneous  affections, 
arid  perhaps  epididymitis.  Deep  lesions  of  the  eye  (choroido- 
retinitis)  and  of  the  central  nervous  system  (syphilitic  monoplegia) 
are  not  uncommon,  the  latter  usually  arising  from  anaemia  of  the 
cerebral  centres  due  to  a  syphilitic  endarteritis.  The  principal 
cutaneous  affection  is  the  so-called  syphilitic  psoriasis,  most  fre- 
quently seen  on  the  palms  and  soles.  A  squamous  syphilide  is 
often  observed  in  the  secondary  stage,  but  is  then  symmetrical  and 


152 


A  MANUAL  OF  SURGERY 


readily  influenced  by  mercury.  In  this  intermediate  period  the 
lesion  may  be  bilateral  or  limited  to  one  side,  according  to  whether  it 
appears  early  or  late.  In  the  former  there  is  a  considerable  tendency 
to  proliferation  of  the  epithelium,  together  with  deep  cracks  and 
fissures ;  in  the  latter  there  is  less  epithelial  overgrowth,  but  the 
edges  are  often  distinctly  serpiginous  in  outline,  and  there  is  an 
infiltrated  border. 

Eupia  and  Ecthyma  are  both  met  with  in  this  stage  of  the  disease, 
but  chiefly  in  patients  whose  nutrition  is  defective.  They  are 
characterized  by  an  infiltration  of  the  skin  (in  reality  gummatous), 
which  progresses  to  ulceration.     In   rupia  the  discharge  forms   a 


Fig.  31.— Rupia  of  Face.     (From  Wax  Model  in  Museum  of  Royal 
College  of  Surgeons.) 

A  diagrammatic  section  of  the  rupial  patch  is  shown  above.  A,  Scab  formed  of 
successive  layers  of  dried  discharge  resting  on— .B,  ulcerated  granulomatous 
surface  of  gumma. 

distinct  scab  on  the  surface,  which  increases  in  thickness  by  the 
deposit  of  successive  layers  one  under  the  other,  each  being  some- 
what larger  than  the  one  which  precedes  it ;  hence  a  scab  shaped 
like  a  limpet-shell  is  produced,  resting  on  an  inflamed  and  hyperaemic 
base  (Fig.  31);  any  part  of  the  body  may  be  affected  in  this  way. 
In  ecthyma  no  scab  forms  over  the  ulcerated  surface,  or,  if  formed, 
it  readily  comes  away,  leaving  exposed  a  hollow  punched-out  sore, 
surrounded  by  an  area  of  vivid  congestion.  Under  appropriate 
treatment  these  conditions  disappear,  but  leave  depressed,  whitish 
cicatrices,  often  surrounded  by  pigmentation. 

A   somewhat   unusual   intermediate  manifestation   is  a  subacute 


SPECIFIC  INFECTIVE  DISEASES  153 

symmetrical  epididymitis,  in  which  the  cord  also  becomes  thickened, 
enlarged,  and  tender. 

IV.  Tertiary  Syphilis. — The  phenomena  occurring  in  this  stage 
may  appear  within  six  months  of  infection,  or  not  for  twenty  or 
thirty  years.  They  are  mainly  characterized  by  infiltration  and 
overgrowth  of  the  connective  tissues  of  the  body.  Such  may  occur 
in  one  or  many  places,  and  may  be  diffuse  or  localized.  When 
diffuse,  the  organ  or  part  affected  becomes  enlarged  and  hard,  and 
unless  the  condition  is  treated  promptly,  remains  permanently 
sclerosed  from  the  development  of  fibro-cicatricial  tissue.  If,  how- 
ever, the  process  is  localized,  a  Gumma  is  formed. 

Any  tissue  in  the  body  may  be  the  seat  of  a  gummatous  deposit, 
which  apparently  arises  without  any  definite  cause,  although 
occasionally  its  onset  may  be  determined  by  an  injury.  The  in- 
volved area  becomes  infiltrated  with  large  oval  endothelial  cells,  and 
small  round  cells  (lymphocytes) ;  plasma-cells  are  usually  present  in 
considerable  numbers.  The  constituents  of  this  mass  are  quite 
similar  to  those  which  are  found  in  a  tubercle,  but  without  the' 
grouping  into  small  nodules  and  the  more  or  less  orderly  arrangement 
in  zones ;  giant  cells  are  usually  absent,  though  their  presence  is  by 
no  means  rare,  and  they  may  closely  simulate  the  tuberculous  type. 
Very  few  vessels  penetrate  into  the  mass  thus  formed,  which  other- 
wise resembles  granulation  tissue ;  it  gradually  increases  in  size, 
infiltrating  and  replacing  the  normal  tissues  of  the  part.  The  fate 
of  the  fully-formed  gumma  varies  according  to  circumstances.  If 
the  infection  is  a  mild  one,  and  especially  if  appropriate  treatment 
is  adopted,  a  certain  amount  of  organization  into  fibrous  tissue  may 
take  place,  and  the  bulk  of  the  cells  become  absorbed,  so  that  even 
a  large  gumma  may  almost  entirely  disappear,  a  small  fibrous  scar 
being  the  only  indication  of  its  occurrence. 

In  the  absence  of  proper  treatment  most  gummata  undergo  a 
necrotic  change,  which  commences  at  the  centre  of  the  nodule  and 
spreads  towards  the  periphery.  This  may  be  a  comparatively  slow 
process,  so  that  fatty  degeneration  occurs,  and  caseation  somewhat 
similar  to  that  seen  in  tubercle  results ;  or  it  may  be  a  more  rapid 
form  of  coagulation-necrosis,  in  which  the  tissues  undergo  a  kind  of 
mucoid  degeneration,  forming  a  gummy  mass  from  which  the  lesion 
acquires  its  name.  Sections  through  such  a  gumma  will  show  a 
large  white  structureless  centre  of  necrotic  or  caseous  material,  sur- 
rounded by  a  shell  of  cellular  tissue,  which  gradually  merges  into 
the  normal  structure  of  the  part.  Two  factors  are  concerned  in  the 
production  of  this  necrosis:  the  toxins  produced  by  the  causative 
organisms  and  the  deficient  blood-supply  of  the  central  portions  of  the 
cellular  mass.  The  vessels  of  the  gumma  are  deficient  from  the 
first,  and  after  a  time  the  amount  of  blood  which  reaches  them  is 
diminished  as  the  result  of  a  syphilitic  endarteritis  of  the  arterioles 
in  the  neighbourhood.  Moreover,  some  gummata  do  not  commence 
to  undergo  central  necrosis  until  a  certain  amount  of  transformation 
into  cicatricial  tissue  has  taken  place,  in  which  case  a  still  further 


154 


A  MANUAL  OF  SURGERY 


interference  with  the  blood-supply  may  be  caused  by  the  compression 
of  the  vessels  traversing  the  newly-formed  fibrous  tissue. 

Under  appropriate  treatment  the  whole  of  the  gummatous  mass 
may  be  absorbed,  even  when  caseation  or  necrosis  has  taken  place ; 
but  not  unfrequently  the  gummy,  semi-purulent  fluid  which  is  formed 
at  the  centre  of  the  mass  finds  its  way  to  the  surface  and  is  dis- 
charged. Where  the  necrotic  mass  is  large,  a  portion  of  it  may 
remain  adherent  to  the  surrounding  tissues  after  ulceration  has  taken 
place,  looking  somewhat  like  a  piece  of  wet  wash-leather.  Under 
exceptional  circumstances  the  central  slough  may  become  encysted 
by  the  formation  of  a  fibrous  capsule,  and  calcification  of  the  centre 
may  even  occur  ;  this  is  stated  to  be  most  frequently  found  in  the 
brain,  testis,  and  liver. 


/  =- 


/. 


Fig.  32. — Cutaneous  Gummata  on  Outer  Side  of  Thigh. 


Clinically,  the  appearances  vary  according  to  whether  the  gumma 
is  cutaneous  or  subcutaneous. 

Cuimteous  gummata  (Fig.  32)  are  very  frequently  observed  in 
tertiary  syphilis,  especially  in  the  earlier  stages.  They  occur  as 
rounded  dusky-red  nodules  of  firm  consistency,  but  slightly  painful, 
and  if  they  break  down  give  rise  to  typical  circular  ulcers.  Many 
such  growths  are  often  grouped  together  in  one  region,  and  when 
ulceration  has  occurred,  they  produce  by  their  confluence  sores 
with  a  rounded  or  serpiginous  outline.  Considerable  destruction  of 
tissue  follows,  but  they  are  readily  cured,  giving  rise  to  depressed 
white  cicatrices,  surrounded  by  pigmentation.  Any  part  of  the 
body  may  be  involved,  but  a  very  common  site  is  about  or  just 
below  the  knee,  on  the  outer,  rather  than  the  inner,  aspect  of  the  leg. 

Occasionally  a  diffuse  infiltration  of  the  skin  is  met  with  in  this 
stage,   appearing   as   a   red    hyperaemic    area   with    a   rounded   or 


SPECIFIC  INFECTIVE  DISEASES 


155 


serpiginous  border,  and  not  at  all  unlike  lupus  in  appearance 
(Fig.  33).  It  spreads  rapidly  at  the  margin,  which  is  distinctly 
thickened,  and  may  contain  scattered  nodules  undergoing  ulceration. 
Whether  ulceration  occurs  or  not,  a  cicatrix  is  produced.  It  is 
readily  amenable  to  treatment,  and  runs  a  much  more  rapid  course 
than  lupus  ;  the  apple- jelly-like  granulations  so  typical  of  the  latter 
disease  are  of  course  not  present. 

A  stibcutaneous  gumma  develops  as  a  firm  nodule  or  an  indefinite 
thickening,  which  gradually  increases  in  size  by  the  infiltration  of 
surrounding  tissues,  and  sooner  or  later  approaches  the  surface  ; 
the  centre  of  the  tumour  in  time  becomes  elastic  and  fluctuant ;  a 
certain  amount  of  pain  and  tenderness  is  noticed,  and  when  the  skin 
is  affected,  it  becomes  dusky  and  even  oedematous.  If  ulceration 
follows,  the  contents  of  the  gumma  escape,  and  the  sore  produced  i- 


Fig,  33. — Diffuse  Gummatous  Sore  on  Forearm. 


circular  and  deep,  the  edges  being  sharply  cut  and  perhaps  under- 
mined ;  the  base  of  the  ulcer  consists  of  granulation  tissue,  although 
it  is  sometimes  covered  by  the  characteristic  slough. 

The  peculiar  features  of  tertiary  syphilis,  as  it  affects  special 
regions,  will  be  described  under  the  appropriate  headings ;  but  the 
general  relation  of  syphilis  to  the  nervous  system  has  been  purposely 
omitted,  since  it  belongs  rather  to  the  physician  than  to  the  surgeon. 

The  Prognosis  of  syphilis  is  good  if  the  patient's  treatment  com- 
mences early  and  is  sufficiently  prolonged.  Any  idiosyncrasy  which 
prevents  the  administration  of  mercury  or  iodide  of  potassium  is 
particularly  unfortunate.  In  persons  suffering  from  extragenital 
chancres,  which  are  not  recognised  till  late,  the  disease  often  runs 
a  more  than  usually  severe  course.  The  general  health  of  the 
patient,  and   perhaps  a  peculiar  predisposition,  may  influence  the 


156  A  MANUAL  OF  SURGERY 

evolution  of  the  case,  whilst  the  co- existence  of  tuberculous  dis- 
ease may  render  the  prognosis  peculiarly  unfavourable,  especially 
when  the  syphilis  is  inherited.  The  character  of  the  rash,  and  the 
extent  of  the  general  glandular  enlargement  in  the  secondary  stage, 
may  perhaps  give  some  indication  of  the  gravity  of  the  case ;  where 
the  eruption  is  but  slightly  marked,  the  other  symptoms  are  usually 
mild,  whilst  a  pustular  eruption  is  almost  always  of  grave  import. 
Death  is  rarely  produced  by  any  of  the  secondary  manifestions, 
except  in  the  virulent  forms  developed  in  the  tropics  ;  but  it  is  not 
uncommon  in  the  tertiary  stage,  when  important  viscera,  such  as  the 
brain,  spinal  cord,  liver,  etc.,  are  involved.  Affections  of  the  nervous 
system,  such  as  tabes  and  general  paralysis,  are  likely  to  be 
developed  in  patients,  such  as  doctors  and  lawyers,  whose  life-work 
entails  considerable  nervous  and  mental  strain. 

As  to  the  Curability  of  syphilis,  the  general  opinion  held  at  present 
is  that,  if  the  disease  is  seen  early,  and  treated  efficiently,  the  patient 
will  in  all  probability  never  suffer  from  any  further  manifestations 
after  the  secondary  symptoms  have  disappeared.  A  cure  can, 
however,  never  be  definitely  promised,  since,  should  the  general 
health  of  the  patient  become  impaired,  characteristic  syphilitic 
phenomena  may  make  themselves  evident  even  thirty  or  forty  years 
after  the  primary  lesion.  Certain  cases,  moreover,  are  to  be  looked 
on  as  absolutely  incurable  [malignant  syphilis),  owing  probably  to  the 
virulence  of  the  infection,  or  to  the  weak  resisting  power  of  the 
patient,  who  at  the  moment  of  infection  may  have  been  in  bad 
health,  or  to  the  late  period  at  which  treatment  was  commenced. 
This  condition  is  most  often  seen  in  women,  and  in  them  the  rash 
quickly  becomes  of  a  rupial  or  gummatous  type,  the  secondary 
manifestations  running  over  into  those  of  the  tertiary  period  at  an 
early  date. 

It  is  probable  that  syphilis  can  be  prevented  by  washing  the  part 
exposed  to  infection  with  a  solution  of  corrosive  sublimate,  and  rub- 
bing in  a  calomel  ointment  (30  per  cent.),  if  such  treatment  is  under- 
taken within  an  hour  or  two  of  infection.  This  has  been  proved 
experimentally  in  apes  and  in  one  carefully  observed  case  in  the 
human  subject.. 

The  Treatment  of  syphilis  consists  in  the  administration  of 
mercury  during  the  primary  and  secondary  stages,  and  of  iodide 
of  potassium,  with  or  without  mercury,  in  the  late  secondary  and 
tertiary  periods. 

Many  different  methods  have  been  suggested  for  the  administration 
of  mercury,  in  order  that  the  patient  may  derive  the  greatest  amount 
of  benefit  from  the  drug  with  the  minimum  of  inconvenience,  [a)  It 
is  often  given  by  the  month,  and  preferably  in  the  form  of  pills, 
composed  of  gray  powder  (grs.  i. — iii.,  t.d.s.),  or  of  the  green  iodide 
(gr.  ^ — i.,  t.d.s.).  Gray  powder  is  perhaps  the  best  means  of  giving  the 
drug  ;  the  patient  should  commence  with  2  grains,  given  three  times 
a  day,  or  in  some  cases  i^  grains  four  times  a  day,  combined  with 
a  little  extract  of  opium  or  pulv.  ipecac,  co.  if  it  causes  diarrhoea  ; 


SPECIFIC  INFECTIVE  DISEASES  157 

but  this  addition  is  not  always  needed.  This  should  be  cautiously 
continued  until  all  prominent  signs  of  the  disease  have  disappeared, 
and  then  the  dose  is  gradually  reduced,  [b)  Inunction  of  the  mercurial 
ointment  is  also  frequently  adopted,  and  with  great  success,  inasmuch 
as  it  is  less  likely  to  cause  digestive  derangements.  If  the  ordinary 
officinal  ointment  is  employed,  a  portion  as  large  as  a  hazel-nut  is 
rubbed  into  the  groin  or  axilla  nightly,  the  part  being  washed  the 
following  morning,  and  not  used  again  for  this  purpose  for  three  or 
four  days  ;  if  the  ointment  is  made  up  with  lanoline,  a  somewhat 
smaller  amount  is  required.  This  is  one  of  the  best  ways  of  bringing 
a  patient  rapidly  under  the  influence  of  the  drug.  At  Aix-la-Chapelle 
and  Harrogate  this  treatment  is  a  speciality,  and  is  combined  with 
the  daily  use  of  sulphur  water  and  baths.  The  mercurial  ointment 
is  rubbed  in  daily  by  the  hand  or  glass  rubbers,  and  the  course  lasts  six 
weeks,  being  repeated  within  the  year,  {c)  Mercurial  vapour  baths  may 
be  advantageously  employed  where  the  cutaneous  eruption  is  very 
extensive.  The  patient  sits  naked  on  a  cane-seated  chair,  and 
covered  with  a  blanket  or  specially  constructed  cloak  reaching  from 
the  neck  to  the  ground,  and  not  touching  the  body  ;  20  or  30  grains 
of  calomel  are  placed  on  a  metal  plate  surrounded  by  a  trough  con- 
taining about  an  ounce  of  water.  The  water  is  boiled,  and  the 
calomel  sublimed,  by  means  of  a  spirit-lamp  placed  under  the  chair. 
In  about  twenty  minutes  all  the  calomel  will  be  volatilized,  and 
deposited  in  part  upon  the  skin  of  the  patient,  who  perspires  freely 
during  the  process.  He  then  gets  into  bed  between  warm  blankets, 
without  wiping  the  skin.  This  treatment  may  be  combined  with 
medication  by  the  mouth,  {d)  The  intramuscular  injection  of  mercurial 
preparations  has  much  to  recommend  it,  and  although  alarmists 
have  emphasized  the  dangers  of  suppuration,  salivation,  and  emboli 
associated  with  it,  yet  increasing  experience  has  proved  it  to  be  safe 
and  efficacious  in  careful  hands,  and  with  due  regard  to  asepsis.  The 
satisfactory  results  following  its  extensive  adoption  by  military 
surgeons  are  strong  arguments  in  its  favour.  Insoluble  preparations 
of  mercury  are  mainly  relied  on,  and  especially  in  the  form  of 
metallic  mercury  suspended  in  a  cream.*  The  dose  is  injected 
deeply  into  the  gluteus  maximus,  and  the  absorption,  if  slow,  is  regular, 
so  that  it  is  little  likely  to  cause  toxic  symptoms. 

During  the  course  of  mercury,  the  patient's  general  health  and 
habits  must  be  carefully  regulated;  alcohol  is  forbidden,  exercise 
limited,  and  strict  instructions  are  given  as  to  keeping  the  teeth  and 
gums  clean.  An  astringent  mouth-wash  containing  alum  and  chlorate 
of  potash  should  be  ordered,  and  it  may  be  necessary  to  remove  or 
stop  diseased  teeth,  but  the  dentist  must,  of  course,  be  informed  of 

*  A  useful  preparation  is  as  follows : 

^  Hydrargyri     . .  . .  . .  . .  . .     gss. 

Adipis  lanae  anhyd.  . .  . .  . .  . .     gii. 

Paraffini  liq.  (carbolized  2  per  cent.)  ad  gv.  (by  volume). 
Finished  product  =  gr.  i.  in  min.  x. 
Min.  X,  as  a  maximum  dose  once  a  week. 

Lambkin  (Brit.  Med.  Jotcrn..  November  11,  1905). 


158  A  MANUAL  OF  SURGERY 

the  nature  of  the  case.  To  minimize  the  risk  of  throat  and  mouth 
trouble,  it  is  wise  to  stop  all  smoking  for  at  least  six  months.  The 
dose  of  mercury  required  varies  in  different  individuals,  being 
increased  in  robust  people,  and  diminished  in  those  who  are  weak  or 
unhealthy.  It  should  always  be  pushed  until  mild  physiological 
effects  are  produced  in  the  shape  of  slight  tenderness  of  the  gums, 
but  salivation  of  the  patient  is  undesirable.  Full  doses  are  usually 
required  for  four  or  five  months,  followed  by  a  milder  course,  which 
should  extend  till  the  end  of  the  first  year.  It  is  advisable,  however, 
to  insist  on  a  three  months'  course  of  mercury  twice  a  year  for 
two  and  a  half  or  three  years. 

Symptoms  of  mercurialism  are  induced  in  some  people  by  very 
small  quantities  of  the  drug,  and  hence  treatment  should  always  com- 
mence with  small  doses.  When  mercury  is  producing  toxic  effects, 
the  gums  become  soft  and  spongy,  and  bleed  readily  on  pressure. 
Salivation  follows,  and  even  acute  glossitis  may  be  produced,  whilst 
the  breath  becomes  offensive.  In  worse  cases  the  teeth  are  loosened, 
and  necrosis  of  the  alveoli  has  followed.  Derangements  of  the 
digestion,  in  the  shape  of  colicky  pain  and  diarrhoea,  are  also 
observed.  The  treatment  of  this  condition  consists  in  suspending 
the  administration  of  the  drug  for  a  time,  and  giving  a  sharp  saline 
purge,  whilst  the  spongy  state  of  the  gums  is  remedied  by  the  use  of 
an  alum  or  chlorate  of  potash  mouth-wash. 

Iodide  of  potassium  is  essential  in  the  treatment  of  the  tertiary 
and  intermediate  stages.  It  appears  probable  that  its  chief  action 
is  the  removal  of  gummatous  tissue,  and  that  it  has  little  influence 
upon  the  causative  disease ;  in  order  to  prevent  recurrence,  mercury 
is  still  required.  The  dose  of  iodide  should  not  exceed  5  grains 
to  start  with,  and  is  gradually  increased  until  in  some  cases  i  drachm 
four  times  a  day  has  been  reached.  Plenty  of  water  should  always 
be  taken  immediately  afterwards  to  assist  in  its  dilution  and  facilitate 
its  absorption.  A  feeling  of  depression  and  sinking  at  the  epigastrium 
is  sometimes  produced,  but  may  be  alleviated  by  the  addition  to  the 
mixture  of  sal  volatile  (n\xv.)  or  carbonate  of  ammonia,  as  suggested 
by  the  late  Sir  James  Paget,  Symptoms  of  coryza  often  follow,  and 
an  acneiform  eruption  over  the  shoulders  and  face,  which  may 
disappear  on  increasing  the  dose.  Occasionally  a  vesicular,  or  even 
bullous,  rash  is  caused  by  this  drug.  When  large  doses  are  given, 
bicarbonate  of  soda  or  potash  must  be  combined  with  it,  in  order  to 
prevent  its  decomposition  by  the  gastric  juice.  If  mercury  is 
required,  it  is  better  to  give  it  in  the  form  of  gray  powder  than  to 
add  liquor  hyd.  perchlor.  to  the  iodide  in  a  mixture,  as  the  latter 
usually  disturbs  the  digestion.  Other  drugs,  such  as  sarsaparilla, 
arsenic  and  iron,  are  often  combined  with  iodide  of  potassium  in  the 
later  stages  of  the  disease,  and  may  be  useful. 

The  recognition  of  the  protozoal  origin  of  syphilis  and  its  kinship 
with  other  similar  diseases,  such  as  sleeping  sickness,  has  led  during 
the  last  few  years  to  many  attempts  to  treat  it  with  organic  prep- 
arations of  arsenic  of  the  arylarsonate  type,  of  which  group  atoxyl, 


SPECIFIC  INFECTIVE  DISEASES  159 

soamin,  arsacetin,  and  orsudan  are  examples.  Some  good  results 
were  obtained,  but  the  majority  were  disappointing,  and  some  disas- 
trous, inasmuch  as  the  prolonged  use  of  such  drugs  was  found  to  be 
followed  by  toxic  phenomena,  amongst  which  optic  nerve  atrophy 
was  one  of  the  most  serious.  Experiments  in  this  direction  were 
still  maintained  by  Ehrlich  and  Hata,  and  finally  they  introduced  a 
substance  now  known  as  salvarsan,  or  '  606 '  (dioxy-diamido-arseno- 
benzol),  which  seems  to  hold  out  a  brilliant  future  in  the  treatment 
of  this  dread  disease.  It  is  a  bright  yellow  powder,  slowly  soluble 
■  in  water,  and  strongly  acid  in  reaction.  It  may  be  administered  by 
intravenous  or  intramuscular  injection,  preferably  the  former.  The 
dose  for  an  adult  varies  from  0-3  to  o-6  gramme,  which  is  dissolved 
in  sterile  normal  saline  solution,  made  with  distilled  water.  It  is  then 
converted  into  a  sodium  salt  of  the  base  by  adding  a  sufficient 
quantity  of  15  per  cent,  solution  of  sodium  hydrate  to  re-dissolve  the 
precipitate  formed  when  it  is  first  added.  This  solution  is  then 
made  up  to  250  or  300  c.c.  with  saline  solution,  and  introduced  into 
one  of  the  veins  of  the  arm  at  the  body  temperature.  The  patient 
should,  if  possible,  be  prepared  as  for  an  operation.  The  administra- 
tion is  often  followed  by  pyrexia  for  a  day  or  two,  and  sometimes  by 
vomiting,  rigors,  headache,  or  pains  in  the  limbs,  but  with  rest  in  bed 
for  forty-eight  hours  these  disappear.  Intramuscular  injections  are 
followed  by  much  local  pain  and  tenderness,  and  even  sloughing  of 
the  surrounding  tissues  has  been  recorded.  This  type  of  treatment 
is  still  in  the  experimental  stage,  so  that  one  cannot  dogmatize  too 
precisely  as  to  its  future.  Thus  far  it  appears  to  be  free  from 
harmful  toxic  effects.  That  it  is  capable  of  destroying  the  spiro- 
chaetes  in  the  blood,  and  in  the  effusions  of  the  body,  seems  un- 
doubted, and  brilliant  results  sometimes  follow  its  administration  in 
the  secondary  and  early  tertiary  stages.  The  primary  sore  is  not 
very  quickly  modified  by  it,  but  heals  and  disappears  in  about  a 
fortnight;  secondary  eruptions  may  show  .signs  of  fading  away 
within  twenty-four  hours,  and  tertiary  phenomena  of  the  gummatous 
type  may  heal  up  in  quite  a  short  time.  On  the  other  hand,  late 
tertiary  manifestations  of  the  sclerosis  type,  such  as  are  seen  in  the 
nervous  system,  are  not  affected  by  it  appreciably. 

The  Local  Treatment  of  syphilitic  sores  consists  mainly  in  the 
application  of  various  preparations  of  mercury.  The  primary,  chancre 
is  usually  treated  with  lotio  nigra  on  lint,  iodoform  being  sometimes 
employed  if  septic  ulceration  is  present.  Mucous  tubercles  in  the 
neighbourhood  of  the  anus  or  vulva,  or  between  the  toes,  are  best 
dealt  with  by  keeping  them  scrupulously  dry  and  clean  and  dusting 
them  over  with  powdered  calomel  and  starch,  or  by  the  application 
of  calomel  ointment,  a  piece  of  lint  being  inserted  between  opposing 
surfaces  to  keep  them  from  rubbing  one  against  the  other.  Secondary 
ulceration  of  the  throat  does  not  usually  require  local  treatment,  as 
it  soon  disappears  under  the  influence  of  mercury.  A  mercurial 
gargle  may,  however,  be  employed,  or  in  bad  cases  the  affected 
parts   should  be   painted   with   glyc.   hyd.  perchlor.    (i     in    2,000). 


i6o  A   MANUAL  OF  SURGERY 

Superficial  gumniatotis  ulcers  are  treated  by  removing  the  scabs,  and 
applying  some  form  of  mercurial  ointment.  A  determined  attempt 
should  be  made  to  keep  deep  gummatous  ulcers  in  an  aseptic  condi- 
tion, since  the  advent  of  sepsis  to  such  sores,  especially  if  they  are 
connected  with  bones,  makes  a  marked  difference  in  their  progress. 
In  neglected  cases  the  wound  may  become  exceedingly  foul,  and  in 
chronic  cases  a  hectic  temperature  and  amyloid  degeneration  of  the 
viscera  have  been  observed.  When  gummata  come  to  the  surface 
and  point,  they  should  be  opened  with  the  same  precautions  as  are 
adopted  in  the  case  of  an  abscess,  and  either  dressed  antiseptically 
or  their  cavity  packed  with  sterilized  lint  or  gauze  soaked  in 
sterilized  lotio  nigra. 

Inherited  Syphilis. 

The  offspring  of  syphilitic  parents  often  fails  to  arrive  at  maturity, 
the  mother  miscarrying  at  the  end  of  six  or  seven  months.  The 
child  may  be  well  formed,  and  may  even  live  independently  for  a 
short  while,  but  not  unfrequently  it  is  dead,  and  in  many  cases 
macerated  ;  under  these  circumstances  the  tissues  of  the  body  are 
often  swarming  with  spirochaetes  (Fig.  28).  The  miscarriage  may 
be  repeated  for  several  pregnancies,  and  then  a  living  child  is 
produced.  In  other  instances,  however,  a  living  child  is  born  at 
full  term  at  the  end  of  the  first  pregnancy  in  spite  of  the  syphilitic 
infection  of  the  parents.  This  child  may  show  evidences  of  the 
disease  at  birth,  but  more  frequently  appears  to  be  healthy,  specific 
manifestations  not  showing  themselves  for  some  weeks. 

Much  discussion  has  arisen  in  the  attempt  to  explain  these 
phenomena,  and  also  as  to  the  relative  frequency  of  infection  by  the 
father  and  mother.  Theoretically,  infection  may  occur  at  one  of 
three  periods :  [a)  At  impregnation  the  disease  may  be  conveyed 
by  one  or  both  parents,  either  the  ovum  or  spermatozoon,  or  both, 
carrying  the  spirochaetes.  The  discovery  of  the  organism  in  the 
semen  of  apes  suggests  the  likelihood  of  its  presence  in  human 
semen,  although  this  has  not  yet  been  actually  demonstrated. 
Infection  ah  initio  is  likely  to  be  followed  by  a  general  development 
in  the  tissues,  and  possibly  the  cases  where  the  mother  aborts  early 
and  produces  a  dead  foetus  infiltrated  with  spirochaetes  belongs  to 
this  type,  {h)  During  the  pregnancy  infection  of  the  foetus  may 
occur  through  a  specific  infection  of  the  endometrium,  especially 
involving  that  portion  of  the  decidua  which  enters  into  the  formation 
of  the  placenta.  As  a  general  rule  the  foetal  and  maternal  circulations 
do  not  commingle,  but  when  the  placenta  is  diseased  it  is  easy  to 
understand  that  the  spirochaetes  might  pass  from  mother  to  foetus, 
(c)  It  is  possible  that  infection  may  be  delayed  until  parturition,  the 
organisms  then  finding  their  way  from  the  separating  placenta 
through  the  umbilical  vein.  Such  an  occurrence  might  explain  the 
delay  of  symptoms  in  the  infant  for  some  weeks  after  birth,  although 
po.ssibly   this   is   due    to   a   removal  of   toxins   into   the   maternal 


SPECIFIC  INFECTIVE  DISEASES  i6i 

circulation  during  pregnancy,  so  that,  although  the  foetus  is  iniected, 
symptoms  are  kept  in  abeyance.  In  this  connection  it  is  interesting 
to  note  that,  although  infective  lesions  may  be  present  in  the  maternal 
passages,  primary  chancres  are  not  seen  in  infants ;  they  are  pre- 
sumably protected  either  by  a  previous  infection  or  by  the  presence 
of  the  vernix  caseosa. 

In  some  cases  the  mother  has  shown  no  obvious  evidence  of 
syphilis,  and  yet  is  able  to  suckle  her  child  without  harm,  even 
though  there  are  ulcerating  lesions  on  the  child's  gums  and  lips, 
whereas  a  healthy  wet-nurse  develops  a  chancre  of  the  nipple. 
This  is  known  as  Colks's  Law,  and  was  first  stated  by  him  in  1837. 
The  immunity  of  the  mother  under  these  circumstances  was  formerly 
attributed  to  the  production  of  antibodies  in  the  foetus  and  trans- 
mission to  the  maternal  blood ;  but  the  researches  of  Neisser  on  the 
higher  apes  has  shown  that  the  serum  of  a  syphilitic  subject  contains 
neither  protective  nor  curative  substances,  and  it  is  therefore 
probable  that  the  maternal  immunity  is  due  to  a  mild  and  un- 
recognised infection  with  the  disease  itself. 

Pvofetas  Law  is  the  reverse  of  Colles's,  and  asserts  that  the  child 
of  a  syphilitic  mother  or  father  is  immune  to  syphilis,  although  it 
has  never  presented  evidences  of  infection  with  the  disease.  In  the 
light  of  modern  research  it  seems  extremely  probable  that  this  is 
not  true. 

The  length  of  time  during  which  a  patient  retains  the  power  of 
transmitting  the  disease  to  the  foetus  is  an  exceedingly  difficult  point 
to  determine,  and  one  which  is  constantly  coming  before  the  practi- 
tioner, who  is  asked  to  decide  at  what  period  it  is  safe  for  a  syphilitic 
patient  to  marry.  The  rule  of  practice  generally  followed  is  that  no 
one  suffering  from  syphilis  should  be  allowed  to  marry  until  he  or 
she  has  been  free  from  all  symptoms  for  two  years,  and  even  then 
it  is  advisable  that  a  mild  course  of  mercury  should  be  given  for 
about  three  months  shortly  before  marriage. 

The  question  of  transmission  to  the  third  generation  is  one  of 
much  interest,  concerning  which  a  good  deal  of  conflicting  evidence 
has  been  forthcoming.  The  dependence  of  this  disease  upon  a 
recognised  organism,  which  it  has  been  possible  to  demonstrate  in 
late  tertiary  stages,  is  presumptive  evidence  in  favour  of  its  trans- 
missibility ;  but  naturally,  one  of  the  chief  difficulties  is  the  demon 
stration  of  the  sexual  purity  of  the  second  generation.  Further 
evidence  of  an  assured  character  on  this  point  is  much  needed. 

At  birth  the  child  often  appears  healthy  and  well  nourished,  but 
is  sometimes  small  and  imperfectly  developed.  The  first  definite 
symptoms  of  the  disease  manifest  themselves  at  a  variable  period, 
extending  from  three  weeks  to  three  months,  after  birth  ;  the  child 
becomes  thin  and  emaciated ;  the  skin,  which  hangs  in  wrinkles 
over  the  body,  changes  to  a  dull  earthy  colour,  whilst  the  features 
looked  pinched  and  wizened,  like  those  of  an  old  man.  Marked 
anaemia  is  always  present,  and  may  persist  for  a  considerable  time. 
Speaking  generally,  the  symptoms  of  inherited  syphilis  are  similar 


1 62 


A  MANUAL  OF  SURGERY 


to  those  of  the  acquired  disease,  except  that  the  primary  lesion  is 
absent.  Thus,  during  the  first  year  of  life  the  child  develops  various 
cutaneous  eruptions,  mucous  tubercles,  and  superficial  ulceration 
of  the  mucous  membranes.  A  dusky  red  roseola,  especially  about 
the  nates  (napkin  area),  may  first  be  noticed,  but  does  not  last  long. 
This  is  usually  followed  by  the  appearance  of  mucous  tubercles  at 
the  angles  of  the  mouth,  in  the  nose,  and  around  the  anus,  as  also  in 
the  moist  folds  of  the  groin,  and  between  the  scrotum  and  thigh. 
The  sores  on  the  lips  are  sometimes  very  marked,  giving  rise  to 
ulcerated  surfaces,  which,  by  their  subsequent  cicatrization,  leave 
radiating  scars  (or  rhagades),  especially  about  the  angles  of  the 
mouth   (Fig.  34).     Other  cutaneous  affections,   such  as  squamous 


Fig.  34.— Child  WITH  Inherited  Syphilis,  showing  Radiating  Scars  round 
THE  Mouth.     (From  a  Photograph  kindly  lent  by  Dr.  G.  F.  Still.) 

syphilides  of  the  soles  of  the  feet,  together  with  papular  syphilides 
of  the  body,  and  a  bullous  eruption  becoming  pustular  (pemphigus), 
are  also  observed,  the  last  mentioned,  however,  only  occurring  in 
debilitated  infants.  A  catarrhal  rhinitis  is  a  very  early  and  constant 
manifestation,  giving  rise  to  obstructed  nasal  respiration,  or  snuffles. 
This  affection  is  often  protracted,  going  on  to  ulceration  and 
destruction  of  the  nasal  bones  and  cartilages ;  their  subsequent 
development  is  thus  prevented  or  impaired,  and  hence  the  bridge  of 
the  nose  remains  depressed  and  sunken,  even  when  adult  life  is 
reached  (Fig.  35).  Enlargement  of  the  spleen  and  liver  is  also 
common. 

Many  infants  during  the  first  year  of  life  die  from  malnutrition  or 


SPECIFIC  INFECTIVE  DISEASES 


163 


marasmus ;  but  if  properly  treated  a  considerable  proportion  regain 
their  health  within  six  or  eight  months,  all  the  manifestations 
described  above  disappearing,  although  their  scars  may  remain. 
The  child's  subsequent  development  is  frequently  impaired,  and  it 
often  retains  an  almost  pathognomonic  facies. 

After  the  first  year,  any  of  the  tertiary  phenomena  which  appear 
in  acquired  syphilis  may  develop,  but,  in  addition  to  these,  peculiar 
manifestations  may  be  produced,  especially  affecting  the  teeth,  bones, 
and  cornea ;  deafness  from  disease  of  the  internal  ear  is  also  not 
uncommon. 

The  Teeth  in  inherited  syphilis  are  sometimes  very  characteristic. 


Fig.  35. — Head  and  Face  of  a  Patient  with  Inherited  Syphilis,  showing 
Depressed  Bridge  of  Nose  and  Frontal  Bosses.     (From  a  Photograph.) 

The  temporary  teeth  usually  appear  early,  are  discoloured,  and 
crumble  away.  The  permanent  teeth  are  often  sound  and  healthy, 
but  are  sometimes  deformed.  The  central  incisors  of  the  upper  jaw 
are  those  most  particularly  affected,  but  the  upper  laterals  and  the 
incisors  of  the  lower  jaw  may  also  be  involved.  Instead  of  being 
broader  at  the  crown  than  at  the  root,  they  diminish  in  size  from 
root  to  crown,  being  stunted,  and  separated  from  one  another  by 
interspaces.  The  angles  of  the  crown  are  rounded  off,  and  a  distinct 
notch,  forming  a  large  segment  of  a  small  circle,  occupies  the  centre 
(Fig.  36).  The  enamel  is  often  imperfectly  developed,  and  hence  they 
decay  early.  Occasionally  they  may  be  shaped  like  a  screw-driver, 
narrowing  from   root    to   crown,  and  with  a  straight  free   border. 


i64  A  MANUAL  OF  SURGERY 

The  notched  and  stunted  teeth  described  above  are  sometimes 
known  as  '  Hutchinson's  teeth,'  but  they  are  not  very  commonly 
seen  at  the  present  day. 

The  Bone  affections  observed  in  inherited  syphiHs  will  be  described 
in  Chapter  XX. 

Interstitial  Keratitis,  or  diffuse  inflammation  of  the  cornea,  usually 
occurs  about  the  age  of  puberty,  or  earlier.  It  is  limited  at  first  to 
one  eye,  but  the  other  is  almost  certain  to  be  yimilarly  affected  at  a 
later  date.  It  commences  as  a  diffuse  haziness  of  the  cornea,  which 
looks  somewhat  like  ground  glass,  associated  with  hyperaemia  of  the 
ciliary  region.  Red  areas,  or  '  salmon  patches,'  may  be  produced  in 
the  midst  of  the  opacity,  due  to  a  new  formation  of  minute  vessels. 
There  is  no  tendency  to  ulceration,  but  in  protracted  cases  the 
anterior  part  of  the  eye  may  bulge  forwards,  constituting  a  condition 
known  as  '  anterior  staphyloma.'  The  inflammation  may  spread  to 
the  iris  and  ciliary  body.  With  suitable  precautions  the  cases  usually 
do  well,  although  treatment  for  several  years  may  be  necessary,  and 
some  corneal  opacity  may  persist. 


FiG,  36. — Hutchinson's  Teeth  in  Inherited  Syphilis. 

The  Treatment  of  inherited  syphilis  should  commence  as  soon  as 
definite  manifestations  of  the  disease  are  present.  The  general  health 
must  be  attended  to,  and  if  the  mother  is  unable  to  nurse  the  child, 
it  must  be  brought  up  by  hand ;  on  no  account  must  it  be  given  to 
a  wet-nurse.  Mercury  is  best  administered  by  anointing  the  under 
surface  of  the  flannel  belly-band  with  mercurial  ointment,  or  the 
same  preparation  may  be  rubbed  into  the  soles  of  the  feet  every 
night.  This  should  be  continued  until  all  secondary  phenomena 
have  disappeared,  and  advisably  until  the  child  is  a  year  old.  Cod- 
liver  oil  may  also  be  ordered  with  advantage  in  some  cases.  When 
tertiary  symptoms  appear,  iodide  of  potassium  and  mercury  should 
be  given  in  suitable  doses. 

The  local  treatment  of  external  lesions  is  conducted  according  to 
the  rules  laid  down  for  the  acquired  type  of  the  disease. 

Tuberculosis. 

By  tuberculosis  is  meant  a  condition  resulting  from  the  develop- 
ment within  the  tissues  of  the  body  of  certain  definite  anatomical 
structures,  known  as  tubercles,  and  caused  by  the  growth  and 
activity  of  the  Bacillus  tuheymlosis. 


SPECIFIC  INFECTIVE  DISEASES  165 

etiology.— I.  It  is  more  than  doubtful  whether  heredity  plays  such 
an  important  part  as  was  formerly  attributed  to  it  in  the  develop- 
ment of  this  disease,  which  is  much  more  commonly  due  to  direct 
infection.  Considerable  ingenuity  has  been  exercised  in  describing 
various  types  of  physiognomy  supposed  to  be  characteristic  of  a 
tuberculous  inheritance,  and  although  not  always  present,  these 
appearances  are  sometimes  observed.  Two  chief  varieties  are 
described,  viz.,  the  sanguine  and  the  phlegmatic.  In  the  former,  the 
individual  is  slight  and  well  proportioned,  possessing  a  thin,  delicate 
skin,  ofton  freckled,  and  so  transparent  that  the  subcutaneous  veins 
are  readily  seen.  The  hair  is  fine  and  auburn-coloured,  or  even 
reddish,  the  conjunctivae  are  thin  and  pearly,  the  eyelashes  well 
developed,  and  the  fingers  long  and  tapering.  Such  children  are 
usually  excitable  and  precocious  in  their  habits,  and  possess  taking 
manners.  The  phlegmatic  type  is  characterized  by  a  short,  stunted 
stature,  often  with  coarse  features,  and  strong  though  somewhat 
short  limbs.  The  skin  is  thick  and  muddy-looking,  the  lips 
full,  the  hair  rough  and  brown.  In  children  of  either  type  there  is 
a  considerable  tendency  to  the  development  of  eczema,  inflamma- 
tion of  the  mucous  membranes,  and  a  subacute  enlargement  of  the 
lymphatic  glands,  all  of  which  are  simple  in  nature,  but  may 
constitute  a  suitable  nidus  for  the  development  of  tubercle,  especially 
if  the  child  is  run  down  by  some  preceding  illness,  such  as  measles 
or  scarlet  fever.  They  also  suffer  frequently  from  cracked  lips,  and 
as  a  result  of  the  irritation  caused  thereby  considerable  infiltration 
and  thickening  may  follow.  Although  tuberculous  disease  is  most 
frequently  seen  in  young  people  or  children,  no  age  is  exempt  from 
its  attacks,  even  elderly  persons  being  affected.  These  senile  mani- 
festations differ  in  no  way  from  those  met  with  in  the  young. 

2.  Unhealthy  surroundings  and  had  hygiene  certainly  predispose  to  its 
development ;  hence  it  is  seen,  perhaps,  in  its  severest  forms  amongst 
the  poor,  although  it  is  only  too  common  in  the  well-to-do,  arising 
usually  from  improper  feeding  and  want  of  fresh  air  in  the  case  of 
children,  and  not  unfrequently  from  faulty  hygiene  or  carelessness, 
especially  as  to  judicious  clothing,  in  adults. 

3.  A  local  nidus  suitable  for  the  development  of  the  micro-organism 
usually  exists,  although  tuberculous  infection  occasionally  follows 
wounds  and  punctures  in  previously  healthy  parts.  Thus,  as  already 
mentioned,  chronically  inflamed  lymphatic  glands  form  a  suitable 
breeding-ground  for  the  bacillus,  as  also  bones  and  joints  in  a 
state  of  congestion  resulting  from  slight  and  often  overlooked 
injuries. 

4.  The  ultimate  exciting  cause  of  tuberculosis  is  the  development 
within  the  tissues  of  the  B.  tubercidosis  of  Koch  (Plate  II.,  Fig.  22). 
It  usually  occurs  in  the  form  of  slender  rods,  which  are  straight  or 
slightly  curved.  They  are  usually  about  4  or  5  /;i  in  length  and 
0-2  or  0-3  fj.  wide,  but  sometimes  they  form  long  branched  filaments, 
especially  in  cultures.  These  characters  differentiate  them  strongly 
from  most  bacilli,  and  have  led  to  the  opinion  that  the  organism  is  in 


[66  A  MANUAL  OF  SURGERY 

reality  allied  to  the  streptothrices,  and  probably  several  members  of 
this  group  may  produce  the  disease.  This  is  interesting  in  view  of 
the  close  clinical  resemblance  between  tuberculosis  and  the  other 
diseases  due  to  streptothricial  infections  (the  so-called  actinomycosis). 
The  tubercle  bacillus  is  a  typical  acid-fast  organism,  and  when 
stained  by  Ziehl-Nielsen's  method  appears  in  the  form  of  slender 
pink  rods,  which  are  often  stained  only  in  part,  so  that  they  seem  to 
consist  of  short  red  lengths  alternating  with  unstained  areas,  the 
whole  looking  not  unlike  a  chain  of  very  minute  streptococci.  In 
vitro  they  develop  very  slowly,  two  or  three  weeks  elapsiug  before 
growth  is  visible,  and  require  a  temperature  approaching  that  of  the 
body  and  an  abundant  supply  of  oxygen.  Many  culture  media  are 
available,  and  all  are  improved  by  the  addition  of  3  or  4  per  cent,  of 
glycerine.  The  colonies  consist  of  yellowish,  white,  or  gray  scales, 
which  have  a  dryish  look.  The  tubercle  bacillus  does  not  liquefy 
blood  -  serum  ;  it  is  non-motile,  has  no  flagella,  and  is  not  known  to 
possess  spores. 

The  question  of  the  identity  of  human  and  bovine  tuberculosis 
raised  by  Koch  is  still  undecided.  Both  can  apparently  cause 
tuberculosis  in  human  beings,  but  it  seems  probable  that  the  bovine 
variety  is  mainly  responsible  for  intestinal  and  surgical  forms  of  the 
disease,  whilst  the  human  variety  leads  to  pulmonary  phthisis  and  the 
acute  miliary  form.  That  there  is  a  distinction  appears  likely  from 
the  fact  that  the  former  are  more  amenable  to  vaccine  treatment 
than  the  latter. 

The  organism  gains  access  to  the  body  in  one  or  other  of  the 
following  ways : 

(a)  Most  commonly  by  inhalation.  Tubercle  bacilli  are  present  in 
vast  numbers  in  the  sputum  of  consumptives,  and,  as  drying  does 
not  immediately  kill  them,  they  frequently  occur  in  the  dust  and  in 
the  air.  More  important  still  is  the  fact  that  in  coughing  and  talking 
the  tuberculous  material  is  expelled  in  a  state  of  very  fine  division, 
and  the  infective  particles  remain  suspended  in  the  air  for  long 
periods.  Tuberculosis  acquired  by  inhalation  usually  manifests  itself 
in  the  form  of  pulmonary  disease,  but  may  appear  as  a  primary 
affection  of  the  bronchial  glands,  from  which  the  infection  may  be 
disseminated  to  other  organs.  The  bacilli  may  also  lodge  on  or  in  the 
crypts  of  the  tonsils,  and  cause  tuberculosis  of  the  glands  in  the  neck, 
but  this  probably  occurs  more  often  when  the  infection  is  carried  by 
the  food. 

(b)  By  ingestion — e.g.,  of  infected  milk  from  cows  with  tuberculous 
disease  of  the  udders.  This  is  by  no  means  rare  in  children,  and 
usually  manifests  itself  in  primary  tuberculosis  of  the  intestines  or 
abdominal  lymph  glands.  It  should  be  remembered  that  these 
lesions  may  also  be  caused  by  swallowing  tuberculous  sputum. 

(c)  By  inoculation.  This  is  very  unusual,  and  occurs  chiefly  in 
pathologists,  post-mortem  room  porters,  etc.,  in  the  form  of  a  verruca 
necrogenica  (p.  246).  A  few  cases  of  tuberculous  infection  from  an 
accidental  cut  inflicted  by  a  broken  sputum  cup  havft  been  recorded. 


SPECIFIC  INFECTIVE  DISEASES  167 

The  laboratory  diagnosis  of  tuberculosis  is  conducted  on  one  or 
other  of  the  following  lines  : 

1.  By  the  microscopic  identification  of  the  tubercle  bacillus,  e.g., 
in  the  sputum.  Films  are  stained  by  the  Ziehl-Nielsen  method, 
and  searched  for  the  characteristic  rods.  This  is  sufficient  when 
bacilli  are  present  in  large  numbers,  but  when  this  is  not  the  case 
(as  frequently  happens  in  the  urine,  pus,  pleuritic  fluids,  etc.)  it  is 
necessary  to  have  recourse  to — 

2.  Inoculation  of  susceptible  animals,  especially  guinea-pigs, 
which  is  a  most  delicate  test.  The  material  is  usually  inserted 
beneath  the  skin  of  the  groin,  and  the  animal  killed  in  three  weeks, 
when  the  lymph  glands  and  probably  the  internal  organs  will  be 
found  tuberculous, 

3.  Tuberculous  exudates  differ  from  most  others  in  that  the  cell 
which  occurs  most  abundantly  is  the  lymphocyte,  and  this  fact  is 
made  use  of  in  the  examination  of  pleuritic  and  peritoneal  exudates, 
the  fluid  obtained  by  lumbar  puncture  of  the  spinal  meninges,  etc. 
It  is  useful,  but  must  not  be  regarded  as  an  absolute  test. 

4.  In  some  cases  a  portion  of  the  lesion  may  be  excised  and 
submitted  to  microscopic  examination,  which  should  include  a 
search  for  bacilli,  since  other  infections  may  give  rise  to  lesions 
indistinguishable  microscopically  from  tuberculosis.  It  is  still 
better  to  inoculate  a  portion  of  the  tissue  into  a  guinea-pig. 

5.  Tuberculin  is  a  solution  of  the  substances  given  off  by  the 
tubercle  bacillus  when  grown  in  glycerine  broth.  When  injected 
into  a  normal  person,  it  produces  no  effect,  but  in  tuberculous 
persons  a  sharp  rise  of  temperature  occurs  in  a  few  hours.  The 
test  is  not  altogether  devoid  of  danger,  and  should  never  be  used 
unless  one  is  certain  of  the  absence  of  a  secondary  infection,  e.g., 
with  streptococci.  In  a  modified  form  of  the  reaction  (Calmette's) 
a  drop  or  two  of  diluted  tuberculin  (i  in  100  or  i  in  200)  is  dropped 
into  the  conjunctival  sac.  In  tuberculous  patients  this  is  followed 
by  mild  conjunctivitis,  which  commences  in  a  few  hours,  and  has 
usually  passed  off  in  twenty-four.  The  test  is  by  no  means  devoid 
of  danger,  cases  of  severe  conjunctivitis,  corneal  ulceration,  and 
even  loss  of  the  eye,  having  followed  its  use.  A  safer  procedure  is 
that  known  as  '  Von  Pirquet's  skin  reaction,'  which  is  apparently 
free  from  danger.  It  consists  in  inoculating  a  small  superficial 
scratch  with  a  drop  of  20  or  25  per  cent,  tuberculin.  The  reaction 
consists  in  the  development  in  from  twenty-four  to  forty-eight  hours 
of  a  small  papule  surrounded  by  a  ring  of  hyperaemia.  This  test 
is  certainly  of  great  value  in  children  up  to  twelve  years  of  age, 
but  of  course  the  tuberculous  deposit  may  be  of  a  quiescent 
character.  A  previous  injection  of  tuberculin  within  a  few  days 
causes  the  reaction  to  be  less  marked  and  to  run  a  more  rapid 
course. 

6.  The  opsonic  index  is  sometimes  of  value  in  dignosis  (see  p.  25). 
In  a  healthy  individual  it  ranges  between  o-8  and  1-2,  and  figures 
above  or  below  that  limit  are  highly  suggestive  ;  whilst  considerable 


168  A  MANUAL  OP  SURGERY 

variations,  even  from  day  to  day,  are  very  characteristic  of  pro- 
gressive tuberculosis. 

Pathological  Anatomy. — The  characteristic  lesion  is  the  miliary 
tubercle,  a  cellular  mass  2  or  3  millimetres  in  diameter,  and  when, 
isolated,  readily  visible  to  the  naked  eye.  When  young  and  in 
course  of  active  evolution,  tubercles  are  soft,  translucent,  and  of  a 
gray  colour  ;  after  a  time  they  undergo  fatty  degeneration  and  become 
yellowish  and  opaque.  It  is  often  impossible  to  recognise  them 
macroscopically,  since  when  closely  set  they  fuse  together. 

The  minute  structure  can  be  best  understood  by  the  examination  of 
a  typical  fully-formed  tubercle  which  has  not  begun  to  undergo 
retrogressive  changes ;  and  this  is  most  readily  observed  in  sections 
from  the  meninges  in  tuberculous  meningitis,  or  from  the  liver  or 
kidney  in  a  case  of  general  tuberculosis.  In  the  centre  of  the  mass 
there  is  a  giant  cell*  (Fig.  37),  the  diameter  of  which  may  be  many 
times  that  of  a  red  blood  corpuscle.  It  has  usually  an  oval  or 
circular  shape,  and  its  outline  is  regular  ;  it  has  many  oval  nuclei, 
and  these  are  arranged  round  the  periphery  of  the  cell,  their  long 
axis  lying  in  a  radial  direction.  Around  the  giant  cell  there  is 
a  zone  of  endothelioid  cells,  usually  oval  in  shape,  and  rather  larger 
than  a  leucocyte.  Each  has  a  single  nucleus,  which  has  a  close 
resemblance  to  one  of  the  nuclei  of  the  giant  cell.  Around  this  zone 
there  comes  the  third,  or  outer  one,  which  is  composed  of  small 
round  inflammatory  cells,  which  appear  to  be  identical  with 
lymphocytes.  It  must  be  understood  that  all  tubercles  do  not 
conform  exactly  to  this  typical  description.  The  giant  cell,  for 
example,  is  frequently  missing,  especially  in  acute  cases,  or  there 
may  be  several  cells  of  this  type,  though  this  is  unusual.  Moreover, 
the  width  of  the  zones  varies  greatly ;  in  some  cases  the  endothelioid 
cells  may  appear  to  be  absent,  but  can  be  detected  mixed  up  with  the 
lymphocytes,  which  extend  to  the  centre  of  the  tubercle. 

It  must  be  clearly  understood  that  a  '  tubercle  '  in  the  histological  sense  is  not 
peculiar  to  tuberculosis,  in  the  sense  of  a  disease  due  to  the  tubercle  bacillus. 
It  is  simply  the  reaction  of  the  tissues  to  an  irritant  of  comparatively  feeble 
activity.  Thus  it  occurs  in  actinomycosis  (see  Fig.  41,  where  a  typical  histo- 
logical tubercle  is  shown  surrounding  a  colony  of  actinomyces),  and  may  be 
produced  by  an  unabsorbed  ligature,  irritants,  such  as  grains  of  pepper,  etc. 
Hence  it  is  not  always  safe  to  make  a  diagnosis  of  tuberculosis  from  an  examina- 
tion of  sections,  unless  the  characteristic  bacilli  are  demonstrated 

The  development  of  a  tubercle  is  not  yet  fully  understood.  The 
bacilli  appear  to  gain  access  to  a  lymph  space  or  to  a  small  vessel, 

*  It  may  be  well  to  notice  here  that  three  forms  of  giant  cells  occur  patho- 
logically, and  are  of  very  different  significance :  (i)  Those  described  above  (the 
tubarculous  type),  having  their  nuclei  arranged  around  the  periphery  of  the  cell ; 
(2)  Myeloplaxes,  which  occur  in  myeloid  sarcomata,  and  have  many  nuclei 
grouped  irregularly  round  the  centre  of  the  cell ;  (3)  Parenchymatous  giant  cells 
occurring  in  the  substance  of  tumours,  especially  sarcomata  and  carcinomata. 
These  have  usually  a  single  nucleus,  or  at  most  a  few,  which  may  be  of  large 
size  and  have  no  definite  arrangement. 


Fig    37. — Miliary  Tubercle  with  Giant  Cell,     (x  120.) 


»-s>^^ 


H 


Fig.   38.— Early  Stage  of  Tuberculous  Abscess  in  Lymphatic  Gland. 

(X30.) 

In  the  centre  is  a  caseating  focus  on  the  point  of  suppuration  ;  outside  it,  granu- 
lation tissue,  in  which  several  giant  cells  can  be  seen  ;  and  external  to  this  a 
zone  of  fibro-cicatricial  tissue. 


SPECIFIC  INFECTIVE  DISEASES  171 

where  they  set  up  an  overgrowth  of  the  endotheUal  elements,  and, 
as  always  happens  when  they  become  inflamed,  the  endothelial  cells 
become  oval  or  spherical,  and  of  large  size  ;  these  constitute  the 
endothelioid  cells  of  the  middle  zone.  The  giant  cells  appear  to  be 
composed  of  a  mass  of  these  cells,  in  which  the  nuclei  have  under- 
gone repeated  divisions,  but  the  protoplasm  has  remained  unseg- 
mented.  The  source  of  the  lymphocytes,  and  whether  they  are 
produced  locally  or  attracted  from  the  blood-stream,  has  been  hotly 
debated.  Probably  they  are  formed  locally,  perhaps  by  a  process 
of  budding  from  pre-existing  endothelial  cells. 

Miliary  tubercles  may  be  embedded  in  practically  normal  tissues, 
but  in  most  cases  an  inflammatory  process  can  be  traced  beyond 
the  nodules.  It  may  be  of  a  chronic  type,  with  an  increased  forma- 
tion of  fibrous  tissue  ;  but  in  the  more  active  forms  the  intervening 
structures  disappear,  being  replaced  by  granulation  tissue,  which  is 
often  oedematous  and  of  a  gelatinous  appearance.  This  latter  is 
especially  frequent  in  tuberculosis  of  the  bones  and  joints.  The 
inflammation  also  involves  the  smaller  vessels,  and  particularly 
the  arterioles,  the  lumina  of  which  may  become  greatly  narrowed,  or 
even  entirely  obliterated,  by  a  process  of  endarteritis.  The  vessel 
wall  becomes  infiltrated  with  leucocytes,  which  collect  in  the  sub- 
endothelial  layer,  and  become  mixed  with  fibroblasts,  the  origin 
of  which  is  uncertain ;  this  cellular  mass  gradually  undergoes 
organization,  layers  of  fibrous  tissue,  concentric  with  the  original 
coats  of  the  artery,  being  produced.  True  tubercles  may  also  be 
produced  in  the  vessel  walls,  but  this  is  much  rarer.  In  either  case 
the  vascular  affection  diminishes  the  blood-supply  of  the  tuberculous 
mass  (already  defective  owing  to  the  non-vascularity  of  the  tubercles), 
and  increases  the  likelihood  of  caseation. 

A  fully-formed  tubercle  may  undergo  evolution  along  one  of  the 
following  lines,  according  to  the  virulence  of  the  bacilli  and  the 
resisting  powers  of  the  patient. 

1.  When  the  bacilli  are  but  slightly  virulent  and  the  patient's 
susceptibility  moderate,  the  tubercle  undergoes  fibrosis  :  this  is  the 
natural  method  of  cure.  The  endothelioid  cells  become  spindle- 
shaped,  their  nuclei  elongated,  apd  the  cells  are  converted  into  fibro- 
blasts. The  periphery  of  the  giant  cell  becomes  drawn  out  into 
delicate  ramifying  processes  which  penetrate  amongst  the  endothe- 
lioid cells,  and  join  with  them  in  forming  fibrous  tissue.  The 
lymphocytes  become  less  numerous,  and  ultimately  the  tubercle  is 
represented  by  an  ill-defined  nodule  of  new  fibrous  tissue. 

2.  When  the  bacilli  are  virulent  and  the  patient  in  a  non-resistant 
condition,  caseation  occurs.  This  is  a  process  of  fatty  degeneration 
and  necrosis  of  the  nodule,  especially  of  the  central  portions.  The 
result  is  the  formation  of  a  uniform  structureless  mass  which  may  be 
readily  recognised  in  ordinary  sections  by  the  absence  of  all  definite 
cells  or  tissue  elements,  and  the  fact  that  it  stains  with  acid  dyes, 
such   as   eosin  (Fig.  38).     It  is  not  often  possible  to  demonstrate 


172  A  MANUAL  OF  SURGERY 

bacilli  in  this  cheesy  mass  ;  they  are  there,  however,  as  inoculation 
experiments  show.  Caseation  occurs  in  lesions  other  than  tubercu- 
losis, and  is  due  to  the  action  of  toxins  on  the  tissues  ;  it  is  especially 
common  in  this  disease,  since  no  vessels  penetrate  the  tubercles, 
which  are  in  consequence  badly  nourished. 

Cure  may  take  place  at  this  stage  by  a  process  of  fibrosis  of  the 
surrounding  parts,  so  that  the  caseous  mass  becomes  walled  in  by 
a  zone  of  fibrous  tissue.  When  this  happens,  the  cheesy  material 
gradually  dries  up,  and  may  become  calcified.  When  this  latter 
phenomenon  happens,  cure  is  probably  complete,  but  living  bacilli 
may  occur  even  in  dried-up  caseous  substance,  and  under  suitable 
conditions  recrudescence  may  ensue,  even  after  an  interval  of  years. 

3.  In  most  cases  in  which  caseation  is  present,  the  process  continues 
to  spread.  New  tubercles  are  formed  on  the  outskirts  of  the  necrotic 
area,  and  these  in  their  turn  caseate ;  in  this  way  cheesy  masses  of 
considerable  size  may  be  produced.  In  some  cases  an  exudation  of 
fluid  takes  place  into  this  mass,  and  the  result  is  a  tuberculous 
abscess,  which  is  the  commonest  form  of  '  chronic '  abscess. 
Wherever  tubercle  is  deposited,  a  chronic  abscess  may  form  ;  but  it 
occurs  most  frequently  in  bones,  joints,  and  lymphatic  glands. 

The  pus  from  such  an  abscess  consists  of  disintegrated  fatty 
material  mixed  with  a  variable  quantity  of  fluid,  so  that  it  is  some- 
times thin  and  milky,  sometimes  so  thick  that  it  will  scarcely  flow 
through  a  cannula.  It  often  contains  masses  or  flakes  of  curdy 
debris,  and  on  microscopic  examination  a  few  lymphocytes  may  be 
found,  together  with  large  quantities  of  fatty  granular  material  which 
will  not  stain.  Tubercle  bacilli  may  be  found  without  much  difficulty 
in  the  more  active  cases,  but  in  chronic  forms  they  are  often  few  and 
far  between,  or  possibly  cannot  be  demonstrated,  though  inoculation 
experiments  show  that  they  are  present.  In  old-standing  cases  an 
abundance  of  cholesterine  crystals  may  be  seen,  a  fact  recognised 
by  the  naked  eye  by  the  glistening  sheen  or  greasy  appearance  im- 
parted to  the  pus ;  microscopically,  they  appear  as  flat  rhomboidal 
plates  with  one  corner  notched  out. 

Secondary  infection  with  pyogenic  bacteria  may  also  lead  to  the 
formation  of  an  abscess  in  a  tuberculous  nodule.  This  is  an  entirely 
different  process,  and  one  that  is  usually  much  more  serious  for  the 
patient.  The  pus  in  this  case  may  not  differ  appreciably  from  the 
ordinary  pus  of  acute  abscesses,  and  the  fact  that  it  contains  tubercle 
bacilli  may  only  be  demonstrable  by  inoculation. 

The  microscopic  appearance  of  a  tuberculous  abscess  wall  is  quite 
characteristic.  The  cavity  is  lined  by  a  layer  of  gray,  yellowish- 
gray,  or  pinkish,  pulpy  granulation  tissue,  containing  miliary 
tubercles,  perhaps  undergoing  caseation.  Its  colour  and  vitality 
are  dependent  upon  the  chronicity  or  not  of  the  process ;  the 
longer  the  abscess  is  in  forming,  the  less  vascular  the  membrane, 
owing  to  the  associated  sclerosis  of  the  surrounding  structures  lead- 
ing to  compression  of  the  bloodvessels,  whilst  it  has  been  already 
mentioned  that  endarteritis  always  accompanies  a  chronic  inflamma- 


SPECIFIC  INFECTIVE  DISEASES 


173 


tion,  and  helps  to  render  the  parts  non-vascular.  This  lining 
membrane,  when  necrotic,  is  but  loosely  connected  with  a  layer  of 
fibro-cicatricial  material,  which  forms  the  outer  part  of  the  wall,  and 
from  which  it  can  be  readily  detached  by  the  finger  or  a  sharp  spoon. 
A  chronic  abscess  forms  a  soft  fluctuating  swelling  which  gradually 
increases  in  size,  and  may  become  painful  by  exerting  pressure  on  a 
nerve  or  other  sensitive  structure.  Should  it  be  superficial,  it  will 
probably  come  to  the  surface  and  burst ;  the  pus  and  caseous  detritus 
will  be  discharged,  and  possibly,  if  the  general  health  is  good,  the 
wound  may  slowly  granulate  and  heal ;  but  more  commonly  the 
tuberculous   tissue  left   behind  prevents  healing,  and  a  ttibenulous 


y 


y 


f  <n^nTfTT/'^/#^/77/.../.^..o 


Fig.  39. — Tuberculous  Ulceration  of  Large  Intestine.     X30.    (Ziegler.) 

a,  Mucosa ;  h,  submucosa  ;  c,  inner  transverse  muscular  coat ;  d,  outer  longi- 
tudinal muscular  coat ;  e,  serosa  ;  /,  tuberculous  focus  in  solitary  gland  ; 
g,  mucosa  infiltrated  with  cells;  h,  tuberculous  ulcer;  h-^,  focus  of  softening 
or  tuberculous  abscess;  i,  early  tubercle,  with  giant  cell  in  centre;  ij,  caseous 
tubercle. 

ulcer  develops.  A  similar  condition  is  found  in  connection  with 
mucous  membranes,  the  tuberculous  foci  starting  in  the  submucosa, 
and  subsequently  bursting  through  the  mucous  membrane  (Fig.  39). 
Whatever  their  location,  the  ulcers  are  characterized  by  an  irregular 
and  ragged  margin  with  undermined  and  congested  edges ;  the  base 
is  formed  by  pulpy  granulation  tissue  containing  caseous  foci  (h), 
which  must  be  removed  before  healing  can  occur. 

On  the  other  hand,  if  the  abscess  is  of  deep  origin,  it  is  likely  to 
burrow  along  fascial  planes,  and  hence  to  become  superficial  at  a 
distance  from  its  original  source.  This  is  especially  the  case  in 
tuberculous  disease  of  the  spine,  in  which  the  pus  may  travel  far 


174  A  MANUAL  OF  SURGERY 

afield— (J.^.,  in  a  psoas  abscess.  The  far-reaching  extent  of  these 
abscesses,  the  impossibihty  of  deaHng  adequately  with  the  lining 
membrane,  together  with  the  infective  nature  of  the  disease  and  the 
often  inaccessible  position  of  the  original  focus  of  the  mischief,  render 
them  most  difficult  to  treat,  and  fully  account  for  the  dread  of  open- 
ing them  experienced  by  surgeons  in  pre-antiseptic  days  ;  for  should 
the  cavity  of  the  abscess  once  become  septic,  there  is  but  little  hope 
of  again  purifying  it,  and  the  result  is  an  increased  discharge  of  pus, 
absorption  of  the  chemical  products  of  putrefaction,  aggravation  of 
the  original  disease,  and  only  too  frequently  death  from  exhaustion 
or  chronic  toxaemia,  associated  with  the  development  of  hectic  fever 
and  amyloid  disease  (p.  74). 

Natural  Cure. — A  tuberculous  abscess,  if  left  to  itself,  does  not 
necessarily  come  to  the  surface.  Occasionally  one  rheets  with  a  mass 
of  putty-like  consistency  lying  in  front  of  the  spine  in  the  body  of  a 
patient  who  has  been  cured  of  spinal  disease.  This  is  evidently  the 
desiccated  remains  of  a  chronic  abscess,  the  fluid  portion  having  been 
absorbed,  and  the  solid  elements  left  behind,  encapsuled  and  perhaps 
infiltrated  with  lime  salts.  Such  debris  can  become  the  seat  of 
recurrent  inflammatory  mischief  years  later,  when  suppuration  may 
suddenly  occur,  giving  rise  to  what  is  known  as  a  residual  abscess. 
Probably  a  large  amount  of  cholesterine  will  be  found  among  its 
^^^  contents.     The  prognosis  of  such  an  abscess  is  good,  and  a  cure  may 

^^"  often  be  obtained  by  one  tapping  and  free  lavage. 

One  of  the  chief  features  of  tuberculous  disease  is  its  great 
tendency  to  diffusion,  which  is  sometimes  lighted  up  by  injudiciously 
vigorous  operative  interference.  It  may  occur  {a)  locally,  by  direct 
continuity  of  tissue,  or  by  extension  along  neighbouring  lymphatics 
,  or  bloodvessels  ;  or  (h)  distant  viscera  or  organs  may  become  infected, 
probably  by  embolic  dissemination  in  the  blood-stream.  Thus 
phthisis  is  a  not  uncommon  sequence  of  a  similar  affection  of  bones, 
joints,  or  lymphatic  glands,  whilst  meningeal  tuberculosis  is  more 
frequently  associated  with  tuberculous  affections  of  the  genital 
organs,  (c)  Moreover,  any  tuberculous  lesion  may  lead  to  acute 
general  tuberculosis,  in  which  the  disease  is  scattered  widely  throughout 
the  body,  giving  rise  to  rapid  emaciation,  high  fever  of  an  inter- 
mittent type,  and  usually  severe  diarrhoea,  dyspnoea,  and  delirium  or 
coma,  death  ensuing  in  a  few  weeks. 

Treatment. — When  Koch  first  discovered  the  tubercle  bacillus,  a 
great  impetus  was  given  to  operative  treatment,  and  some  authorities 
went  so  far  as  to  maintain  that  every  particle  of  the  diseased  tissue 
must  be  extirpated  with  as  much  care  as  in  the  case  of  cancer.  The 
pendulum  has  now  swung  slowly  back,  and  we  are  relying  more  and 
more  on  the  natural  powers  of  repair  inherent  in  the  patient,  and  are 
endeavouring  to  maintain  and  increase  these  in  every  way  by  suitable 
general  and  local  treatment,  reserving  operative  measures  for  the 
comparatively  small  class  of  cases  which  resist  such  treatment,  or  to 
the  larger  class  where  such  treatment,  for  various  reasons,  most  often 
financial,  cannot  be  carried  out. 


SPECIFIC  INFECTIVE  DISEASES  175 

1.  General  Treatment  consists  chiefly  in  giving  the  patient  an 
abundance  of  fresh  air,  as  free  from  germs  as  possible.  For  surgical 
cases  residence  by  the  seaside,  especially  in  such  bracing  places  as 
Margate,  or,  if  that  be  too  cold,  Ramsgate,  Bournemouth,  or  Ventnor, 
is  usually  recommended.  Equally  good  results  will  often  follow 
residence  in  hilly  districts,  provided  that  they  are  not  too  heavily 
wooded,  that  there  is  plenty  of  sunshine,  and  that  the  soil  dries 
quickly  after  rain.  Failing  seaside  or  country,  it  is  wonderful  what 
exposure  to  the  air  in  suburban  gardens  or  even  on  town  roofs  will 
do.  The  patient  must  be  kept  warm  and  well  wrapped  up,  and 
given  an  abundance  of  nutritious  food,  such  as  milk,  cream,  and 
eggs,  and  at  a  later  date  fish.  The  amount  of  exercise  must  be 
strictly  limited  so  as  to  conserve  the  patient's  energies  towards  the 
cure  of  his  disease,  and  in  this  connection  it  is  well  to  point  out  that 
prolonged  rest  in  a  spinal  carriage  is  suitable  for  many  conditions 
other  than  disease  of  the  spine  or  of  the  lower  extremities.  The 
internal  administration  of  cod-liver  oil,  the  phosphates  and  iodides  of 
iron,  organic  preparations  of  iodine,  guaiacol,  arsenical  preparations, 
and  other  tonics  is  also  indicated. 

The  value  of  Koch's  latest  tuberculin  (TR)  as  a  therapeutic  agent 
is  still  under  discussion ;  that  it  has  some  value  in  some  cases — e.g., 
some  forms  of  tuberculous  ulceration  of  the  bladder — seems  evident 
from  reports,  but  it  is  quite  open  to  question  whether  its  use  in 
general  is  advisable. 

2.  Local  Treatment  (Non-operative). — In  the  first  place  all  tuber- 
culous foci  must  be  kept  free  from  irritation,  whether  extrinsic  or 
intrinsic.  Thus,  wherever  possible  the  affected  part  must  be  main- 
tained at  rest,  both  from  movement  and  pressure.  Joints  should  be 
immobilized  by  plaster  of  Paris  or  suitable  splints ;  the  effect  of  the 
weight  of  the  body  minimized  by  recumbency  or  other  means  when 
the  disease  affects  the  spine  or  lower  extremities  ;  a  tuberculous 
testis  should  be  supported  by  a  suspensory  bandage,  etc.  The  advent 
of  sepsis  must  be  carefully  guarded  against,  if  possible,  and  especially 
in  connection  with  lymphatic  glands.  A  patient  with  glandular 
trouble  in  the  neck  should  be  carefully  examined  and  treated  for  any 
peripheral  septic  lesions,  such  as  sore  lips,  septic  teeth,  impetigo 
capitis,  or  otorrhoea ;  enlarged  tonsils  and  adenoids  should  also  be 
removed,  inasmuch  as  septic  foci  are  constantly  found  in  the  crypts 
of  the  former  or  between  the  lamellae  of  the  latter. 

These  rneasures  may  be  supplemented  by  counter-irritation — e.g., 
blisters,  iodine  paint,  or  Scott's  dressing,  and  Bier's  method  of 
passive  congestion  (p.  46).  Parenchymatous  injections  of  iodoform, 
or  of  some  sclerogenic  agent  such  as  chloride  of  zinc,  have  also  been 
employed,  acting  probably  by  determining  an  increased  flow  of  blood 
to  the  part,  and  thus  strengthening  the  protective  mechanism  of 
Nature. 

3.  Operative  Treatment  is  required  when  the  measures  indicated 
above  have  failed  to  check  the  disease,  or  when  accidental  complica- 
tions— e.g.,  abscesses — develop  in  the  course  of  the  case,  or  when  the 


176  A  MANUAL  OF  ^tURGERY 

disease  is  so  extensive  or  progressive  as  to  make  it  inadvisable 
to  trust  alone  to  the  natural  processes  of  repair.  Obviously  extirpa- 
tion of  the  tuberculous  focus,  if  practicable,  is  the  ideal  treatment 
in  all  cases,  and  for  some  conditions  no  other  treatment  need 
be  considered.  Thus,  in  superficial  lymphatic  glands  in  the  neck 
excision  is  the  best  treatment  whenever  progress  to  recovery  is 
delayed  or  absent.  In  many  other  conditions,  as  in  bone  and 
joint  disease,  total  extirpation  is  practicable  by  excision  or  amputa- 
tion ;  but  such  a  proposal  involves  the  consideration  of  many 
other  questions,  such  as  the  operative  risk,  the  possibility  of  diffusing 
tuberculous  material  into  the  system  generally  by  the  necessary 
manipulations,  the  possible  infection  of  the  wound  or  surround- 
ing healthy  tissues  by  tubercle,  and  the  degree  of  post-operative 
disability  that  may  result.  The  cure  by  a  local  excision  is  not  always 
certain,  and  the  after-treatment  is  often  very  prolonged.  On  the 
other  hand.  Nature's  cure  may  be  equally  uncertain,  possibly  less 
satisfactory,  and  the  chances  of  dissemination  and  diffusion  are  not 
absent.  The  final  decision  as  to  the  advisability  of  undertaking  a 
radical  operation  of  this  type  must  be  made  by  a  careful  consideration 
of  (i)  the  stage  of  the  disease,  whether  early  or  late  ;  (2)  its  position 
and  extent ;  (3)  its  character,  whether  active  and  progressive,  or 
chronic  ;  (4)  the  probable  resisting  power  of  the  patient  to  the  spread 
of  the  disease  ;  and  (5)  the  hygienic  conditions,  etc.,  under  which 
treatment  has  to  be  undertaken. 

Partial  operations  are  sometimes  required,  consisting  in  cutting 
or  scraping  away  as  much  of  the  diseased  tissues  as  is  practic- 
able, swabbing  out  the  cavity  thus  produced  with  some  powerful 
germicide,  such  as  liquefied  carbolic  acid,  and  dressing  the  part  with 
gauze  soaked  in  some  modifying  or  antiseptic  substance,  such  as 
an  emulsion  of  iodoform,  the  wound  being  left  to  heal  by  granulation. 
Diseased  bones,  glands,  and  sinuses  have  often  to  be  dealt  with 
in  this  way,  and  satisfactory  cures  may  be  established  after  a  while. 
Open-air  treatment  must  be  instituted  at  the  same  time,  or  com- 
menced as  soon  after  as  possible.  Theoretically,  it  is  better  to  do 
the  operation  in  the  country  rather  than  in  town,  but,  of  course, 
this  is  not  always  practicable. 

When  the  patient  has  more  than  one  focus  of  disease — e.g., 
pulmonary  phthisis  at  the  same  time  as  disease  of  some  joint,  or 
of  the  testis — it  is  often  found  that  no  progress  is  being  made 
towards  recovery,  in  spite  of  suitable  treatment.  It  then  may  be 
advisable  to  remove  entirely  one  of  the  foci,  if  such  be  possible, 
when  steady,  and  perhaps  rapid,  repair  will  show  itself  in  the  other. 

The  manifestations  of  tubercle  as  it  affects  special  organs  are 
dealt  with  elsewhere  under  the  appropriate  headings  (see  diseases  of 
skin,  bones,  joints,  lymphatic  glands,  kidney,  testis,  etc.). 

The  Treatment  of  Chronic  Tuberculous  Abscess  must  necessarily 
vary  considerably  according  to  the  position  and  condition  of  the 
part.  A  superficial  chronic  abscess  is  comparatively  easy  to  treat, 
but  one  placed   deeply,  and   connected  with  such  an  affection  as 


SPECIFIC  INFECTIVE  DISEASES  177 

tuberculous   disease  of   the   spine,   must   be   approached   with   the 
utmost  caution,  in  order  to  avoid  septic  contamination 

1.  In  certain  cases  of  external  chronic  abscess,  especially  when  connected  with 
lymphatic  glands,  it  may  be  possible  to  dissect  out  the  whole  cavity  en  masse,  and 
if  such  be  feasible,  it  is  the  most  satisfactory  plan  to  adopt.  Should  the  posterior 
wall  of  the  cavity  be  adherent  to  important  deep  structures,  it  should  be 
thoroughly  scraped  so  as  to  remove  all  tuberculous  material,  and  disinfected  with 
liquefied  carbolic  acid  or  solution  of  zinc  chloride  (40  grains  to  i  ounce). 
An  attempt  may  then  be  made  to  gain  healing  by  first  intention,  or  the  cavity 
may  be  packed  and  allowed  to  granulate. 

2.  When  the  skin  is  thin  and  undermined,  and  the  abscess  nearly  pointing,  it 
is  hopeless  to  avoid  leaving  an  open  wound  ;  and  hence  the  condition  must  be 
treated  by  the  open  method.  The  cavity  is  freely  incised,  diseased  tissue  scraped 
away,  unhealthy  skin  removed,  and  the  cavity,  if  not  too  large  or  deep,  treated 
with  pure  carbolic  acid  or  chloride  of  zinc  (gr.  xl.  ad  §i.),  packed  with  gauze  in- 
filtrated with  iodoform,  and  allowed  to  heal  from  the  bottom.  Healing  is  often 
slow,  if  sure ;  but  a  tuberculous  abscess  ought  never  to  be  allowed  to  reach  a 
condition  in  which  it  is  necessary  to  leave  an  open  wound  of  this  type. 

3.  When  a  chronic  abscess  is  situated  deeply  and  covered  with  healthy  tissues, 
treatment  consists  in  emptying  the  cavity  of  its  contents,  removing  as  far  as 
possible  the  tuberculous  lining  membrane,  and  closing  up  the  wound  after  intro- 
ducing into  the  cavity  some  modifying  or  antiseptic  injection. 

In  many  cases  tapping  with  trocar  and  cannula  suffices  for  this  purpose.  The 
modus  operandi  is  as  follows:  The  skin  over  the  abscess  is  incised,  and  a  large 
trocar  and  cannula  introduced  so  as  to  allow  the  contents  to  escape.  The  cavity  is 
then  washed  out  with  sterilized  salt  solution  (5i.  ad  Oi. )  at  a  temperature  of  105° 
to  110°  F.,  and  the  abscess  wall  gently  kneaded  from  the  outside  so  as  to  detach 
curdy  material  and  necrotic  pyogenic  membrane.  This  is  continued  until  the 
escaping  fluid  is  nearly  clear  or  only  slightly  opalescent,  and  then  an  ounce  or 
two  of  a  sterilized  emulsion  of  iodoform  in  glycerine  (10  per  cent.)  is  introduced, 
and  the  opening  closed  by  stitches.  In  this  way  it  is  often  possible  to  cure  a 
chronic  abscess  at  one  sitting.  The  treatment  is  most  likely  to  be  efficacious 
when  all  active  bone  or  joint  disease  has  disappeared,  and  residual  abscesses  are 
the  most  favourable  of  all.  It  is  well  to  ascertain  that  the  positive  phase  of  the 
opsonic  index  is  present  before  undertaking  this  treatment ;  failing  this,  an 
endeavour  should  be  made  to  raise  the  index  by  tuberculin  injections. 

Where  the  disease  is  more  active,  it  is  often  wiser  to  make  an  incis'!on  into 
the  abscess  sufficiently  large  to  introduce  the  finger.  Through  this  opening 
diseased  bone  can  possibly  be  removed  and  the  lining  wall  scraped,  and  for 
this  purpose  a  Barker's  flushing  gouge  is  often  useful.  The  instrument  consists 
of  a  gouge  or  sharp  spoon  with  a  long  hollow  handle,  which  communicates  by 
a  tube  with  a  reservoir  of  fluid  placed  at  some  height  above  the  patient.  During 
its  application  the  constant  rush  of  water  or  lotion  through  the  handle  clears  the 
gouge  and  removes  the  debris.  It  is  admirably  adapted  for  certain  cases,  but  its  use 
needs  considerable  care,  as  the  sharp  edge  can  readily  scrape  through  an  abscess 
wall,  and  do  much  mischief.  If  much  bleeding  occurs,  the  cavity  should  be  irrigated 
with  hot  sterilized  salt  solution.  The  wounds  are  subsequently  closed  after  inject- 
ing the  iodoform  emulsion,  and  an  attempt  is  made  to  gain  immediate  healing  of 
the  denuded  cavity  by  bringing  the  sides  into  apposition  by  suitable  pressure. 

Not  uncommonly  the  cavity  refills  in  the  course  of  three  or  four  weeks,  and 
the  irrigation  may  then  have  to  be  repeated.  The  fluid  withdrawn  on  this 
occasion  is  often  blood-stained  serum,  perhaps  smelling  strongly  of  iodoform. 
It  is  possible  that  in  such  cases  a  sinus  develops  sooner  or  later,  and  has  to  be 
dealt  with  by  simple  drainage.  Sometimes  it  is  possible  to  hasten  the  cure  of  a 
chronic  tuberculous  sinus  by  injecting  it  with  a  paste  consisting  of  bismuth  sub- 
nitrate,  one  part,  and  vaseline,  two  parts.  This  is  said  to  cause  a  rapid  curative 
effect,  owing  to  its  chemotactic,  bactericidal,  and  astringent  action.  In  acute 
suppurative  lesions,  or  where  large  cavities  are  involved — e.g.,  in  empyema — this 
proceeding  should  not  be  employed,  as  toxic  effects  from  absorption  may  follow, 
and  fatal  results  have  been  reported. 


17^  A  MANUAL  OF  SURGERY 

Gla.nders. 

Glanders  is  primarily  a  disease  of  the  horse,  ass,  or  mule,  which  is  transmitted 
to  men  by  direct  inoculation,  and  hence  is  usually  seen  only  in  stable  attendants 
and  those  brought  in  contact  with  such  animals.  It  is  characterized  by  the 
development  of  inflammatory  swellings  under  the  mucous  membrane  of  the 
respiratory  tract,  which  break  down  and  ulcerate,  and  by  the  formation  of 
similar  growths,  embolic  in  origin,  in  the  lungs  and  other  viscera,  which  go  on 
to  abscess  formation. 

There  is  now  no  doubt  that  the  disease  is  due  to  a  definite  micro-organism, 
the  Bacillus  mallei,  which  was  isolated  about  1882  by  Schutz  and  Loffler,  and 
has  since  been  cultivated  outside  the  body ;  the  experimental  evidence  as  to  its 
being  the  cause  of  the  malady  is  quite  complete. 

In  Horses  and  other  animals  glanders  manifests  itself  by  a  formation  of  larger 
or  smaller  rounded  swellings  in  the  mucous  membrane  of  the  nose,  which  break 
down  and  ulcerate,  giving  risk  to  a  thin,  sero-purulent  discharge,  and  perhaps  to 
destruction  of  the  bones  and  cartilages.  The  lymphatic  glands,  especially  those 
under  the  jaw,  early  become  enlarged,  constituting  the  '  farcy  buds  '  of  farriers, 
and  by  their  ulceration  may  leave  ragged,  foul  sores.  The  lymphatic  trunks  to 
and  from  the  glands  are  involved  ('  corded  veins  '),  whilst  the  lungs  and  internal 
viscera  may  also  be  infected,  and  undergo  destructive  changes,  usually  ending  in 
suppuration.  The  disease  is  often  chronic,  lasting  perhaps  for  years  ;  any  undue 
strain  put  upon  the  animal  may  lead  to  an  acute  outbreak,  which  is  fatal  in  six  to 
twelve  days. 

In  Man,  glanders  generally  starts  about  the  hands  and  face,  but  occasionally  in 
the  nasal  mucous  membrane.  In  acute  cases  the  incubation  period  lasts  from 
three  to  five  days,  and  is  succeeded  by  the  occurrence  of  malaise  and  febrile 
disturbance,  followed  by  severe  pains  in  the  bones  and  joints.  The  site  of 
inoculation  becomes  swollen  and  angry,  whilst  the  lymphatics  leading  from  this 
to  the  nearest  glands  are  enlarged  and  inflamed.  An  eruption  of  papules,  which 
somewhat  resembles  those  of  small-pox,  occurs  around  the  primary  lesion,  on  the 
face,  and  in  other  parts  of  the  body  ;  but  each  papule,  as  also  the  primary  lesion, 
breaks  down  and  goes  on  to  the  formation  of  an  ecthymatous-looking  ulcer.  It 
is  not  an  uncommon  feature  of  these  sores,  when  placed  over  a  bony  surface,  to 
involve  the  periosteum  and  lay  bare  the  subjacent  bone.  Similar  changes  occur 
in  the  viscera,  muscles,  and  joints,  and  these  being  associated  with  high  fever  of 
an  asthenic  type,  may  suggest  the  existence  of  pyaemia.  In  such  cases  death 
may  ensue  in  seven  to  ten  days. 

In  chronic  glanders  similar  symptoms  are  met  with,  but  the  course  is  slower  ; 
there  is  little  or  no  fever  ;  the  disease  is  less  extensive,  and  intermissions  are  not 
uncommon.  Total  recovery  is  stated  to  occur  in  50  per  cent,  of  the  cases.  It 
may  affect  the  nasal  mucosa,  leading  to  chronic  ulceration,  but  more  commonly 
it  appears  in  the  shape  of  chronic  abscesses,  which  often  extend  deeply,  even 
down  to  the  bones,  and  are  very  difficult  to  deal  with.  In  one  case  the  disease 
gradually  spread  down  along  the  peronei  muscles,  and  in  spite  of  repeated 
scrapings  and  the  application  of  pure  carbolic  acid,  the  process  was  only  arrested 
a,t  the  point  where  the  peroneus  longus  disappears  into  the  foot. 

It  is  important  to  determine  the  Diagnosis  as  early  as  possible,  in  order  to 
undertake  energetic  local  treatment.  The  local  lesions  are  distinguished  from 
small-pox  by  the  presence  of  the  characteristic  bacilli  in  the  discharge,  by  the 
fact  that  they  involve  the  subcutaneous  tissues  more  extensively,  and  by  the 
absence  of  umbilication.  Chronic  cases  resemble  syphilis  and  ttiberculosis ,  but 
the  history  of  exposure  to  infection  from  animals  suffering  from  the  disease  is 
most  important,  as  also  the  result  of  cultivations  made  from  the  discharge. 
When  the  bacilli  are  grown  on  potatoes,  a  colony  of  a  yellowish,  honey-like 
character  forms  in  two  or  three  days,  which  gradually  turns  to  a  chocolate - 
brown  colour.  Inoculation  of  the  peritoneal  cavity  of  a  guinea-pig  with  some 
of  the  secretion  leads  to  acute  orchitis  in  two  or  three  days,  the  testicles  being 
enlarged  and  the  skin  over  them  reddened;  the  affection  usually  runs  on  to 
suppuration.  Mallein,  a  sterilized  culture  of  the  organisms,  may  be  used  for 
diagnostic  purposes  in  animals,  the  injection  of  a  minute  dose  causing  a  sharp 


SPECtPiC  tNpECTlVE  DISEASES  J?9 

febrile  reaction  if  glanders  is  present ;  but  it  is  of  no  use  for  diagnosis  or  treat- 
ment in  the  human  subject. 

Treatment  in  acute  cases  can  be  successful  only  wheni  undertaken  early,  and 
before  general  infection  has  ensued.  The  local  foci  should  be  thoroughly  extir- 
pated, either  by  the  knife,  or  by  scraping  and  applying  some  active  cauterizing 
agent.  The  same  treatment  must  be  adopted  in  chronic  cases,  and  may  then 
need  frequenfrepetition. 

Leprosy. 

Leprosy  (syn. :  lepra,  or  elephantiasis  GrcBcorum)  is  a  general  infective  disease  due 
to  the  Bacillus  leprae,  characterized  by  the  formation  of  granulation-like  neoplasms 
which  arise  primarily  in  connection  with  the  skin  and  nerves. 

The  bacillus  of  leprosy  closely  resembles  that  of  tuberculosis,  and,  like  it,  is 
strongly  acid-fast,  staining  by  Ziehl-Nielsen's  method.  The  two  organisms  are 
difficult  to  distinguish,  but  the  leprosy  bacilli  are  usually  straighter  and  more 
uniform  than  those  of  tubercle  ;  and  when  seen  in  sections  of  leprous  material 
they  are  often  present  in  far  larger  numbers  than  are  the  tubercle  bacilli  in  tuber- 
culous tissues.  They  are  usually  packed  together  like  bundles  of  cigarettes 
(Plate  II.,  Fig.  25).  Numerous  attempts  have  been  made  to  cultivate  them,  and 
a  few  observers  claim  to  have  succeeded,  but  their  results  have  not  been  generally 
accepted.  All  attempts  to  inoculate  animals  have  failed,  and  inoculation  con- 
stitutes the  best  and  most  definite  test  between  the  two  diseases. 

Leprosy,  though  formerly  common  in  this  country,  is  now  only  observed  in 
imported  cases.  In  Iceland,  Norway,  Russia,  and  the  East,  it  is  still  frequently 
met  with,  although  the  method  of  segregation  of  lepers  enforced  in  Norway  has 
greatly  diminished  the  number  in  that  country.  It  is  apparently  very  slightly 
contagious.  The  medical  attendants  and  nurses  in  leper  hospitals  rarely  contract 
the  disease,  and  inoculation  experiments  in  criminals  have  led  to  negative  results. 
Mr.  Jonathan  Hutchinson  has  argued  that  infection  only  takes  place  in  persons 
who  eat  badly-cured  or  partially  decomposing  fish.  Opinions  differ  as  to  whether 
the  disease  is  transmitted  to  the  descendants,  but  probably  this  is  not  the  case. 

Sjonptoms. — Two  chief  varieties  of  leprosy  exist,  viz.,  the  tuberculated,  and  the 
anaesthetic  or  non-tuberculated ;  but  the  two  are  often  associated. 

Tuberculated  or  Cutaneous  Leprosy  is  the  form  most  commonly  seen  in  Europe. 
Nothing  may  be  noticed  for  months  or  years  after  exposure  to  the  contagion, 
and  then,  after  a  period  of  malaise,  associated  with  dyspepsia,  diarrhoea,  and 
drowsiness,  a  distinct  febrile  attack  is  noted,  lasting  for  days  or  weeks ;  it  may 
be  ushered  in  by  a  rigor,  and  the  temperature  is  usually  of  a  remittent  type. 
This  is  followed  by,  or  associated  with,  the  appearance  of  shiny,  red,  hyperasmic 
spots,  which  are  from  the  first  infiltrated,  slightly  raised,  and  hyperaesthetic ; 
they  are  usually  situated  on  the  forehead  or  cheeks,  on  the  outer  side  of  the 
thighs,  or  on  the  front  of  the  forearms.  They  may  fade  away  and  disappear 
entirely,  and  then  again  become  evident,  or  fresh  patches  may  be  developed,  and 
always  with  febrile  symptoms.  After  a  variable  period,  '  tuberculation  '  ensues  : 
numbers  jf  little  pink  nodules  form  over  the  site  of  one  or  more  of  the  erythe- 
matous patches,  and  these  gradually  increase  in  size  and  coalesce,  until  possibly 
they  become  as  large  as  a  walnut  or  hen's  egg,  and  are  then  of  a  brownish-yellow 
colour.  Almost  any  part  of  the  surface  of  the  body  may  be  invaded  in  this 
manner,  but  the  face  is  especially  prone  to  be  involved,  and  the  resulting 
disfigurement  is  very  marked,  a  curious  leonine  appearance  being  imparted  to 
the  features  (Fig.  40).  The  nodules  are  more  or  less  anaesthetic  from  the 
pressure  of  the  infiltration  on  the  nerves,  and  the  ultimate  result  of  the  process 
may  vary  considerably ;  resolution  sometimes  occurs,  or  the  nodules  may  be 
transformed  into  depressed  and  pigmented  cicatrices,  or  ulceration  may  ensue. 
Visceral  complications  and  enlargement  of  the  lymphatic  glands  follow,  any  fresh 
deposit  being  associated  with  febrile  phenomena.  The  testes  atrophy,  and  sexual 
power  is  lost  in  both  sexes.  Death  is  usually  due  to  septic  phenomena,  laryngeal 
obstruction,  or  disease  of  the  lungs  or  kidneys ;  but  the  patient  may  live  for  many 
years. 

The  nodules  consist  of  masses  of  granulation  tissue,  and  scattered  through  them 
are  numbers  of  large  cells,  containing  multitudes  of  bacilli. 


i8o 


A  MANUAL  OF  SURGERY 


Anaesthetic  or  Non-tuberculated  Leprosy  is  the  most  common  form  met  witb 
in  hot  climates.  The  earliest  phenomena  consist  in  a  certain  amount  of  malaise 
without  appreciable  fever,  together  with  sharp  tingling  or  lancinating  pains  and 
tenderness  along  the  course  of  certain  peripheral  nerves.  The  ulnar,  median, 
peroneal,  and  saphenous  nerves  are  those  most  often  affected.  This  is  followed 
by  muscular  weakness,  running  on  finally  to  paralysis,  various  modifications  of 
sensation,  and  trophic  phenomena,  involving  at  first  only  the  skin,  but  later 
on  attacking   bones,  joints,  and  muscles.     Circular  yellowish-white  patches  are 


Fig.  40. — Leprosy.     (From  a  Photograph  kindly  lent  by  W.  Thelwall 
Thomas,  Esq.,  of  Liverpool.) 

The  patient  had  lived  as  a  sailor,  and  contracted  leprosy  abroad  many  years 
before.  The  facial  aspect  is  very  characteristic,  and  the  forearms  are  enlarged 
owing  to  leprous  deposits  in  the  subcutaneous  nerves. 

observed  in  the  skin,  spreading  peripherally,  and  tending  to  run  together,  forming 
large  irregular  ovals  ;  the  border  is  often  raised,  and  hypersensitive,  but  the 
central  portions  become  atrophic,  dry,  white,  and  anaesthetic.  The  anaesthesia 
gradually  spreads,  and  serious  lesions,  partly  due  to  trauma,  partly  arising  from 
trophic  changes,  result.  The  muscles  atrophy  and  contract,  and  give  rise  to 
deformity,  the  hands  sometimes  becoming  markedly  'clawed,'  as  in  ulnar 
paralysis.  Interstitial  absorption  of  the  bones  of  the  peripheral  portions  of  the 
limbs  may  lead  the  fingers,  toes,  and  other  portions  to  shrivel  and  disappear, 


SPECIFIC  INFECTIVE  DISEASES  l8l 

preceded  by  ankylosis  of  the  joints.  The  affected  nerves  can  usually  be  felt 
distinctly  enlarged  and  tender.  Visceral  lesions  are  not  so  marked  in  this  as  in 
the  other  form  of  the  disease,  and  the  patient  may  retain  a  considerable  degree 
of  health  and  strength,  while  his  sexual  powers  are  not  much  interfered  with. 
Finally  he  dies  from  general  debility,  or  from  various  complications,  but  the 
case  may  last  twenty  or  more  years. 

The  Treatment  is  still  very  unsatisfactory.  Chaulmoogra  oil,  administered 
both  internally  and  externally,  is  the  drug  most  frequently  depended  on,  whilst 
intramuscular  injections  of  corrosive  sublimate  have  been  employed  with  some 
success.  Some  good  results  have  been  attributed  to  the  use  hypodermically  of 
Nastin  (Deycke),  a  neutral  fat  extracted  from  cultures  of  the  Streptothrix  leproides, 
obtained  from  leprous  nodules.  It  is  employed  in  combination  with  benzoyl 
chloride  (Nastin  B),  and  acts  by  withdrawing  fats  from  the  lepra  bacilli,  which 


Fig.  41. — Bovine  4-CXInomyces  in  Tongue.     (From  Crookshank's  '  Textbook 
OF  Bacteriology.') 

are  thereby  killed.  Hypodermic  injections  cause  a  reaction  of  an  inflammatory 
nature  and  necrosis  of  the  leprous  tissue.  Amputation  of  extremities  is  sometimes 
useful  in  late  stages  of  the  disease. 

Actinomycosis. 

Actinomycosis  is  a  disease  of  man  and  cattle,  due  to  infection  by  various  types 
of  a  group  of  streptothrices  called  Actinomyces  (ray  fungus).  The  organisms 
found  in  man  are  rarely  identical  with  those  present  in  the  bovine  variety,  the 
differences  being  mainly  in  the  staining  reactions. 

Actinomycosis  in  cattle  is  usually  acquired  by  eating  infected  barley  or  other 
cereal,  fragments  of  which  are  sometimes  found  in  the  primary  lesion.  It  most 
commonly  affects  tht,  tongue  or  jaw,  and  causes  a  chronic  fibrosing  inflammation 
(the  wooden  tongue,  big  jaw,  or  '  osteo-sarcoma '  of  cattle).  These  often  suppurate 
in  many  places,  producing  multiple  chronic  abscesses,  which  discharge  externally 
and  leave  a  diffuse  inflammatory  mass  riddled  with  sinuses.  The  pus  from  such 
abscesses  contains  small  yellow  or  brown  gritty  bodies  (often  looking  like  grains  of 
iodoform)  which  consist  of  colonies  of  the  fungi,  sometimes  undergoing  calcareous 
changes.  The  structure  of  these  colonies  may  be  made  out  by  crushing  the 
oat  tides  between  two  slides  and  staining  the  film  thus  produced,  but  is  better 


1 82 


A  MANUAL  OF  SURGERY 


seen  by  an  examination  of  sections.  Each  colony  consists  of  a  tangled  mass  of 
mycelium,  the  central  portion  of  which  often  shows  the  presence  of  '  chain 
spores,'  whilst  the  peripheral  part  has  a  definite  radial  arrangement,  from  which 
the  organism  derives  its  name.  The  mycelial  filaments  which  project  from  the 
outer  portion  of  the  colony  are  often  greatly  thickened,  and  appear  in  the  form 
of  Indian  clubs,  the  narrow  ends  being  pointed  inwards.  These  '  clubs '  were 
formerly  thought  to  be  reproductive  organs,  but  are  probably  caused  by  a  de- 
generation of  the  sheaths  of  the  filaments.  They  are  very  well  seen  in  bovine 
actinomycosis  (Fig.  41),  but  are  often  absent  or  very  badly  formed  in  man. 

In  Man  the  disease  is  very  similar  in  its  clinical  character,  and  may  be  caused 
by  a  number  of  organisms  belonging  to  the  streptothrix  group.  Strictly  speak- 
ing, it  is  not  a  specific  disease  like  tuberculosis,  but  a  group  like  the  suppurative 
diseases.     The  organisms  form  colonies  in  the  tissues  resembling  those  of  the 

bovine  disease,  but  the  radial  arrange- 
ment at  the  periphery  is  often  ill-marked, 
and  clubs  are  absent  or  ill-developed 
(Fig.  42).  The  cultural  characters  differ 
greatly  in  different  cases,  and  the 
organisms  causing  the  disease  have  not 
yet  been  fully  investigated.  All  the 
streptothrices  which  affect  man  stain  by 
Gram's  method. 

Actinomycosis  is  found  to  be  not  un- 
I  common  when  a  systematic  examination 
is  made  of  the  pus,  etc.,  from  all 
patients  treated ;  when  this  is  not  done, 
a  considerable  number  are  diagnosed 
as  tuberculosis  or  syphilis.  It  usually 
occurs  in  farmers,  millers,  and  others 
who  are  brought  in  contact  with  grain, 
and  in  a  few  cases  infection  from  these 
materials  may  be  definitely  traced.  In 
many  cases  the  fungus  enters  the  body 
from  a  carious  tooth  or  from  the  tonsil, 
and  the  primary  lesion  is  usually  some- 
The  absence  of  the  radially-arranged  where  in  the  region  of  the  mouth. 
'  clubs  '  is  very  obvious.  Less  frequently  it  may  occur  in  other 

parts  of  the  alimentary  canal,  especially 
m  the  caecum,  appendix  (causing  a  condition  which  may  not  be  diagnosed  from 
ordinary  appendicitis  in  the  absence  of  a  microscopic  examination),  or  in  the 
liver,  giving  rise  to  a  very  characteristic  reticulated  swelling,  in  which  diffuse 
suppuration  may  occur.  Again,'  it  may  be  primary  in  the  lung,  causing  lesions 
similar  to  those  of  tuberculosis,  and  often  giving  rise  to  localized  empyemata. 
The  skin  may  also  be  affected,  but  in  the  majority  of  cases  only  by  extension  from 
the  deeper  tissues.  Lastly,  a  few  cases  of  primary  actinomycosis  of  the  central 
nervous  system  have  been  recorded. 

The  structure  of  these  lesions  resembles  that  of  a  tubercle,  except  that  giant 
cells  are  perhaps  less  frequent  (the  disease  being  usually  more  rapid),  and  the 
centre  of  the  nodule  is  occupied  by  a  characteristic  colony  of  the  fungus.  At  a 
later  period  the  lesion  breaks  down  and  forms  pus,  containing  the  granular 
nodules  described  above.  The  disease  is  very  chronic,  and  has  a  tendency  to 
spread  locally ;  although  not  dangerous  in  itself,  it  may  become  so  by  attacking 
important  organs,  or  by  generalization,  giving  rise  to  pyaemic  abscesses  in  all  parts 
of  the  body. 

The  commonest  site  for  the  primary  lesion  is  close  to  the  angle  of  the  jaw, 
where  it  constitutes  a  cervico-facial  growth  of  tolerably  characteristic  appear- 
ance. At  first  the  mass  has  a  smooth,  regular,  and  even  surface,  and  merges 
gradually  into  the  surrounding  tissues ;  the  skin  over  it  is  usually  hyperasmic. 
As  time  passes,  little  nodular  excrescences,  with  a  peculiar  yellowish  apex,  form 
here  and  there  on  the  surface  of  the  tumour,  and  these  finally  soften,  point,  and 
burst,  giving  exit  to  a  small  amount  of  glutinous  pus,  in  which  the  actinomycotic 


Fig. 


42. — Colony   of  Human  Actino- 
myces.  AS   SEEN   IN   Pus. 


SPECIFIC  INFECTIVE  DISEASES 


183 


nodules  can  be  demonstrated.  When  all  the  fungus  has  been  discharged,  the 
abscess  contracts  and  the  wound  closes.  The  cicatrization  induced  by  the  con- 
stant repetition  of  this  process  makes  the  surface  of  the  mass  curiously  nodular 
and  puckered  (Fig.  43),  and  this  appearance,  when  present,  is  almost  pathogno- 
monic. At  other  times  sinuses  persist,  and  the  affected  area  may  become  riddled 
with  them.  Trismus  is  an  almost  constant  symptom  in  the  cervico-facial  form  of 
the  disease,  coming  on  early,  and  being  apparently  independent  of  the  size  of 
the  mass  or  its  involvement  of  nerves. 

The  Treatment  most  recently  advised  consists  in  the  administration  of  large 
doses  of  iodide  of  potassium  (grs.  20  to  30  three  times  a  day)  or  of  some  of  the 
organic  preparations  of  iodine,  which  seem  to  have  almost  as  great  an  influence 


Fig.  43 


-Cervico-Facial   Actinomycosis.      (By  kind  Permission  of 
Sir  Malcolm  Morris.) 


in  this  disease  as  in  syphilis.  This  alone  may  suffice  when  there  is  no  open 
wound;  but  if  open  sores  are  present,  surgical  measures  must  also  be  employed. 
Extirpation  of  all  the  infiltrated  tissue,  either  by  the  knife  or  by  vigorous 
scraping  after  opening  up  sinuses,  should  be  undertaken,  and  the  part  freely 
cauterized  ;  in  fact,  it  must  be  treated  in  exactly  the  same  way  as  a  diffuse 
tuberculous  mass.  This  can,  however,  only  be  carried  out  very  partially  in  the 
visceral  affections,  where  the  disease  may  prove  fatal,  not  so  much  from  the 
primary  affection  as  from  the  septic  complications 


CHAPTER  VIII. 

TUMOURS  AND  CYSTS. 

Although  the  term  '  tumour '  is  often  used  for  any  abnormal 
swelling  which  may  be  met  with  in  the  body,  yet  for  scientific 
purposes  its  application  is  much  more  Hmited.  A  tumour  may  be 
defined  as  '  a  mass  of  new  formation  that  tends  to  grow  or  persist, 
without  fulfilling  any  physiological  function,  and  with  no  typical 
terminatioi:.'  The  fact  that  it  has  no  typical  termination  dis- 
tinguishes it  from  inflammatory  overgrowths,  which  always  lead 
sooner  or  later  to  the  formation  of  fibro-cicatricial  tissue  or  some 
modification  of  it ;  inflammatory  growths,  moreover,  may  disappear 
completely,  and  often  diminish  in  size  temporarily.  Pure  hyper- 
trophies are  excluded  by  this  definition,  since  they  always  depend 
more  or  less  on  some  increased  physiological  function,  and  are 
composed  of  an  increased  development  of  normal  tissues,  as,  for 
instance,  the  blacksmith's  biceps.  Congenital  overgrowth  of  a  limb 
or  portion  of  a  limb  also  occurs,  and  is  known  as  *  gigantism  ' ;  it 
cannot  be  considered  a  tumour,  being  merely  an  exaggerated 
development  of  normal  tissues. 

The  .etiology  of  tumours  is  still  obscure,  the  most  definite  fact 
being  that  in  a  considerable  number  of  cases  (variously  calculated  at 
7  to  14  per  cent.)  they  follow  and  appear  to  be  caused  by  some 
injury  or  irritation,  which  determines  an  abnormal  development  of 
some  of  the  tissues  of  the  part.  Thus  an  adenoma  of  the  breast  is 
often  attributed  to  a  blow,  and  the  irritation  of  a  clay-pipe  may 
produce  epithelioma  of  the  lip.  In  India  the  natives  of  Kashmir 
wear  under  their  robes  an  earthenware  pot  or  kangri,  suspended 
from  the  waist,  and  containing  burning  charcoal ;  the  heat  of  this 
leads  to  chronic  eczema  of  the  abdominal  wall,  and  this  is  in  turn 
frequently  followed  by  squamous-celled  carcinoma.  In  some  cases 
the  irritation  may  be  due  to  chemical  substances  such  as  soot  (in  the 
case  of  chimney-sweeps),  tar,  or  petroleum,  all  of  which  occasionally 
lead  to  the  production  of  epithelioma  in  persons  brought  much  into 
contact  with  them  ;  except  in  these  cases,  occupation  is  not  known  to 
exercise  any  influence  in  the  causation  of  tumours. 

The  question  of  heredity  as  a  predisposing  factor  is  still  unsettled. 
It  was  formerly  thought  to  be  of  considerable  importance,  but  recent 
observations  and  statistics  have  not  strengthened  this  view. 

The  geographical   distribution   of   tumours    has    only   been    inves- 


TUMOURS  AND  CYSTS  185 

tigated  in  the  case  of  cancer.  The  results  of  different  series  of 
observations  have  been  fairly  concordant,  and  tend  to  show  that  the 
disease  is  most  common  in  low-lying,  damp,  well- wooded  areas, 
especially  if  they  are  liable  to  periodical  floods,  as,  for  example,  the 
Thames  Valley.  It  also  seems  proved  that  certain  houses  claim 
more  than  their  average  proportion  of  victims  from  cancer — in  other 
words,  that  cancer  is  to  a  certain  extent  a  house-disease.  This  has 
been  taken  to  indicate  an  infectious  origin  for  the  disease,  but  other 
interpretations  are  possible. 

The  age-incidence  varies  with  the  type  of  tumour.  Most  innocent 
forms  may  occur  at  any  age,  though  to  this  rule  there  are  several 
interesting  exceptions — e.g.,  adenomata  of  the  breast  and  fibro- 
myomata  of  the  uterus,  which  grow  only  during  the  period  of 
functional  activity ;  certain  osteomata,  which  arise  from  ossifying 
cartilage  and  continue  their  growth  only  during  the  activity  of  that 
structure.  In  the  malignant  tumours  the  age- incidence  is  better 
niarked.  Sarcomata  occur  at  all  ages,  but  are  especially  common  in 
the  first  half  of  life,  whilst  carcinomata  are  rare  before  the  age  of 
thirty,  and  most  common  after  forty. 

The  effect  of  sex  on  the  incidence  of  the  innocent  tumours  and  the 
sarcomata  is  not  marked.  Women  are  more  liable  to  carcinomata 
than  males,  but  this  is  in  large  measure  owing  to  the  frequency  with 
which  this  disease  attacks  the  uterus  and  breast ;  cancer  of  the  mouth 
and  other  portions  of  the  alimentary  canal  is  more  common  in  men 
than  in  women. 

Many  theories  have  been  brought  forward  to  explain  the  patho- 
genesis of  tumours,  but  the  only  ones  that  need  be  mentioned  are  the 
three  following:  (i)  The  parasitic  theory  rests  mainly  on  analogy 
with  undoubtedly  infectious  diseases,  and  has  been  formulated  chiefly 
for  the  malignant  growths.  There  is  at  first  sight  a  close  clinical 
similarity  between  the  infective  granulomata,  especially  tubercle,  and 
cancer ;  in  each  there  is  a  primary  lesion  marked  by  invasion  and 
destruction  of  tissues,  followed  by  secondary  growths  in  the  glands 
or  internal  organs,  reproducing  the  structure  of  the  primary  focus. 
But  the  analogy  is  only  superficial ;  the  secondary  tubercles  are  due 
to  the  carrying  of  the  infective  agents  (the  bacilli)  in  the  blood  or 
lymphatic  stream  to  distant  regions,  where  they  are  deposited,  and 
continue  to  grow  and  give  rise  to  an  inflammatory  reaction.  The 
secondary  nodules  of  cancer  are  caused  by  the  transference  in  the 
blood  or  lymph  of  actual  cancer  cells  derived  from  the  primary 
tumour,  which  are  deposited  elsewhere,  and  continue  their  growth 
undisturbed,  in  spite  of  their  change  of  environment.  So-called 
'  cancer  parasites '  have  been  described  by  numerous  pathologists, 
but  are  now  generally  recognised  as  leucocytes  or  red  corpuscles, 
which  have  entered  cancer  cells  and  undergone  various  forms  of 
degeneration,  or  as  portions  of  nuclei,  etc.  A  few  investigators 
claim  to  have  cultivated  blastomycetes  from  cancers,  and  to  have 
produced  cancers  by  the  injection  of  the  cultures  into  animals,  but 
these  results  have  not  been  generally  accepted. 


,l86  A  MANUAL  OF  SURGERY 

Recent  researches,  though  not  solving  the  problems  of  the  origin 
and  nature  of  cancer,  have  yielded  much  valuable  and  suggestive 
information.  Most  of  these  researches  have  been  carried  out  in  mice, 
the  tumours  of  which  (adeno-carcinoma  of  the  breast,  sarcoma, 
chondroma,  etc.)  are  inoculable  into  other  animals  of  the  same  species. 
The  mouse  is,  however,  the  only  animal  in  which  c9.rcinoma  has  been 
successfully  propagated  (Bashford).  It  has  been  possible  to  transfer 
mouse-cancer  to  rats,  but  the  disease  quickly  dies  out. 

It  is  essential  that  living  cells  or  fragments  of  tissue  should  be 
inoculated  if  successful  results  are  to  follow.  The  fragment  con- 
tinues to  grow  in  its  new  host,  and,  since  the  transplantations  can  be 
carried  on  (as  far  as  is  known)  indefinitely,  a  minute  portion  may 
continue  to  develop  in  one  animal  after  another  until  many  pounds' 
weight  of  cancer  have  been  produced.  It  would  appear,  therefore, 
that  the ,  essential  character  of  a  malignant  cell  is  its  power  of 
indefinite  growth  and  division  independently  of  the  surrounding 
tissues,  provided,  of  course,  that  these  are  of  suitable  nature.  The 
connective  tissue  of  the  graft  atrophies  and  disappears.  The  inocu- 
lation of  these  tumours  is  not  comparable  with  that  of  tubercle  or 
other  infective  diseases.  In  the  latter  case,  any  cells  derived  from 
the  first  animal  soon  die,  but  the  micro-organism  continues  to  live 
and  produce  fresh  tissue  changes  in  the  new  host.  In  the  former, 
the  cells  themselves  live  and  divide,  and  do  not  induce  any  cancerous 
changes  in  the  cells  of  the  second  animal.  Hence  there  is  some 
analogy  between  these  cancer  cells  and  the  known  parasites,  which 
are  capable  of  indefinite  life  and  subdivision  in  suitable  hosts  ;  more- 
over, if  cancer  is  actually  due  to  a  parasite  (which  appears  more  and 
more  improbable),  this  must  be  contained  within  the  malignant  cell. 
Inoculation  experiments  are  followed  by  a  comparatively  small 
proportion  of  successes,  indicating  that  conditions  must  be  present  in 
the  tissues  or  blood  of  the  host  which  are  favourable  to  the  growth 
of  the  tumour.  Some  tumours  are,  however,  highly  virulent,  yielding. 
a  large  proportion  of  successes,  and  there  is  usually  an  increase  in 
virulence  brought  about  by  repeated  inoculations. 

The  question  of  immunity  has  also  been  raised.  That  natural 
immunity  exists  follows  from  the  facts  that  not  all  inoculations  are 
attended  by  success,  and  that  mice  from  different  localities  show 
very  different  degrees  of  susceptibility  to  the  same  tumour.  That 
immunity  can  be  acquired  appears  from  the  observation  that  a  mouse 
unsuccessfully  inoculated  with  a  tumour  of  low  virulence  becomes 
refractory  to  tumours  of  great  infective  power  to  normal  mice. 

2.  The  theory  of  foetal  residues  was  originated  by  Virchow's  sug- 
gestion that  in  the  ossification  of  cartilage  small  islets  might  be  left, 
which  subsequently  grow  and  develop  into  chrondromata ;  the 
idea  was  at  a  later  date  expanded  by  Cohnheim  to  include  all 
tumours.  It  certainly  affords  an  explanation  of  some  varieties  of 
growth,  such,  for  instance,  as  the  dermoid  cysts,  which  originate  in 
portions  of  epidermic  structures  left  behind  during  embryonic 
development.  But  it  is  not  a  complete  explanation,  since  it  is 
obviously  inapplicable  to  the  formation  of  epitheUomata  in  scars ; 


TUMOURS  AND  CYSTS  '         igj 

and  even  where  it  may  apply,  no  reason  is  assigned  why  the 
embryonic  '  rest '  should  suddenly. take  on  renewed  growth  in  after-life. 

3.  Ribbert's  theory  of  tissue  tension  is  especially  applicable  to 
the  carcinomata,  and  attributes  the  initial  defect  to  a  weakness 
in  the  connective  tissues  in  proximity  to  the  epithelial  cells,  so  that 
the  latter  are  allowed  to  proliferate  and  invade  the  surrounding 
structures.  The  balance  of  evidence  seems  decidedly  opposed  to 
this  theory,  although  it  affords  a  satisfactory  explanation  of  the 
frequency  of  carcinomata  in  advanced  life,  when  the  vitality  and 
resisting  power  of  the  tissues  may  be  assumed  to  be  lowered. 

Tumours  may  be  divided  into  two  great  classes  from  a  clinical 
standpoint,  viz.,  the  benign  and  the  malignant. 

Benign  or  Simple  Tumours  are  characterized  by  their  more  or  less 
exact  limitation,  being  frequently  encapsuled,  and  by  their  method 
of  growth,  which  results  from  a  proliferation  of  all  the  cells  con- 
stituting their  structure.  There  is  no  tendency  to  infiltrate  or  invade 
surrounding  tissues,  which  are  merely  pushed  aside  and  compressed ; 
pain  and  atrophy  are  sometimes  caused  by  this  pressure.  The 
capsule  is  formed  by  an  ensheathing  layer  of  fibro-cellular  tissue,  the 
outcome  of  the  chronic  irritation  and  inflammation  engendered  by  the 
growth  and  development  of  the  mass ;  hence  enucleation  is  easy,  and 
recurrence  uncommon.  They  are  not  unf  requently  multiple,  and  may 
be  hereditary ;  but  there  is  no  tendency  to  produce  secondary  growths. 

Malignant  Tumours,  unless  removed  by  operation,  are  almost  in- 
variably fatal.  The  following  are  the  chief  characteristics  of 
malignancy :  (i)  The  primary  growth  is  usually  single,  rarely  multiple. 
(2)  It  progresses  steadily  and  constantly,  but  with  varying  rapidity 
in  different  cases.  (3)  The  local  development  is  characterized  by  an 
infiltration  of  the  surrounding  tissues,  which  are  gradually  replaced 
by  the  tumour  substance.  A  capsule  is  rarely  formed,  or,  if  at  all, 
only  in  the  early  stages,  and  thus  the  limits  of  the  growth  are  not 
clearly  defined.  Moreover,  many  varieties  spread  locally  along  the 
efferent  lymphatics,  and  hence,  although  the  growth  may  appear  to 
have  been  completely  excised,  recurrences  are  very  common,  owing 
to  the  non-removal  of  these  invisible  extensions  of  the  disease  into 
apparently  normal  tissue.  If  a  malignant  tumour  with  all  its  ramifi- 
cations is  completely  removed,  it  does  not  recur.  The  impossibility 
of  knowing  whether  all  the  growth  has  been  removed,  or  how  far  it 
has  extended,  is  responsible  for  the  frequent  recurrences.  (4)  When 
a  malignant  tumour  invades  the  skin,  it  usually  leads  to  ulceration 
and  is  very  liable  to  septic  infection,  and  then  not  uncommonly  a  foul 
f ungating  mass  results  (the  fungtis  hcematodes  of  the  older  pathologists). 
(5)  Secondary  deposits  due  to  embolic  dissemination  of  the  cells  of 
the  growth  are  often  found  in  neighbouring  lymphatic  glands  or 
distant  viscera.  (6)  Cachexia  develops  in  the  later  stages,  partly  due 
to  the  pain,  partly  to  the  pressure  of  the  growth  on  important 
structures,  and  in  part  to  the  absorption  of  toxic  products  from  the 
tumour.  The  patient  becomes  thin  and  emaciated,  the  face  drawn 
and  with  an  expression  of  pain  on  it;  the  appetite  is  impaired,  and 
the  skin  often  sallow  and  earthy-looking.     Pyrexia  is  usually  absent 


i88  A  MANUAL  OF  SURGERY 

unless  septic  ulceration  of  the  growth  occurs,  as  is  usually  the  case  in 
the  stomach  or  intestine ;  some  rapidly-growing  sarcomata  of  bones 
are  also  associated  with  fever.  (7)  Finally,  death  ends  the  scene, 
after  a  longer  or  shorter  period  of  suffering. 

The  degree  of  malignancy  varies  with  different  tumours.  In 
some  the  local  phenomena  predominate,  whilst  in  others  the  con- 
stitutional symptoms  are  the  more  important.  Thus,  rodent  ulcer 
is  slow  in  its  progress,  and  produces  no  visceral  deposits ;  it  destroys 
life  merely  by  implication  of  vital  parts.  Melanotic  sarcoma,  on  the 
other  ha:nd,  may  produce  only  a  small  primary  growth,  but  the  most 
extensively  diffused  secondary  deposits  may  form  in  the  viscera. 
The  sarcomata  are  usually  disseminated  by  the  blood-stream,  and 
hence  secondary  growths  are  not  very  common  in  lymphatic  glands, 
whilst  the  carcinomata  spread  by  means  of  the  lymphatics.  Even 
among  the  latter  considerable  differences  are  manifested ;  thus,  in 
glandular  cancer  secondary  growths  occur  both  in  the  lymphatics 
and  the  viscera;  whilst  in  squamous  epithelioma  neighbouring 
lympnatics  are  affected,  but  the  viscera  usually  escape. 

As  a  general  rule  malignant  tumours  differ  structurally  from  the 
innocent  forms  in  deviating  more  widely  from  the  normal  histology 
of  the  region  in  which  they  develop  ;  thus  a  simple  adeno-fibroma  of 
the  breast  approaches  more  closely  to  the  structure  of  the  normal 
mammary  gland  than  does  an  adeno-carcinoma  of  the  same  region. 
This  deviation  from  the  normal  is  called  anaplasia,  and  in  general  the 
greater  the  degree  of  anaplasia  the  greater  the  malignancy.  It  is 
seen  in  the  structure  of  the  cells  as  well  as  in  their  arrangement,  and 
m  highly  malignant  tumours  the  constituent  cells  to  a  large  extent 
lose  their  distinctive  appearance  {e.g.,  prickle-cells  lose  their  prickles, 
etc.),  and  revert  to  more  simple  forms.  Highly  specialized  functions 
are  also  lost  or  badly  performed. 

Classification  of  Tumours. — The  following  is  a  practical  scheme  of 
classification,  based  partly  on  the  structure  of  the  tumour,  and  partly 
on  that  of  the  tissue  from  which  it  originates. 

1.  Tumours  derived  from  the  Connective  Tissues: 

(a)  Of  embryonic  type : 
Sarcoma. 

{b)  Of  adult  type  : 

Myxoma  (mucoid  tumour) 

Lipoma  (fatty  tumour). 

Fibroma  (fibrous  tumour). 

Chondroma  (cartilaginous  tumour). 

Osteoma  (bony  tumour). 

Myoma  (muscle  tumour). 

Neuroma  (tumour  in  connection  with  nerves). 

Glioma  (tumour  of  neurogha). 

Angioma  (tumour  composed  of  bloodvessels). 

Lymphadenoma  and  lymphangioma  (tumours  of 

lymphatic  origin). 
Odontoma  (tumour  connected  with  the  teeth). 


TUMOURS  AND  CYSTS  189 

II.  Tumours  composed  Wholly  or  CMefly  of  Epithelium. — These 
may  resemble  papillae  or  glands,  or  may  infiltrate  the  connective 
tissue  in  a  wholly  irregular  way,  and  hence  may  be  subdivided  as 
follows : 

(a)  Tumours  resembling  papillae  : 

{Squamous-celled. 
Cuboidal-celled. 
Columnar-celled. 

(i)  Tumours  resembling  glands  : 

A  J  ( Cuboidal-celled. 

Adenoma        i  r-  ^  n  j 

(^  Columnar-celled. 

(c)  Atypical  tumours : 

{Squamous-celled  (epithelioma). 
Cuboidal-celled  (glandular  carcinoma). 
Columnar-celled. 

III.  Tumours  growing  from  Endothelium : 

Endothelioma. and  perithelioma. 

IV.  Tumours  formed  by  the  Inclusion  of  Part  of  another  Embryo  : 

Teratoma. 

I.  The  Connective-Tissue  Group  of  Tumours :  (i)  Tumours 
composed  of  Embryonic  Connective  Tissue. 

Sarcoma  (  =  a  flesh-like  tumour  ;  Greek,  o-apf^  flesh). — A  sarcoma  is 
a  malignant  tumour  which  is  derived  from  connective  tissue.  Like 
all  tumours,  it  consists  of  a  parenchyma,  formed  of  cells  which  have 
taken  on  the  power  of'  continued  and  apparently  Umitless  growth, 
and  of  a  more  or  less  inert  supporting  network  or  stroma  consisting 
of  fibrous  tissue,  bloodvessels,  etc.  It  is  characteristic  of  the 
sarcomata  that  these  two  elements  are  intimately  mingled  together, 
each  parenchyma  cell  being  separated  from  its  neighbours  by 
delicate  fibrillse  of  the  stroma;  in  the  carcinomata  this  is  not  the 
case,  since  the  parenchyma  cells  occur  in  masses  or  alveoli  which 
are  enclosed  by,  and  sharply  marked  off  from,  the  stroma.  The 
parenchyma  cells  of  the  sarcomata  are  of  mesoblastic  origin,  and 
resemble  the  cells  from  which  the  connective  tissues  are  formed  in 
the  embryo  both  in  shape  and  in  their  capacity  for  continued  growth ; 
hence  they  are  often  referred  to  as  embryonic  connective-tissue  cells. 
There  is,  moreover,  a  great  resemblance  between  the  sarcomata  and 
inflammatory  new  formations,  which  are  also  composed  of  meso- 
blastic cells  which  have  assumed  the  power  of  growth;  and  this 
resemblance  is  increased  by  the  fact  that  in  both  cases  these 
embryonic  cells  may  undergo  organization  into  more  mature  forms 
of  connective  tissue,  such  as  fibrous  tissue  or  bone.  There  is,  how- 
ever, this  marked  difference  between  the  two :  the  inflammatory  new 
formations  arise  as  the  result  of  a  definite  irritant,  and  cease  to 
spread  when  that  irritant  ceases  to  act ;  whereas  the  sarcomata  usually 
arise  without  apparent  cause,  and  continue  to  spread  indefinitely. 


igo  A  Manual  of  surgery 

A  sarcoma  may  at  first  be  well  defined  or  even  encapsulated  ;  but 
many  forms  from  the  first,  and  all  later  on,  infiltrate  the  surrounding 
tissues,  replacing  thera  with  their  own  particular  structure,  a  process 
which  can  be  well  observed  in  sarcomata  of  muscles.  The  blood- 
supply  is  very  abundant,  and,  indeed,  may  be  so  free  as  to  cause  the 
tumour  to  pulsate.  The  vessels  consist  of  spaces  or  clefts  within 
the  tumour  substance,  and  are  lined  merely  by  the  most  delicate 
endothelium ;  the  arteries  and  veins  in  the  neighbourhood  are  much 
dilated.  Interstitial  haemorrhage  is  frequent,  owing  to  the  thinness 
of  the  vessel  walls,  and  cysts  may  in  this  way  be  produced.  Dis- 
semination is  usually  dependent  on  the  relation  of  the  tumour  to  the 
veins.  As  already  stated,  the  veins  communicate  with  spaces 
hollowed  out  of  the  tumour  substance ;  into  and  along  these  the 
sarcomatous  tissue  may  burrow,  until  the  apex  of  this  intravascular 
growth  projects  into  the  lumen  of  a  vessel  in  which  the  blood  is  freely 
circulating.  It  may  be  detached  by  some  slight  mechanical  injury, 
and  is  then  carried  away  as  a  malignant  embolus  ;  if  a  large  portion 
is  set  free,  it  may  lodge  in  the  right  side  of  the  heart,  or  in  the  lungs, 
and  cause  a  fatal  result.  Smaller  emboli  are  either  detained  in  the 
lungs,  or  pass  through  into  the  general  circulation,  giving  rise  to 
secondary  growths  wherever  they  are  arrested ;  it  is  quite  usual  for 
general  visceral  implication  to  be  secondary  to  the  pulmonary 
growths.  Nothing  is  known  as  to  the  existence  of  nerves  or 
lymphatics  in  sarcomata ;  occasionally,  however,  dissemination  by 
way  of  the  lymphatic  glands  is  met  with,  especially  in  melanotic 
sarcoma  of  the  skin,  lympho-sarcoma,  and  sarcoma  of  the  tonsil, 
testis,  and  thyroid  body. 

The  various  forms  of  sarcoma  described  below  have  a  tendency 
to  become  organized  into  tissues  which  bear  a  close  resemblance  to 
the  normal  connective  tissues,  and  tumours  in  which  this  process 
has  taken  place  to  a  marked  extent  often  receive  Special  names — e.g., 
fibro-sarcoma,  in  which  the  parenchyma  cells  become  organized  into 
fibrous  tissue ;  osteo-sarcoma,  in  which  they  develop  into  bone ; 
chondro-sarcoma ;  and  lipo-sarcoma. 

Degenerative  changes  are  also  apt  to  occur  in  the  older  portions 
of  a  sarcoma,  but  not  at  the  spreading  edges,  so  that  the  malig- 
nancy of  the  tumour  is  not  thereby  affected.  Fatty  degeneration  is 
the  commonest,  and  leads  to  the  formation  of  a  tumour,  which  must 
be  distinguished  from  a  lipo-sarcoma;  mucoid  softening  may  also 
take  place,  and  tumours  in  which  this  has  happened  are  often 
known  as  myxo-sarcomata.  Haemorrhage  is  frequent  into  the  softer- 
varieties,  and  calcification  is  not  unfrequent  in  the  more  chronic  forms^ 

On  naked-eye  examination,  a  sarcoma  presents  a  more  or  less 
homogeneous  appearance,  the  colour  varying  with  the  amount  of  the 
blood-supply,  from  a  grayish-white  in  the  fibro-sarcoma  to  a  deep 
maroon  colour  in  the  myeloid. 

This  form  of  malignant  disease  occurs  most  commonly  in  young 
and  middle-aged  people,  especially  affecting  the  first  and  fourth 
decades  of  life;  it  may  also  be  congenital.     The  degree  of  malign 


TUMOURS  AND  CYSTS  161 

ftancy  varies  considerably,  some  forms  being  almost  benign,  or,  at 
any  rate,  only  locally  malignant,  whilst  others  are  exceedingly 
virulent  in  nature. 

Sarcomata  are  divided  artificially  into  the  following  groups, 
depending  on  the  size,  shape,  arrangement,  and  character  of  the 
constituent  cells :  (a)  The  round-celled ;  (b)  the  spindle-celled ; 
(c)  the  myeloid  ;  (d)  the  alveolar  ;  and  {e)  the  melanotic. 

(a)  Round-celled  Sarcomata  (Fig.  44)  consist  of  a  mass  of  round 
cells  containing  a  very  definite  circular  or  oval  nucleus  ;  the  inter- 
cellular substance  is  slight  in  amount,  and  often  homogeneous  in 
character.  The  mass  is  very  vascular,  and  may  even  pulsate ;  it 
is  soft,  like  granulation  tissue,  and  usually  grows  rapidly.  Several 
subdivisions   are    described :    (i.)    The   small   round-celkd   sarcoma    is 


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Fig.  44- — Small  Round-celled  Sarcoma,  showing  the  Advancing  Edge 
OF  THE  Growth  infiltrating  Muscle  and  Salivary  Gland,     (x   120.) 

ex  rem"  y  malignant,  infiltrating  surrounding  parts,  and  early  giving 
rise  to  secondairy  deposits ;  lymphatic  glands  are  not  unfrequently 
affected  in  this  variety.  The  small  size  of  the  cells  is  thought  to 
be  an  indication  of  thei  rapidity  of  development,  since  they  divide 
before  growing  to  a  large  size.  Any  part  of  the  body  may  be 
involved,  and  it  may  be  met  with  at  any  age.  (ii.)  The  large  round- 
celled  sarcoma  is  made  up  of  larger  cells,  which  contain  one  or  two 
large  oval  nuclei  with  an  abundant  protoplasm  around.  A  well- 
marked  stroma  is  interspersed  between  the  cells,  and  an  alveolar 
arrangement  is  sometimes  present ;  it  occur;;  in  the  same  position 
as  the  former,  but  is  rather  less  malignant,  (iii.)  Lymphosarcoma  is 
very  similar  in  structure  ;  the  cells,  however,  are  small,  and  the  inter- 
cellular substance  is  of  a  delicate  reticular  nature,  corresponding  to 
the  retiform  tissue  met  with  in  lymphatic   glands.     Such  tumours 


192 


A  MANUAL  OF  SURGERY 


grow  rapidly,  and  are  exceedingly  malignant ;  they  usually  start  in 
lymphatic  glands,  or  in  the  lymphoid  tissue  of  mucous  membranes, 
and  are  disseminated  by  means  of  the  lymphatics.  For  the  clinical 
characters  of  these  tumours,  see  Chapter  XIV. 

(b)  Spindle-celled  Sarcomata  (Fig.  45)  consist  of  large  or  small 
spindle  cells,  which  are  often  arranged  in  a  somewhat  fasciculated 
manner  with  a  greater  or  less  amount  of  intercellular  substance. 
When  consisting  of  small  cells,  the  tumour  grows  rapidly,  and  is  firmer 
and  less  succulent  than  the  round-celled  variety.  They  may  originate 
in  any  part  of  the  body,  but  more  especially  from  aponeuroses, 
fasciae,  tendons,  etc.,  constituting  localized  growths,  which  are  at  first 
tolerably  well  defined,  but  later  on  invade  and  infiltrate  surrounding 


^i:r~^^jZ^^:'^i 


Fig.  45. — Spindle-celled  Sarcoma,     (x  100.) 

Some  of  the  fibres  are  running  in  longitudinal  bundles  ;    others  are 
cut  transversely. 


parts.  When  growing  rapidly,  the  cells  become  less  fusiform  in 
shape,  and  may  even  approach  to  the  round  cell  in  character,  aftef 
passing  through  a  stage  known  as  the  oval  or  oat-shaped  sarcoma. 
A  few  giant  cells  are  often  seen  in  these  cases.  These  tumours, 
consisting  of  small  spindle  cells,  are  usually  very  malignant. 

In  some  few  cases  the  cells  undergo  organization  into  well-formpd 
fibrous  tissue,  and  the  tumour  closely  resembles  a  simple  fibroma, 
being  well  encapsuled,  so  that  it  can  be  shelled  out  with  ease.  These 
tumours  are  known  as  Jibro -sarcomata  ('recurrent  fibroid  '  tumours  of 
Paget),  and  are  not  imcommon  in  the  subcutaneous  tissues.  They 
are  on  the  border-line  of  malignancy,  since  they  rarely  form  secondary 
growths,  and  often  do  not  return  for  two  or  three  years  after  removal. 
After  each  operation,  however,  they  usually  recur  more  rapidly,  and 


TUMOURS  AND  CYSTS 


t93 


show  signs  of  greater  malignancy,  until,  after  perhaps  being  removed 
a  dozen  times,  they  recur  with  all  the  characters  of  an  ordinary  spindle- 
celled  sarcoma. 

The  large  spindle -celled  sarcomata  are  softer  and  of  a  deeper  colour 
than  the  former.  They  grow  from  the  fibrous  tissues,  and  not 
uncommonly  from  the  viscera.  The  congenital  sarcoma  of  the 
kidney  is  of  this  nature,  though  some  of  the  cells  become  transversely 
striated,  looking  like  muscle  fibres  ;  such  tumours  are  sometimes 
called  '  my o- sarcomata.' 

(c)  Myeloid  Sarcomata  (Fig.  46)  are  characterized  by  the  presence 
of  large  numbers  of  multi-nucleated  giant  cells  [mycloplaxes),  im- 
bedded in  a  considerable  quantity  of  round  or  spindle  cells,  the 
intercellular  substance  being  usually  of   a  gelatinous  nature.     The 


I'' 


'*   ^■, 


Fjg.  46. — Myeloid  Sarcoma,  showing  the  Molti- nucleated  Mveloid  Cells 
(Myeloplaxes)  lying  amongst  the  More  Abundant  Round  and  Spindle 
Cells,     (x  100.) 

myeloid  cells  vary  a  good  deal  in  size,  but  always  contain  a  large 
number  of  distinct  nuclei,  which  are  not  distributed  regularly  in  the 
periphery  of  the  cell,  as  in  the  case  of  the  giant  cells  of  tubercle ; 
they  may  be  regular  in  outline,  or  prolonged  into  numerous  inter- 
lacing processes,  although  these  latter  are  usually  not  very  evident. 
There  is  also  no  definite  arrangement  of  cells  around  them,  as  in  the 
tubercular  giant-cell  systems.  These  tumours  are  soft  in  consistency, 
and  on  scraping  a  slimy  fluid  is  obtained.  They  are  exceedingly 
vascular,  and  may  pulsate.  Haemorrhage  into  their  substance  is 
common,  giving  rise  to  cysts,  filled  with  serum  and  a  yellowish 
fibrinous  clot  stained  with  the  colouring  matter  of  the  blood.  When 
fresh,  the  growing  edge  is  of  a  dark  maroon  colour  on  section,  and 
has  been  likened  to  the  appearance  of  a  pomegranate ;  when  preserved 

13 


t^4  ^  MANUAL  OF  SURGERY 

in  spirit,  these  tumours  are  always  of  a  characteristic  brown  coiouf, 
owing  to  the  formation  of  haematin.  They  are  the  least  malignant 
of  all  the  sarcomata,  but  rarely  or  never  giving  rise  to  secondary 
deposits,  either  in  the  lymphatic  glands  or  viscera.  Their  growth  is 
tolerably  rapid,  and  they  may  attain  enormous  dimensions.  Myeloid 
sarcoma  is  almost  invariably  found  growing  from  the  medulla  of 
bones,  and  hence  has  been  termed  a  myeloma  :  for  the  particular  sites, 
symptoms,  and  treatment,  see  Chapter  XX. 

(d)  Alveolar  Sarcoma  is  a  variety  in  which  the  cells  are  grouped 
together  in  alveoli,  separated  by  a  distinct  fibrous  stroma.  On 
microscopic  examination  they  closely  resemble  cancer ;  but  on  care- 
fully pencilling  a  section  with  a  camel's-hair  brush,  it  will  be  found 
that  the  stroma  sends  delicate  prolongations  between  each  of  the 
cells.  It  is  quite  possible  that  the  majority  of  these  tumours  are  in 
reality  endotheliomata.  They  are  most  commonly  found  growing 
from  the  skin,  are  occasionally  of  a  melanotic  nature,  and  often  very 
malignant. 

(e)  Melanotic  Sarcoma  is  the  most  virulent  of  all  this  group  of 
tumours,  because  of  the  early  date  at  which  it  forms  secondary 
deposits  in  lymphatic  glands  and  internal  organs.  It  grows  from 
those  portions  of  the  body  which  are  naturally  pigmented,  especially 
the  choroid  coat  of  the  eye  and  the  skin.  Those  growing  from  the 
former  situation  are  usually  composed  of  spindle  cells,  all  of  which 
contain  granules  of  melanin ;  these  choroidal  tumours  are  true 
sarcomata,  and  have  a  special  tendency  to-  form  secondary  deposits 
in  the  liver.  The  melanomata  of  the  skin  most  frequently  develop 
from  pigmented  moles  (Plate  III.,  Fig.  i).  They  have  an  alveolar 
structure,  and  were  formerly  regarded  as  alveolar  sarcomata,  but 
most  pathologists  now  follow  Unna  in  regarding  the  tumour  cells  as. 
being  derived  from  downgrowths  of  the  surface  epithelium,  and 
classify  the  tumours  themselves  as  carcinomata.  The  pigment 
granules  in  this  form  are  very  unevenly  distributed,  some  lying  in 
the  stroma  between  the  alveoli,  whilst  others  are  contained  in  the 
cells ;  some  portions  of  the  primary  tumour  are  often  quite  free  from 
pigment,  and  some  of  the  secondary  growths  are  often  colourless, 
whilst  adjacent  growths  may  be  absolutely  black.  The  nature  of 
the  pigment  (melanin)  is  still  uncertain,  but  the  fact  that  it  does  not 
contain  iron  seems  to  indicate  that  it  is  not  derived  from  haemoglobin. 
It  maybe  deposited  in  the  skin  of  the  patient  apart  from  the  tumours 
(melanosis),  or  may  be  excreted  in  the  urine. 

If  the  primary  tumour  is  not  removed  very  early,  the  nearest 
lymphatic  glands  are  soon  affected,  and  secondary  deposits  in  the 
viscera  follow.  The  original  tumour  is  often  not  very  large,  and  the 
secondary  deposits  are  frequently  characterized  by  their  number  rather 
than  by  their  size,  scarcely  an  organ  in  the  body  being  free. 

Of  late  years  a  more  benign  type  of  cutaneous  melanosis  has  been  described, 
and  is  now  well  recognised  by  dermatologists.  It  usually  spreads  from  a  con- 
genital mole  as  a  deeply  pigmented  patch,  which  may  extend  over  an  area  of 
several  square  inches,  and  presents  at  first  no  sign  of  induration  or  infiltration; 


PLATE    III. 


,^^^K 


Fig.  I. — Melanotic  Sarcoma  of  Buttock,  with  secondary  coloured  nodules  in  the 
line  of  the  lymphatics  between  the  growth  and  the  inoperable  inguinal  glands. 


Fig.  2.— Fungating  Carcinoma  of  outer  side  of  the  right  Breast  (Fungus 
Hsematodes)  with  dissemination  through  skin  between  the  growth  and  the  nipple,  and 
around  the  nipple,  constituting  an  eczematous-looking  patch,  somewhat  akin  to 
Paget's  disease. 

S^To  face  page  194. 


TUMOURS  AND  CYSTS  I95 

in  this  stage  microscopic  examination  reveals  no  change  in  texture  except 
pigmentation  of  tlie  deeper  layers  of  the  cutis  vera.  Sooner  or  later,  a  tumour 
develops  in  the  centre  of  this  patch  ;  it  is  not  very  rapid  in  its  course,  but  if  left 
alone  will  finally  become  disseminated.  In  treating  this  type  of  melanosis,  it  is 
essential  to  remove  every  portion  of  pigmented  tissue  as  well  as  the  tumour. 

The  Treatment  of  sarcoma  consists  in  its  removal  as  early  and 
completely  as  possible.  This  may  be  a  simple  matter  in  cases  where 
the  tumour  is  encapsuled,  but  even  then  recurrence  is  very  likely  to 
follow  unless  the  capsule  is  also  taken  away,  and  a  considerable 
margin  of  tissue  beyond  it.  Where,  however,  the  growth  is  more 
diffuse,  the  only  hope  lies  in  cutting  widely,  so  as  to  get  beyond  its 
furthest  limits ;  the  prognosis  of  such  cases  is  very  bad. 

In  hopelessly  inoperable  cases  somewhat  similar  measures  have  been 
employed  as  for  the  similar  stage  of  cancer  {vide  p.  218).  Many 
cures  have  been  recorded  from  the  use  of  Coley's  fluid,  which  consists 
of  a  sterilized  culture  of  the  Streptococcus  pyogenes  and  Micrococcus 
prodigiostis  in  bouillon.  This  fluid  is  intensely  toxic,  and  the  injections 
commencing  with  doses  of  half  a  minim,  are  gradually  increased  up 
to  7  or  8  minims  or  more ;  severe  reaction  usually  follows,  and  the 
surgeon  should  aim  at  obtaining  two  or  three  such  effects  each  week. 
The  fluid  is  introduced  partly  into  the  abdominal  wall,  and  partly 
into  or  around  the  tumour.  In  favourable  cases  the  growth  gradually 
dwindles.  The  spindle-celled  and  some  ossifying  sarcomata  are 
apparently  the  most  suitable  for  this  treatment,  whilst  melano- 
sarcomata  are  but  little,  if  at  all,  affected.  It  is  important  to  ascer- 
tain that  the  Coley's  fluid  is  really  active ;  most  of  that  sold  in 
England  up  to  a  recent  date  has  been  inoperative.  .■  As  to  the  value 
of  X  rays  for  sarcoma,  see  p.  218.  .  ' 

(2)  Tumours  consisting  of  Connective  Tissue  of  Adult  Type. 

Myxoma. — A  myxoma  is  a  tumour  consisting  of  connective-tissue 
cells,  surrounded  by  and  separated  from  each  other  by  an  inter- 
cellular substance  of  a  mucoid  character ;  a  similar  type  of  material 
occurs  normally  in  the  substance  of  the  umbilical  cord.  The  cells 
are  usually  polygonal  in  shape,  and  present  long  branched  processes 
which  interlace  with  those  from  adjacent  cells.  The  intercellular 
substance  is  homogeneous  and  translucent,  containing  wandering 
connective-tissue  corpuscles,  and  traversed  by  bloodvessels;  the 
density  of  the  tumour  varies  inversely  with  the  amount  of  inter- 
cellular substance.  It  is  not  uncommon  for  this  form  of  growth  to 
be  associated  with  sarcoma,  and  hence  a  thorough  and  early  removal 
of  the  mass  is  always  advisable. 

Myxomata  occur  as  rounded  tumours,  perhaps  lobulated,  in  the 
neighbourhood  of  mucous  membranes — e.g.,  the  face,  intestine,  and 
bladder ;  they  also  grow  in  the  sheaths  of  nerves,  and  are  the  com- 
monest form  of  simple  tumour  of  the  spinal  cord. 

Lipoma. — A  fatty  tumour  is  an  overgrowth  of  fibro-cellular  tissue, 
infiltrated  wittj  fat.     On  microscopical  examination  it  differs  in  no 


tg6 


A  MANUAL  OF  SURGERY 


respect  from  ordinary  adipose  tissue,  and  is  not  very  freely  supplied 
with  bloodvessels. 

When  localized  (Fig.  47)  it  forms  a  tumour,  soft  and  semi- 
fluctuating  in  consistence,  rounded  and  lobulated  in  outline,  and  if 
occurring  in  the  subcutaneous  tissues,  the  skin  becomes  dimpled  on 
moving  it  from  side  to  side,  owing  to  the  fact  that  fibrous  trabeculae 
pass  from  the  capsule  to  the  skin.  The  growth  is  usually  encapsuled 
and  freely  moveable ;  but  if  exposed  to  pressure  or  friction,  as  when 
situated  on  a  man's  shoulder  and  rubbed  by  the  braces,  it  becomes 
firmly  adherent  to  surrounding  structures.  Such  growths  are  either 
single  or  multiple,  in  the  latter  case  perhaps  occurring  in  hundreds, 
and  are  most  commonly  found  about  the  trunk  or  the  upper  extremi- 
ties. Occasionally  subcutaneous  tumours  become  pedunculated  and 
pendulous. 

The  diagnosis  of  a  subcutaneous  lipoma  from  a  chronic  abscess  is 
made  by  noting  that  in  the  former  there  is  a  defined  outline  of  a 

lobulated  character,  that  the  edge 
slips  away  on  making  pressure 
over  it,  and  that  the  skin  dimples 
on  moving  the  growth  from  side 
to  side.  In  a  chronic  abscess 
the  swelling  is  less  defined  in 
outline,  has  a  shelving  margin, 
and  the  skin  is  either  quite  free 
or  adherent  over  a  considerable 
area.  Fluctuation  is  present  in 
both,  since  fat  at  the  temperature 
of  the  body  is  fluid. 

Deep  intermuscular  lipomata 
ave  sometimes  met  with,  and  the 
diagnosis  may  then  be  uncertain, 
since  their  mobility  and  lobu- 
lated outline  are  masked  by  the 
superjacent  tissues ;  they  have 
even  been  mistaken  for  sarco- 
matous growths.  Still  more  difficult  of  recognition  are  those  known 
as  Parosteal  Lipomata,  growing  from  the  outer  surface  of  the  peri- 
osteum. They  are  often  congenital,  and  appear  as  soft  swellings, 
lying  beneath  the  muscles  in  close  proximity  to  a  bone  and  suggesting 
the  presence  of  a  chronic  abscess. 

A  painful  lipoma  of  the  foot*  has  been  described  (Tubby)  as  occur- 
ring on  the  inner  side  of  the  sole,  causing  great  pain  on  walking  a^xd 
simulating  flat-foot.  Removal  by  operation  is  necessary,  and  must 
be  very  thorough,  if  recurrence  is  to  be  avoided. 

Pericranial  Lipoma  is  of  a  somewhat  similar  nature.  It  is  usually 
congenital  in  origin,  and  the  cranium  may  be  hollowed  out  beneath 
it.  An  angiomatous  element  is  sometimes  present  in  these  growths 
(naevo-lipoma). 

*  American  Journal  0/ OrtJiopadic  Surgery,  May,  1909. 


Fig.  47. — ^^  Lipoma,  showing  Charac- 
teristic Lobulated  Outline.  (From 
King's  College  Hospital  Museum.) 


TUMOURS  AND  CYSTS 


197 


By  the  term  Diffuse  Lipoma  (Fig.  48)  is  meant  a  fatty  infiltration 
of  the  subcutaneous  tissues  of  some  region  of  the  body,  particularly 
beneath  the  chin  and  at  the  back  of  the  neck,  and  more  rarely  in  the 
pubic  region.  These  growths  are  often  multiple  and  almost  always 
symmetrical.  They  usually  occur  in  men  who  drink  beer  freely  and 
take  but  little  exercise.  Their  size  sometimes  diminishes  on  limiting 
the  amount  of  alcohol  and  making  the  patient  do  physical  work. 

In  some  of  these  cases  the  term  '  diffuse '  is  not  strictly  merited,  as 
the  growths  are  in  reality  limited,  but  the  limitations  are  difficult  to 
define  in  the  midst  of  the  surrounding  fat.  They  have  a  consider- 
able tendency  to  burrow,  and  by  their  pressure  on  important  organs 
may  sometimes  lead  to 
serious  symptoms. 

A  somewhat  dif- 
ferent type  of  fatty 
overgrowth  is  met 
with  generally  in 
women  about  the 
climacteric,  in  whom 
masses  of  fat  accumu- 
late in  various  parts 
of  the  body,  associated 
with  severe  pain  of  a 
neuralgic  type,  and 
constituting  the  condi- 
tion known  as  Adiposis 
dolorosa  (Dercum's 
disease).  The  thyroid 
body  is  often  deficient, 
and  the  mental  state 
dull.  It  is  an  open 
question  whether  or 
not    this    affection     is  pj^_  48.-Diffuse  Lipoma. 

allied  to  myxoedema.  ,„  ,    ,  ,  . 

T  1-      J  j-rr  (From  a  photograph.) 

Localized  or  diriuse 

overgrowths   are  often  met  with  in  the  subperitoneal  tatty  tissue, 

constituting  Subserous  Lipomata.    They  occur  not  unfrequently  in  the 

lower  part  of  the  abdomen,  and  may  extend  into  the  inguinal  and 

crural   canals,  forming   the  so-called   fatty  tumour  in  these  parts. 

By  their  traction  a  process  of  peritoneum  may  eventually  be  drawn 

down,    and  a  true  hernia  produced.     A    similar    condition    occurs 

in  the  anterior  abdominal  wall,  small  pedunculated  masses  of  fat 

projecting  through  congenital  or  acquired  openings  in  the  linea  alba 

or  linea  semilunaris ;  these  are  known  as  Fatty  Hernia  of  tlie  Linea 

Alba,  and  are  often  painful. 

Occasionally  the  connective-tissue  basis  of   a  lipoma  undergoes 

modifications ;  e.g.,  it  may  become  increased  in  amount,  and  fibrous 

in  character ;  it  may  be  associated  with  a  myxomatous  element,  or 

even  become  sarcomatous.     For  naevo-lipoma,  see  p.  355. 


198  A  MANUAL  OF  SURGERY 

'  The  Treatment  of  lipomata  consists  in  their  removal.  When  they 
are  loosely  encapsuled,  this  is  a  very  simple  matter,  all  that  is 
required  in  many  cases  being  to  squeeze  the  mass  forwards  between 
the  thumb  and  finger,  making  the  skin  tense  over  it,  and  then  to 
incise  the  capsule  freely,  when  the  tumour  almost  jumps  out ;  but  if 
there  are  many  adhesions  it  may  not  be  so  easy.  In  the  diffuse  forms 
dietetic  and  hygienic  meaeures  should  first  be  tried,  and  possibly  the 
prolonged  administration  of  thyroid  extract  (grs.  5  every  night)  will 
suffice  to  diminish  their  bulk.     Should  an  operation  be  required,  it  is  ■ 


Fig.  49. — Section  of  Hard  Fibroma.      (Royal  College  of  Surgeons' 

Museum.) 

well  to  cut  through  the  whole  thickness  of  the  tumour  at  once,  and 
deal  with  each  half  separately,  dissecting  it  away  from  its  deep 
attachments. 

Fibromata  consist  of  overgrowths  of  fibrous  tissue  ;  they  were 
formerly  divided  into  two  groups,  the  hard  and  the  soft,  and  although 
there  is  no  essential  difference,  it  is  a  useful  clinical  distinction. 

The  Hard  Fibroma  is  composed  of  firm  dense  tissue,  which  creaks 
on  section  with  the  knife,  the  exposed  surface  showing  numerous 
trabeculae  of  glistening  fibres,  similar  in  character  to  those  met  with 
in  a  tendon  (Fig.  49).  Microscopically,  interlacing  fibrillae  are  seen, 
which  are  sometimes  arranged  concentrically  around  the  blood- 
vessels ;  there  are  but  few  nucleated  cells  in  the  more  slowly  growing 
tumours.  The  vascular  supply  is  somewhat  defective,  although 
dilated  veins  are  often  present  in  the  capsule,  and  sometimes  in  the 


TUMOURS  AND  CYSTS 


199 


substance  of  the  mass ;  these,  if  opened  by  ulceration,  may  lead  to 
profuse  haemorrhage.  Hard  fibromata  are  met  with  in  the  form  of 
epulis,  fibrous  polypus  of  the  naso -pharynx,  and  not  uncommonly  in  the 
sheaths  of  nerves. 

Soft  Fibromata  develop  as  localized  overgrowths  of  the  subcu- 
taneous fibro- cellular  tissue,  or  as  the  so-called  Molluscum  fibrosum. 
In  the  latter  case  many  different  forms  of  the  growth  are  met  with  ; 
sometimes  many  small  nodules  develop,  scattered  widely  over  the 
surface,  usually  pinkish,  and  with  the  skin  over  them  somewhat 
corrugated ;  sometimes  it  exists  in  the  form  of  pendulous  folds, 
perhaps  involving  a  large  area  of  the  trunk ;  the  so-called  pachy- 
dermatocele of  the  scalp  is  of  this  nature.  Most  of  these  growths 
are  now  considered  to  be  neuro-fibro- 
matous  in  origin  (p.  204). 

Chondroma. —  Cartilaginous 
tumours  are  met  with  growing  in 
connection  with  either  bones  or  carti- 
lages. They  consist  of  hyaline  carti- 
lage, which  instead  of  being  uniform 
in-  texture  and  devoid  of  vessels,  as 
at  the  articular  ends  of  bones,  occurs 
in  the  form  of  pellets  or  nodules  of 
varying  size,  held  together  by  vascular 
connective  tissue,  which  may  even 
penetrate  into  its  substance.  The 
cells  are  also  less  regular  in  shape 
than  is  the  case  with  normal  cartilage, 
and  are  not  arranged  according  to  any 
definite  plan. 

Chondromata  are  liable  to  become 
calcified,  and  even  ossified.  When 
large,  the  central  parts  may  undergo 
a  mucoid  change,  giving  rise  to  a 
cavity  which,  if  sepsis  is  admitted, 
becomes  exceedingly  foul.  They  are 
not  uncommonly  accompanied  in  their  growth  by  sarcomatous  and 
other  elements. 

Chondromata  are  not  uncommon,  growing  from  the  smaller  hones, 
usually  from  those  of  the  hand,  and  generally  in  young  people.  They 
are  frequently  multiple  (Fig.  50).  The  growth  commences  in  the 
interior,  close  to  the  epiphyseal  cartilage,  and  results  in  expansion  of 
the  bone,  the  hand  becoming  thereby  much  deformed.  Treatment 
consists  in  incising  the  capsule,  and  scooping  out  the  cartilaginous 
tissue,  a  proceeding  which  may  result  in  defective  growth  and 
subsequent  deformity.  In  the  later  stages,  however,  amputation 
is  inevitable. 

When  growing /ro7«  the  long  hones,  chondromata  usually  start  from 
beneath   the   periosteum,    and   are   independent   of    the    epiphyseal 


Fig.  50. — Multiple  Chondro- 
mata OF  THE  Fingers. 


200 


A   MANUAL  OF  SURGERY 


cartilage,  although  it  has  been  suggested  by  Virchow  that  they  may 
originate  from  a  nodule  of  cartilage  which  has  been  displaced  from 
its  usual  situation  during  an  attack  of  rickets.  They  constitute  firm 
lobulated  encapsuled  tumours,  and  give  rise  to  no  pain,  except  when 
they  encroach  on  neighbouring  nerves.  They  often  attain  a  great 
size.  The  growth  may  extend  secondarily  into  the  medullary  canal, 
and  thus  cause  expansion  of  the  bone ;  or  it  may  erode  the  compact 
tissue,  and  lead  to  spontaneous  fracture.  Amputation  of  the  limb 
will  probably  be  necessary,  unless  the  case  comes  under  observation 
in  the  early  stages,  when  the  tumour  can  be  gouged  or  scraped 
away. 

Overgrowths  of  cartilage,  known  as  Ecchondroses,  occur  around 
the  articular  cartilages  in  connection  with  osteo-arthritis  ;  they  also 


Fig.  51. — Cancellous  Osteoma 
OF  Lower  End  OF  Femur  (Semi- 
diagrammatic,  FROM  A  Skia- 
gram). 


Fig.  52. — The  Same,  with  Osteoma 
divided  Longitudinally  to 
SHOW  THE  Extent  of  the  In- 
vesting Cartilage. 


arise  from  the  cartilages  and  septum  of  the  nose,  and  from  the 
laryngeal  cartilages.  Some  of  the  loose  bodies  which  form  in  joints 
are  of  a  similar  nature. 


Osteoma. — Bony  tumours  are  of  two  chief  forms  :  the  cancellous 
and  the  ivory. 

Cancellous  Osteomata  are  usually  met  with  growing  near  the 
articular  end  of  a  bone,  being  derived  originally  from  some  isolated 
portion  of  the  epiphyseal  cartilage,  which  has  perhaps  been  separated 
from  its  original  connection  after  an  attack  of  rickets.  In  this 
affection  irregular  outgrowths  from  the  epiphyseal  cartilage  occur, 
and  if  one  of  these  near  the  periphery  of  the  bone  becomes 
separated   from    its    epiphyseal    attachment,   it   is   easy  to    under- 


TUMOURS  AND  CYSTS 


20 1 


stand  its  development  into  a  tumour,  which  consists  of  cancellous 
bone,  capped  by  a  layer  of  hyaline  cartilage,  from  which  it  grows 
(Figs.  51.  and  52).     It  is  pedunculated  or  sessile,  and  may  attain  to  a 
large    size,   leading    to    considerable    de- 
formity.    It  necessarily  develops  in  young 
people,  and  may  be  congenital.      As  the 
individual  grows,  the  basis  of  attachment 
may  become  separated  from  the  epiphysis 
to  an  extent  corresponding  to  the  amount 
of  growth  which  has  taken  place  at  that 
spot,  or  it  may  still  remain  attached  to  the 
epiphyseal   line.      As   a   rule    its   growth 
and  development  cease  at  maturity,  when 
the  cartilage  covering  it,  as  well  as  the 
epiphyseal  cartilage,  ossifies.  A  bursa  occa- 
sionally forms  over  the  most  prominent 
part  of  these  tumours  as  a  result  of  friction  pj^_  53._SnBUNGUAL  Exos- 
or  pressure,  giving  rise  to  the  condition      xosis.     (Bland  Sutton.) 
known  as  Exostosis  Bursata  ;  this  cavity 

may  communicate  with  the  joint.  An  effusion  of  blood  or  serum  into 
the  bursa  may  be  the  first  evidence  of  the  existence  of  such  a  growth. 
Multiple  exostoses  are  not  unfrequently  met  with,  and  are  then  often 


Pig.  5^. Ivory  Exostosis  growing  from  Frontal  Sinus,  and  encroaching 

BOTH    ON    THE    ORBIT    AND    THE    CrANIA^^    CaVITY. 

(From  Specimen  in  the  College  of  Surgeons'  Museum.) 

inherited.  The  most  common  situation  for  such  a  tumour  is  the  inner 
condyle  of  the  femur,  close  to  the  adductor  tubercle  (Fig.  51),  but  they 
are  not  rare  on  the  inner  aspect  of  the  mandible.  The  Subungual  Exos- 
tosis (Fig.  53)  develops  as  a  rounded,  cherry-like  swelling  under  the 


202  A  MANUAL  OF  SURGERY 

ngil  of  the  great  toe.  It  is  very  painful,  and  should  be  treated  by 
removing  the  nail,  incising  the  tissues  over  it  down  to  the  bone,  and 
clipping  it  away  with  cutting  pliers. 

Ivory  Exostoses  develop  most  frequently  on  the  inner  or  outer 
aspect  of  the  cranial  bones,  especially  affecting  the  orbit,  external 
auditory  meatus,  antrum,  and  frontal  sinus  (Fig.  54).  They  consist 
of  masses  of  very  dense  compact  tissue,  covered  by  periosteum,  from 
which  they  grow.  They  are  usually  lobulated,  and  when  situated  in 
the  frontal  sinus,  or  growing  from  the  under  surface  of  the  skull,  may 
give  rise  to  serious  symptoms  from  irritation  or  compression  of  the 
brain  or  its  membranes.  In  a  few  cases  necrosis  has  resulted,  and 
they  have  sloughed  out,  thus  bringing  about  a  spontaneous  cure. 

Occasionally  diffuse  overgrowths  of  the  bones  of  the  skull  (Hyper- 
ostoses) are  met  with,  affecting  either  the  calvarium  alone,  being  then 
probably  syphilitic  in  nature,  or  the  facial  and  cranial  bones,  as  in 
leontiasis  ossea.  New  formation  of  bone  occurs  in  the  substance  of 
muscles  and  tendons  which  are  exposed  to  irritation  or  excessive 
action — e.g.,ih.&  tendon  of  the  adductor  longus  in  riders,  producing 
what  is  known  as  '  the  rider's  bone,'  but  these  are  inflammatory  in 
origin. 

The  Treatment  of  osteomata  consists  in  their  removal  when 
necessary.  This  may  be  simple  in  the  case  of  the  cancellous  osteo- 
mata of  the  limbs,  but  is  sometimes  a  formidable  proceeding  when 
dealing  with  sessile  compact  exostoses  of  the  calvarium.  The  fact 
that  cancellous  osteomata  cease  to  grow  when  the  patient  reaches 
maturity  explains  the  rule  of  surgery  that  they  do  not  need  to  be 
removed  unless  causing  pain  or  mechanical  inconvenience  by  their 
size.  After  careful  purification  a  suitable  incision  is  made,  the 
tumour  exposed,  and  its  limits  defined.  It  is  chiselled  or  sawn  away 
from  its  attachment  to  the  bone,  special  attention  being  directed  to 
the  total  removal  of  the  covering  cartilage,  since  growth  continues 
unless  this  is  completely  excised.  In  dealing  with  the  osteoma 
situated  near  the  adductor  tubercle,  the  knee  joint  is  occasionally 
opened  ;  if  possible,  the  lesion  in  the  synovial  membrane  is  sub- 
sequently closed  by  sutures. 

Compact  osteomata  of  the  cranium  may  be  set  free  and  removed 
by  chiselling  away  the  bone  around  them,  but  occasionally  a  burr 
driven  by  electricity  is  required  in  order  to  divide  their  attachments. 

Myoma. — Myomata  almost  always  consist  of  unstriped  muscle 
fibres  (Leiomyoma  or  fibromyoma),  forming  rounded  and  often 
encapsuled  tumours,  the  cells  of  which  are  long  and  fusiform, 
and  contain  a  rod-like  nucleus.  Bundles  of  these  cells  are 
grouped  together  into  fasciculi,  which  are  arranged  more  or  less 
regularly.  The  tumours  themselves  are  not  very  vascular,  but 
vessels  of  considerable  size  are  found  in  the  capsule.  It  is  often 
difficult  to  distinguish  these  tumours  microscopically  from  fibro- 
rtiata  on  the  one  hand,  and  from  fibro-sarcomata  on  the  other. 
From  the  former  they  are  known  by  the  fact  that  individual  cells 


TUMOURS  AND  CYSTS  203 

can  be  recognised,  and  by  the  absence  of  wavy  tendinous  fibrillae ; 
from  the  latter  the  distinction  depends  on  the  facts  that  other  types 
of  tissue  may  occur  in  the  sarcoma,  and  that  the  growing  edge  is 
usually  more  or  less  embryonic  in  character,  whilst  a  myoma  is  of 
the  same  structure  throughout.  Again,  in  a  myoma  the  blood- 
vessels have  distinct  and  definite  walls,  and  in  a  sarcoma  they  are 
simply  clefts  or  passages  in  the  tumour  substance. 

Myomata  are  met  with  in  the  uterus,  occasionally  in  the  prostate, 
and  more  rarely  in  the  walls  of  the  alimentary  canal  or  in  the  ovary. 
Secondary  changes  sometimes  occur — e.g.,  mucoid  softening,  calcifica- 
tion, ulceration  with  profuse  haemorrhage,  and  possibly  consequent 
septic  inflammation,  whilst  malignant  disease  may  supervene. 

Tumours  consisting  of  striped  muscle  fibres  (Rha'bd.omyoma)  have 
been  described,  but  are  exceedingly  rare. 

Neuroma. — True  Neuroma  is  seldom  met  with,  only  five  undoubted 
cases  being  on  record.  It  is  formed  by  a  mass  of  newly-formed 
ganglion  cells  and  nerve  fibres,  which  may  be  medullated  or  not. 
In  all  but  one  case  it  involved  the  sympathetic  system,  and  occurred 
in  children  or  young  people.  The  tumours  may  attain  considerable 
dimensions,  are  often  multiple,  and  may  be  quite  soft,  like  a  lipoma, 
or  firm.  They  are  insensitive  and  innocent,  and  may  be  freely 
removed. 

False  Neuromata,  or  those  developing  in  connection  with  the 
sheaths  of  nerves,  are  more  common,  and  may  be  described  under 
three  headings  : 

1.  Localized  Pseudo-Neuroma,  which  may  be  innocent  or  malig- 
nant, the  former  being  a  fibroma  or  myxoma,  the  latter  usually  a 
sarcoma.  It  may  project  from  one  side  of  the  nerve,  or  more 
frequently  the  nerve  fibres  are  spread  out  over  it.  It  moves  more 
freely  at  right  angles  to  the  axis  of  the  nerve  than  along  its  course. 
When  developing  from  a  small  nameless  subcutaneous  twig,  it  is 
termed  a  painful  subcutaneous  nodule,  and  gives  rise  to  intense  neuralgic 
pain,  especially  when  compressed  or  irritated,  or  when  exposed  to 
cold.  A  false  neuroma  growing  from  a  larger  mixed  nerve  (trunk 
neuroma)  is  less  painful,  because  there  are  relatively  fewer  nerve 
fibrillae,  and  the  mass  is  less  exposed.  A  growth  on  a  pure  motor 
nerve,  though  sensitive,  is  not  associated  with  radiation  of  pain. 
It  is  uncommon  for  tumours  of  this  type  to  cause  complete  paralysis 
or  anaesthesia,  unless  they  are  of  a  malignant  nature.  They  occur 
most  frequently  in  healthy  adults,  and  in  women  a  little  more 
commonly  than  in  men. 

Treatment. — A  neuroma,  if  painful,  should  be  removed,  care  being 
taken,  if  possible,  not  to  interfere  with  the  continuity  of  the  nerve 
fibrillae,  the  section  of  the  sheath  being  made  in  the  long  axis.  If 
this  cannot  be  accomplished,  the  nerve  must  be  divided,  and  the 
ends  sutured  together. 

2.  Diffuse  or  Generalized  Neuro-Fibromatosis. — This  consists  of 
a  diffuse  thickening  of  the  nerve  sheaths,  causing  multiple  elliptic  or 


204  A  MANUAL  OF  SURGERY 

spherical  tumours,  or  a  generalized  enlargement.  The  growths  may 
be  encapsuled  and  limited,  or  not;  they  may  be  few  in  number, 
or  hundreds  may  be  present,  and  they  are  usually  whitish  and  firm 
in  texture.  They  originate  from  the  endoneurium  of  the  primary 
nerve  bundles.  Any  part  of  the  peripheral  nervous  system  may  be 
affected,  including  the  sympathetics,  but  it  is  most  common  in  con- 
nection with  the  cranial  nerves  and  the  large  plexuses  of  the  trunk. 
The  actual  symptoms  are  sometimes  very  slight,  but  the  tumours 
may  be  sensitive  to  pressure,  and  some  of  them,  more  exposed 
than  the  others,  may  be  exquisitely  tender.     Motor  phenomena  are 


Fig.  55. — Multiple  Molluscous  Tumours  and  Pigmentation  of  Skin  (A) 
IN  A  Case  of  Recklinghausen's  Disease. 

(For  the  loan  of  this  block  we  are  indebted  to  Dr.  F.  Parkes  Weber.) 

rare,  and  paralysis  is  usually  due  to  involvement  of  the  nerve 
roots  in  the  spinal  canal,  or  to  the  supervention  of  sarcoma, 
which  is  a  not  uncommon  termination.  The  disease  may  start 
at  any  time  during  life,  and  although  progressing  slowly,  sooner  or 
later  terminates  fatally.  No  known  treatment  is  of  any  avail,  but 
should  any  particular  tumour  become  large  and  tender,  it  may  be 
removed. 

A  Piexiform  Neuroma  is  a  special  modification  of  this  process, 
occurring  congenitally  or  in  young  people,  and  usually  involving  the 
trigeminal  or  superficial  cervical  nerves  ;  it  may  be  associated  with 


TUMOURS  AND  CYSTS  205 

the  former  condition.  The  overgrowth  is  of  a  softer,  more  gelatinous 
type  (myxo-fibromatous),  and  the  resulting  tumour  consists  of  a 
plexus  of  thickened,  tortuous,  vermiform  strands,  of  soft  consistence, 
held  together  by  loose  connective  tissue,  but  easily  separable  into 
their  constituent  elements,  which  are  of  a  nodulated  character,  so 
that  the  dissected  mass  looks  '  not  unlike  grains  of  boiled  tapioca  on 
a  string '  (Alexis  Thomson).  The  plexiform  neuroma  is  almost 
always  subcutaneous,  but  often  dips  deeply  between  and  into  the 
substance  of  muscles.  When  limited  in  extent,  the  growth  may  be 
dissected  out,  and  this  is  usually  required  for  cosmetic  purposes. 
The  final  prognosis  is  rather  better  than  in  the  former  condition,  as 
secondary  sarcomatous  changes  are  rare. 

In  this  affection  one  not  unfrequently  observes  a  large  develop- 
ment of  fibrous  growths  of  the  skin,  similar  to  what  we  have  already 
described  as  molluscum  fibrosum.  On  careful  microscopical  examina- 
tion of  specimens  stained  by  Weigert's  method,  the  presence  of 
nerve  fibrillag  can  be  demonstrated  in  these  growths,  shouting  that 
they  are  really  neuro-fibromatous  in  origin.  So  excessive  does  this 
overgrowth  occasionally  become  that  a  form  of  elephantiasis  is  pro- 
duced— e.g.,  the  irregular  hyperplasia  of  the  scalp  tissues  known  as 
a  pachydermatocele.  The  association  of  molluscous  tumours  with 
neuro-fibromatous  changes  in  the  nerves  and  cutaneous  pigmenta- 
tion  constitutes    the    affection     known     as    Recklinghausen's    disease 

(Fig.  55)- 

3.  The  bulb  formed  upon  the  proximal  end  of  a  nerve  after  its 
division  is  sometimes  described  as  a  neuroma  (Traumatic  Neuroma). 
It  consists  of  a  mass  of  fibro-cicatricial  tissue  containing  spaces, 
coiled  up  within  which  are  numbers  of  newly-formed  axis  cylinders. 
They  are  almost  always  present  in  amputation  stumps,  but  are 
not  painful  unless  adherent  to  the  periosteum  of  the  neighbouring 
bone  or  to  the  cicatrix,  when  every  movement  of  the  nearest  joint 
causes  traction  upon  them,  and  induces  severe  neuralgia. 

Gliomata  are  tumours  arising  from  the  neuroglia  of  the  brain 
and  spinal  cord,  and  occasionally  in  the  retina.  Most  of  the 
growths  occurring  in  the  retina,  and  supposed  to  be  gliomata,  are 
in  reality  round-celled  sarcomata  ;  the  distinction  is  one  of  some 
importance,  since  true  gliomata  are  never  followed  by  secondary 
growths.  They  consist  of  cells  (which  may  be  round,  spider-shaped, 
or  spindle-shaped)  and  of  fibres  ;  these  occur  in  varying  proportions 
in  different  cases,  giving  rise  to  the  hard  and  soft  varieties.  Their 
colour  often  closely  resembles  that  of  the  brain  itself,  and  there  is 
usually  no  sharp  line  of  distinction  between  the  tumour  and  the 
surrounding  tissue.  They  vary  greatly  in  rapidity  of  growth  and  in 
vascularity,  but  are  always  benign  in  nature. 

Angioma  is  the  term  applied  to  conditions  in  which  a  new  forma- 
tion of  bloodvessels  occurs  ;  aneurisms  and  varicose  veins  are  not 
included  in  this  category. 


2o6  A  MANUAL  OF  SURGERY 

Three  main  types  of  angioma  may  be  describsd :  (i)  The 
simple  nsevus ;  (2)  the  cavernous  naevus ;  and  (3)  the  plexiform 
angioma. 

The  Simple  Nsevus  is  exceedingly  common,  and  consists  of  a  mass 
of  dilated  capillaries,  bound  together  by  a  small  amount  of  connective 
tissue.  It  is  usually  congenital,  and  may  increase  rapidly  in  size 
during  the  first  few  months  of  life.  It  is  located  in  the  skin,  or  may^ 
also  involve  the  subcutaneous  tissues,  but  the  tubular  form  of  the 
constituent  vessels  always  remains.  It  may  be  of  a  bright  red  colour 
or  of  a  dusky  tint.  For  a  fuller  account,  including  treatment,  see 
Chapter  XIII.  If  untreated,  simple  nsevi  may  persist  unchanged, 
or  may  disappear ;  in  a  few  instances  they  increase  rapidly  in  size, 
either  early  or  late  in  life,  sometimes  giving  rise  to  a  considerable 
vascular    growth,    purplish    in    colour,    and   occasionally   becoming 


PiG.  56.— Section  of  Cavernous  Angioma.     (Museum  of  Royal  College 

OF  Surgeons.) 

In  one  or  two  of  th?  cavernous  spaces  thrombi  more  or  less  adherent 
can  be  seen. 

prominent  and  pendulous.  Such  a  tumour  is  soft  and  easily  com- 
pressible, being  in  reality  a  cavernous  angioma;  it  may  ulcerate, 
and  profuse  haemorrhage  may  result. 

The  Cavernous  Nsevus  (Fig.  56)  consists  of  dilated  spaces,  where 
the  tubular  form  of  the  constituent  vessels  is  lost,  the  arteries 
usually  opening  directly  into  thin-walled  cavities  lined  with  endo- 
thelium without  the  intervention  of  capillaries.  The  tumours  are 
thus  more  or  less  erectile  in  nature,  somewhat  resembling  the  corpus 
cavernosum.  They  are  met  with  in  the  skin  and  subcutaneous 
tissues,  or  in  connection  with  mucous  membranes,  constituting  diffuse 
or  circumscribed  tumours  of  a  reddish-blue  colour,  which  can  be 
emptied  on  pressure,  but  rapidly  refill  when  such  is  removed,  and  in 
which  pulsation  is  occasionally  present.  A  similar  condition  arises 
in  the  viscera,  especially  the  liver,  and  it  is  not  difficult  in  suitable 


TUMOURS  AND  CYSTS  20; 

tases  to  demonstrate  that  it  has  been  formed  by  a  dilatation  of  the 
capillaries  between  the  lobules,  the  liver  substance  meanwhile  dis- 
appearing by  a  process  of  simple  atrophy.  Occasionally  a  cavernous 
angioma  undergoes  spontaneous  cure  as  the  result  of  some  inflam- 
matory affection  similar  in  nature  to  phlebitis,  a  non-vascular  fibro- 
cystic mass  remaining. 

Under  the  term  Plexiform  Angioma  may  be  included  the  cirsoid 
aneurism,  or  aneurism  by  anastomosis,  the  former  term  being  applied 
by  some  authors  to  tumours  consisting  of  large  vessels,  and  then 
most  commonly  seen  about  the  scalp  and  face,  and  the  latter  to  a 
congeries  of  small  vessels.  The  treatment  is  always  a  matter  of 
considerable  difficulty  (see  Chapters  XX.  and  XXV.). 

Lymphadenoma  and  Lymphangioma.  —  The  primary  tumours 
developing  in  connection  with  lymphatic  glands  and  vessels  are 
described  in  Chapter  XIV. 

Odontoma. — Tumours  originating  from  some  abnormal  condition  of 
the  teeth  or  teeth-germs  are  known  as  '  odontomes.'  Bland  Sutton, 
in  his  work  on  tumours,*  has  described  seven  different  varieties, 
several  of  which  are,  however,  rarely  met  with  in  man.  We  can 
only  deal  here  with  the  more  important  of  these,  and  must  refer  our 
readers  to  Chapter  XXVII.  and  to  Sutton's  book  for  a  fuller  descrip- 
tion, (i)  Epithelial  Odontome. — In  this  condition,  formerly  known  as 
'  fibro-cystic  disease  of  the  jaw,'  the  mandible  is  most  commonly 
affected.  A  tumour  forms,  consisting  of  spaces  lined  by  epithelium, 
which  are  developed  as  irregular  outgrowths  from  the  enamel  organ. 
It  occurs  most  frequently  in  young  adults,  and  may  give  rise  to  a 
growth  of  enormous  size.  (2)  Follicular  Odontomes,  or,  as  they  are 
often  termed,  '  dentigerous  cysts,'  are  produced  by  the  development 
of  a  cavity  around  a  misplaced  or  ill-developed  tooth  of  the  permanent 
set,  which  often  lies  horizontally,  so  that  its  eruption  is  impossible. 
(3)  ribrous  Odontomes  are  the  result  of  a  thickening  and  condensation 
of  the  connective  tissue  around  a  tooth  sac.  They  are  most  frequently 
observed  in  the  lower  animals,  but  are  also  said  to  occur  in  rickety 
children.  (4)  Radicular  Odontome  is  the  term  applied  to  a  tumour 
composed  of  cement,  developing  at  the  root  of  a  tooth.  It  gives  rise 
to  severe  pain,  and  may  result  in  septic  inflammation  of  the  surround- 
ing bone.  (5)  Composite  Odontomata  consist  of  a  conglomeration  of 
the  various  forms  of  tissue  entering  into  the  formation  of  a  tooth, 
and  developing  in  the  neighbourhood  of  the  jaw.  They  may  be  very 
large,  and  probably  some  of  the  bony  tumours  described  as  osteomata 
of  the  antrum  are  of  this  nature. 

1 1 .  Tumours  of  Epithelial  Origin. 

The  various  tumours  grouped  under  this  heading  are  composed 
mainly  of  epithelium,  with  a  variable  admixture  of  connective  tissue. 
They  are  derived  from  pre-existing  epithelial  structures,  and  vary  in  the 
*  Bland  Sutton,  '  Tumours  and  Cysts.'     Cassell  and  Co. 


2o8  A  MANUAL  OF  SURGERY 

arrangement  and  character  of  the  epitheHum  with  the  site  of  origin. 
Epithehal  cells  can  practically  be  of  only  three  types :  {a)  The 
spheroidal  or  cuboidal,  in  which  the  three  diameters  are  more  or  less 
equal ;  (b)  the  flat  or  squamous,  in  which  two  diameters  are  long  and 
one  very  short ;  and  (c)  the  columnar,  in  which  one  diameter  is  long 
and  two  are  short.  These  three  forms  of  cells  are  found  in  most  of 
the  groups  of  epithelial  tumours.  In  some  the  structure  conforms 
more  or  less  to  the  normal  type,  and  then  the  growth  is  probably  of  an 
innocent  nature,  as  in  the  papillomata  and  adenomata ;  but  when  the 
structure  becomes  atypical,  the  tumour  is  likely  to  be  malignant  and 
of  a  cancerous  nature. 

Papilloma. — This  term  ought  really  to  be  limited  to  tumours  formed 
by  an  overgrowth  of  papillae,  and  since  papillae  are  confined  to  regions 
covered  with  epithelium  of  epiblastic  origin,  they  are,  strictly  speak- 
ing, only  found  in  the  skin  and  the  so-called  '  mucous  membranes,' 


Fig.  57. — Section  of  a  Warty  Papilloma  to  show  the  Arrangement 
OF  the  Epithelium. 

The  normal  skin  is  seen  on  each  side  running  into  the  hypertrophied  papillae, 
over  which  is  heaped  up  a  mass  of  thickened  keratinised  cuticle.  There  is 
no  infiltration  of  the  subcutaneous  tissues,  as  in  an  epithelioma  (c/.  Fig.  59). 

which  are  morphologically  of  the  same  nature — i.e.,  that  lining  the 
mouth,  vagina,  larynx,  anus,  etc.  They  consist  of  the  same  structures 
as  a  normal  papilla,  there  being  a  central  core  of  mesoblastic  tissue 
(connective  tissues,  vessels,  etc.)  covered  by  squamous  epithelium, 
which  may  or  may  not  undergo  excessive  horny  development,  and, 
like  the  normal  papillae,  of  which  they  are  an  exaggeration,  they  pro- 
ject outwards  from  the  general  surface  of  the  body,  and  never  invade 
the  subcutaneous  or  submucous  tissues  (Fig.  57). 

The  term  is,  however,  often  used  loosely  to  indicate  a  growth 
composed  of  a  mesoblastic  core  with  an  investment  of  epithelium, 
whatever  its  origin ;  thus,  we  speak  of  papillomata  of  the  large 
intestine,  although  in  this  region  papillae  do  not  occur.  Hence  it 
becomes  convenient  to  classify  the  papillomata  according  to  the  nature 
of  the  epithelium  with  which  they  are  covered,  since  this  is  readily 
recognised  microscopically,  and  affords  a  clue  to  their  place  of  origin. 

(i)  Those  covered  by  squamous  epithelium  occur  in  the  skin, 
mouth,  larynx,  etc.,  and  consist  of  bundles  of  papillae,  which  undergo 


TUMOURS  AND  CYSTS 


209 


extensive  proliferation  and  frequently  branch,  forming  secondary 
papillae.  If  the  epithelium  undergoes  keratinization,  as  in  the 
common  warts,  they  become  hard,  and  may  constitute  horn-like 
outgrowths.  When  they  occur  in  moist  situations — e.g.,  between 
the  toes,  on  the  prepuce,  or  growing  from  mucous  membranes 
(except  that  covering  the  vocal  cords) — this  formation  of  horny 
substance  is  usually  very  imperfect,  and  the  papillomata  remain 
soft.  It  must  be  pointed  out  that  many  of  the  squamous  papillo- 
mata are  of  infective  origin,  and  not  true  tumours  at  all — e.g.,  the 
venereal  warts,  condylomata,  and  mucous  tubercles.  There  are 
some  reasons  for  thinking  that  warts  may  be  infective  and  due  to  the 
action  of  a  micro-organism.  Not  unfrequently  a  papilloma  which 
has  become  irritated  may  take  on  malignant  action  and  be  trans- 
formed into  an  epithelioma,  a  change  which  would  be  characterized 
clinically  by  the  base  becoming  infiltrated. 

The  papillomata  which  develop  in  the  bladder  and  pelvis  of  the 
kidney  are  covered  by  many-layered  tfansitional  epithelium,  and 
usually  form  long  delicate  fimbriated'  tufts  containing  delicate 
bloodvessels,  which  readily  give  Way  and  rnay  lead  to  considerable 
haemorrhage.  Not  unfrequently  they  occur  in  conjunction  with 
malignant  growths.  "  "  - 

(2)  Papillomata  covered-  by  cuhoidal  or  spheroidal  epithelium  occur 
in  glandular  structures,  especially  in  cystic  adenomata  of  the  breast, 
kidney,  etc. 

(3)  Papillomata  covered  by  columnar  epithelium  are  sometimts 
found  projecting  into  cystic  cavities  in  other  tumours,  as  in  the  pro- 
liferous ovarian  cysts  and  in  duct  carcinoma  of  the  breast,  as  also 
into  dilatations  of  other  ducts.  The  '  papillomata '  of  the  intestine 
are  usually  either  adenomata  or  fibromata. 

Adenomata  consist  of  new  growths"  arising  in  connection  with 
secreting  glands,  and  in  structure  simulating  somewhat  closely  the 
organs  from  vv^hich  they  rise  (Fig.  58).  They  dififer  from  them,  how 
ever,  in  that  they  are  incapable  of  producing  the  characteristic 
secretion,  that  they  are  devoid  of  ducts,  and  that  the  mimicry  is  in- 
complete, since  the  alveoli  are  less  perfectly  developed,  and  may  be 
entirely  occupied  by  several  layers  of  epithelial  cells.  The  epithelium, 
which  from  the  nature  of  the  case  is  spheroidal,  cuboidal,  or  columnar 
in  shape,  does  not  pass  beyond  the  basement  membrane  into  the  con- 
nective tissue,  and  by  this  lack  of  infiltration  they  are  distinguished 
from  cancerous  tumours.  A  variable  amount  of  connective  tissue  is 
always  present,  and  may  be  normal  in  texture,  or  may  manifest 
various  modifications.  Adenomata  are  usually  encapsuled,  being 
merely  connected  with  the  original  gland  by  a  pedicle,  through  which 
the  vessels  enter.  When  growing  from  mucous  membranes,  they  are 
sometimes  pedunculated,  as  in  the  so-called  polypus  recti.  The  alveoli 
in  some  cases  become  distended  with  effusion,  giving  rise  to  a  cysto- 
adenoma  or  adenocele.  They  are  free  from  malignancy,  except  that 
occasionally  the  connective  tissue  undergoes  a  sarcomatous  change ; 
very  rarely  carcinoma  supervenes.     When  of  large  size,  they  may 

14 


3IO 


A  MANUAL  OF  SURGERY 


cause  trouble  by  compression  of  important  structures.  Any  glandular 
organs  may  become  affected  with  adenoma,  e.g.,  the  breast,  thyroid 
body,  prostate,  testis,  etc.  They  are  also  found  as  congenital 
tumours  in  connection  with  the  thyroid  body,  post-anal  gut,  and 
possibly  the  kidney. 

Carcinoma. — The  malignant  forms  of  epithelial  new  growth  are 
known  as  cancers  or  carcinomata,  and  are  classified  as  epithelioma, 
columnar  cancer,  or  spheroidal-celled  cancer,  according  to  whether 
the  epithelium  from  which  the  tumour  is  derived  is  of  the  squamous, 
columnar,  or  spheroidal  type.  The  term  '  colloid  cancer  '  is  used  to 
indicate  a  degenerative  change  occurring  in  some  forms. 

The  essential  character  of  a  cancerous  growth  consists  in  an  un- 
limited  miilUplication  of   the  epithelial   cells   in   the  organ   or  tissue 


Fig.    $S- — FiBRO-ADENOMA    OF    THE    BrEAST.       (X    30.) 


attacked.  The  cells  thus  affected  lose  to  a  greater  or  less  extent  that 
inter-relation  which  normally  makes  them  grow  into  glands  or  other 
structures,  so  that  in  the  malignant  tumours  the  epithelial  cells  form 
masses  which  show  a  varying  degree  of  resemblance  to  the  glands, 
etc.,  of  the  normal  part :  in  general,  the  greater  the  malignancy,  the 
greater  the  anaplasia,  until  in  the  most  malignant  forms  the  epithelium 
is  arranged  in  masses  or  alveoli,  bearing  not  the  slightest  resemblance 
to  the  structure  from  which  it  springs.  There  is  also  an  alteration  of 
the  mutual  relations  between  the  epithelial  cells  and  the  connective 
tissue  of  the  part.  The  former  take  on  unlimited  powers  of  growth, 
but  are  not  (as  is  the  case  in  innocent  tumours  and  in  epithelial 
proliferation   due   to   irritants  or  other  causes)   limited  by  normal 


TUMOURS  AND  CYSTS  211 

basement-membranes  and  other  mesoblastic  elements,  but  burst 
through  these,  producing  infiltration  of  surrounding  tissues.  Columns 
of  epithelial  cells  can  be  seen  to  penetrate  into  the  tissues  (Fio-.  rg) 
following  the  lines  of  least  resistance  and  usually  extending  deeply 
along  the  lymph-clefts.  There  is  thus  no  longer  a  sharp  and  definite 
Ime  of  demarcation  between  the  epithelial  and  connective -tissue 
portions  of  the  tumour,  but  the  two  are  inextricably  blended.  The 
epithelial  cells  themselves  are  also  anaplastic,  losing  their  more 
specialized  characters  and  reverting  to  simple  masses  of  proto- 
plasm which  have  lost  all  powers  except  that  of  growth  and  sub- 
division. They  often  differ  greatly  among  themselves  in  size, 
character  of  nuclei,  etc.,  and  in  rapidly  -  growing  carcinomata 
numerous  mitoses  (which  may  be  irregular,  tripolar,  or  multipolar) 
may  be  seen.  ' 

Marked  changes  occur  in  the  connective  tissues  around  the  cancer ; 
they  are  irritated  by  the  growth,  and  become  infiltrated  with  small 


Fig.  59-— Section  of  an  Epithelioma. 
The  normal  skin  is  seen  on  each  side  running  into  the  growth,  which  dips  down 
into  and  invades  the  underlying  tissues.     This  diagram  should  be  compared 
carefully  with  F:^.  52.  ^ 

round  cells  (lymphocytes)  and  plasma  cells,  which  undergo  a  greater 
or  less  degree  of  organisation,  leading  to  the  development  of  a  stroma 
of  variable  density  and  vascularity  around  the  epithelial  columns.  In 
chronic  cases  the  stroma  is  usually  fibro-cicatricial  in  type,  and 
contains  few  bloodvessels  ;  in  the  more  actively  growing  parts  and  in 
acute  cases  the  stroma  is  comparatively  small  in  quantity,  more 
cellular,  and  decidedly  vascular.  When  septic  ulceration  of  the 
growth  is  present,  polynuclear  leucocytes  are  also  abundant,  and  other 
inflammatory  manifestations  may  be  seen  ;  pyogenic  bacteria  may 
sometimes  be  detected. 

Cancerous  tumours  are  not  necessarily  tender  to  the  touch,  but  a 
considerable  degree  of  pain,  usually  of  a  neuralgic  type,  is  often  com- 
plained of,  especially  in  the  harder  forms,  when  tissues  get  dragged 
upon  by  the  contracting  stroma. 

The  enlargement  of  the  neighbouring  lymphatic  glands  is  usually 
an  early  and  important  sign,  but  it  must  be  remembered  that  when 
the  primary  growth  has  a  septic  ulcerating  surface,  the  enlargement 
may  be  largely,  if  not  entirely,  due  to  the  absorption  of  toxins,  and 
treatment  directed  to  cleansing  the  surface  of  the  sore  may  lead  to  a 


A  MANUAL  OF  SURGERY 


disappearance  of  the  enlargement.  In  the  later  stages  of  the  disease 
septic  contamination  of  the  primary  growth  is  frequently  present  in 
the  more  superficial  varieties,  and  the  resulting  foetor  and  smell  may 
be  very  distressing. 

I.  Epithelioma  {syn. :  Squamous  Epithelioma,  Epithelial  Cancer). — 
B}'^  this  term  is  meant  a  cancerous  tumour  growing  from  skin  or  from 

those  portions  of  the  mucous 
membranes  which  are.  covered 
with  squamous  epithelium. 

Epithelioma  is  usually  met 
with  in  middle-aged  or  elderly 
individuals,  occasionally  in 
young  adult  life.  Any  part  of 
the  skin  may  be  the  site  of  this 
tumour,  as  also  the  mucous  mem- 
brane of  the  mouth,  pharynx, 
and  oesophagus,  and  that  lining 
the  genito-urinary  tract.  It  com- 
monly results  from  some  long- 
continued  irritation,  as  in  the  lip 
or  tongue,  whilst  upon  the  penis 
it  is  always  associated  with  a 
long  foreskin.  Old  scars,  espe- 
cially if  they  become  ulcerated, 
are  likely  to  be  invaded,  and  the 
disease  may  supervene  on  in- 
FiG.  Co.  —  Typical  Epitheliomatous  tractable  lupus. 
.Ulcer,  showing  Heaped-up  Margins  Clinically,  epithehoma  may  be 
'?S™KOK  o?!™":"""-  looked  upon  as  a  «dign.nt  wart, 
which  not  only  grows  outwards 
from  the  surface,  but  also  bur- 
rows deeply  into  adjacent  tissues  (Fig.  59) ;  sooner  or  later  ulceration 
follows.  Several  characteristic  forms  are  described :  (a)  It  may  occur 
as  a  nodular  indurated  mass,  with  hard  everted  edges  and  central  ulcera- 
tion, giving  rise  to  a  somewhat  crateriform  ulcer  (Fig.  60).  (h)  The 
destructive  process  may  extend  equally  with  the  new  formation, 
leading  to  the  appearance  of  a  depressed  sore,  with  sharply-cut  edges, 
closely  resembling  a  rodent  ulcer,  {c)  Occasionally  the  superficial 
outgrowth  is  excessive,  and  the  destructive  process  limited,  giving 
rise  to  a  projecting  cauliflower-like  mass,  which,  is  soft  and  easily 
bleeds  [malignant  papilloma),  (d)  A  chronic  epithelioma  is  sometimes 
seen,  in  which  the  fibrous  stroma  contracts  and  compresses  the 
columns  of  epithelial  cells ;  -the  surface  is  then  indurated  and  wart- 
like, with  but  little  ulceration,  whilst  the  base  is  very  hard,  and  the 
progress  of  the  case  much  less  ra,pid  than  in  other  forms.  This  form 
is  not  uncommon  in  the  lip. 

The  disease,  as  a  rule,  early  infects  neighbouring  lymphatic  glands, 
which  become  the  seat  of  a  similar  growth,  and,  if  superficial,  sooner 
or  later  involve  the  skin  and  give  rise  to  characteristic  ulceration. 


and     Deep 
Excavation. 

^lUSEUM.) 


TUMOURS  AND  CYSTS 


213 


As  the  disease  progresses,  more  distant  groups  of  lymphatic  glands 
are  attacked ;  it  is  unusual  to  find  this  form  of  cancer  disseminated 
through  the  internal  viscera.  The  glands  sometimes  become  cystic, 
especially  in  the  neck,  and  on  cutting  into  them  a  thin,  turbid  fluid 


Fig.  61.— EriTHELiOMA  of  Lip. 

The  epithelium  at  the  left-hand  margin  of  the  figure  is  normal,  whilst  at  A  the 
altered  appearance  of  the  cells  indicates  that  they  have  become  malignant ; 
at  B,  C,  D,  they  are  growing  down  into  the  stroma  in  irregular  columns ; 
B  indicates  a  small  cell-nest,  and  C  passes  through  one  half  an  inch  from  its 
extremity.  The  connective-tissue  stroma  is  inflamed.  This  is  most  marked 
at  F. 

like  sero-pus  escapes,  mixed  perhaps  with  white  masses  of  epithelial 
debris ;  from  time  to  time  similar  material  is  discharged  through  the 
resulting  sinuses.  Ulceration  into  the  main  vessels  of  the  neck  may 
also  follow,  and  cause  death  from  haemorrhage:  otherwise  the  fatal 
event  is  due  to  cachexia  and  exhaustion. 


*.H  A  MANUAL  OF  SURGERY 

Microscopically,  an  epithelioma  consists  of  columns  of  epithelial 
cells  (Fig.  6i),  ramifying  in  the  subcutaneous  tissues,  and  interlacing 
freely  with  each  other,  so  as  to  produce  an  irregular  network,  the 
meshes  of  which  are  occupied  by  a  fibro-cellular  stroma,  which  is 
frequently  infiltrated  by  an  inflammatory  exudate  of  small  round 
cells  (largely  lymphocytes  or  plasma  cells).  The  parenchymatous  or 
true  cancer  cells  are  derived  from  the  prickle-cell  layer  of  the 
epidermis,  and  in  most  cases  their  nature  can  be  readily  made  out. 
In  some  rapidly-growing  very  malignant  cases,  however,  the  cells 
undergo  so  much  alteration  that  the  prickles  are  difficult  to  find. 
The  cells  in  contact  with  the  stroma  are  usually  regular,  and  resemble 
the  basal  layer  of  normal  skin  ;  the  cells  next  to  this  are  polygonal 


E 
Fig.  62. — Epithelial  Cell-nest,  from  an  Epithelioma  of  the  Mouth. 

A,  Stroma,  with  collections  of  small  round  cells  ;  B,  layer  of  basal  epithelial 
cells  ;  C,  prickle  cells,  which  at  D  have  become  flattened  ;  E  and  F  show  the 
final  stage,  the  cells  being  transformed  into  badly-formed  keratinous  scales. 

in  shape,  and  in  the  deepest  layers  may  become  flattened  and  undergo 
imperfect  keratinization.  This  is  best  seen  in  the  cell  nests  (Fig.  62) 
which  develop  in  the  substance  of  the  columns,  and  in  these  the 
diff"erent  layers  can  be  readily  traced.  They  are  best  seen  in  com- 
paratively chronic  cases,  and  may  be  absent  in  the  rapidly-growing 
forms. 

2.  Spheroidal-celled  Cancer  usually  develops  in  connection  with 
glands,  and  may  be  looked  on  as  a  malignant  form  of  adenoma,  bearing 
the  same  relation  to  the  latter  as  does  an  epithelioma  to  a  benign 
papilloma.  The  epithelium  of  the  glandular  acini,  from  which  it 
originates,  is  not  retained  by  the  basement  membrane,  but  travels 
beyond  it  along  the  lymphatics  into  surrounding  parts,  which  are 


TUMOURS  AND  CYSTS  215 

transformed  into  the  tumour  substance  by  a  process  already  described. 
The  amount  of  stroma  varies  considerably,  and  according  to  whether 
it  is  abundant  or  small  in  quantity,  the  tumour  is  hard  or  soft  in  con- 
sistence, and  slow  or  rapid  in  groAvth.  To  the  former  type  the  term 
ScirvJms  is  applied ;  to  the  latter,  Encephaloid. 

Scirrhus  is  met  with  most  frequently  in  the  breast,  but  also  occurs 
in  the  prostate,  pancreas,  and  pyloric  end  of  the  stomach.  On 
naked-eye  examination  a  scirrhous  tumour  appears  as  a  hard  nodular 
mass,  the  limits  of  w^hich  are  imperfectly  defined.  When  cut  across, 
it  creaks  under  the  knife,  and  presents  a  yellowish-white  surface, 
which   rapidly  becomes   concave   owing  to  the   contraction  of   the 


Fig.   63. — Scirrhus  Mammae,      (x  120.) 
(A  lobule  of  normal  breast  tissue  is  seen  at  the  lower  margin.) 

fibrous  stroma.  It  has  often  been  compared  to  the  section  of  an 
unripe  pear  or  turnip,  both  on  account  of  the  grating  sensation 
imparted  to  the  knife  and  from  its  appearance.  On  scrapincr  the  cut 
surface  with  the  blade  of  a  knife,  a  typical  cancer  juice  is  obtained, 
consisting  of  epithelial  cells  and  debris. 

On  microscopical  examination,  the  tumour  is  found  to  consist  of 
an  abundant  and  well-marked  stroma  of  a  definite  fibrous  nature, 
the  acini  of  which  are  filled  with  epithelial  cells  (Fig.  63),  In  the 
centre  fatty  degeneration  is  often  present,  small  cysts  being  occa- 
sionally produced  in  this  way.  At  the  periphery  the  growth  may  be 
seen  extending  in  all  directions  along  the  lymphatics,  whilst  a  round- 
celled  infiltration  af  the  surrounding  tissues  is  also  evident. 

Where  the  stroma  is  very  excessive,  the  cell  elements,  and, 
indeed,   the   whole   tumour,    may  undergo  atrophy,  owing   to  com- 


2l6 


A  MANUAL  OF  SURGERY 


pression   of   the   nutrient   vessels,    constituting   the  variety   known 
as  atrophic  scirrhus. 

Enciphaloid,  Medtcllary,  or  Acute  Cancer,  is  a  term  given  to  a  growth 
of  a  similar  nature,  in  which  the  stroma  is  much  less  abundant 
than  the  cell  elements.  It  constitutes  a  rapidly-growing  tumour, 
not  so  hard  as  a  scirrhus,  abundantly  supplied  with  bloodvessels,  and 
very  early  infiltrating  surrounding  parts  and  affecting  neighbouring 
lymphatic  glands.  The  skin  over  such  a  tumour  is  stretched,  and 
dilated  blue  veins  can  be  seen  through  it.  Ulceration  occurs  early, 
and  from  this  surface  a  foul,  bleeding,  fungating  mass  sprouts  up, 
formerly  known  as  a  '  fungus  haematodes  '  (Plate  III.,  Fig.  2).  En- 
cephaloid  cancer  is  met  with  in  the  breast,  testis,  kidney,  and  a  few 
other  glandular  organs. 


4.     '^^ 


K 


--«? 


itSO^ 


Fig.  64. — Columnar-celled  Carcinoma  of  the  Intestine,     (x  iG.) 
(Normal  mucous  membrane  is  shown  at  the  left-hand  side.) 

On  section  it  is  found  to  be  composed  of  a  soft  whitish  mass, 
somewhat  resembling  brain  substance.  It  is  usually  very  vascular, 
perhaps  pulsating  and  haemorrhagic  extravasation  into  its  tissues  is 
not  uncommon.  An  abundant  juice  is  obtained  on  scraping.  Under 
the  microscope  large  groups  of  spheroidal  epithelial  cells  are  seen, 
held  together  by  a  scanty  fibro-cellular  stroma. 

3.  Columnar  Carcinoma. — This  affection,  which  was  formerly  termed 
'  columnar  epithelioma,'  is  in  the  majority  of  cases  a  true  glandular 
cancer.  It  is  met  with  most  frequently  in  the  alimentary  canal, 
arising  from  any  portion  of  it  in  which  columnar  epithelium  occurs, 
and  usually  originating  as  an  overgrowth  of  Lieberkiihn's  follicles 
(Fig.  64).  These  form  a  projecting  growth  from  the  surface,  and 
also   penetrate    deeply   into    the    submucous   and   muscular   coats. 


TUMOimS  AND  CYSTS 


217 


The  deep  processes  retain  an  imperfect  alveolar  arrangement,  and 
between  them  is  found  a  certain  amount  of  stroma,  upon  the 
character  of  which  the  hardness  of  the  tumour  depends.  In  the 
firmer  types  the  stroma  is  abundant,  and  fibro-cicatricial  in  quality, 
the  growth  of  the  tumour  being  slow ;  in  the  softer  and  more 
rapidly-growing  forms  the  stroma  is  less  abundant,  and  more  fibro- 
cellular  in  nature.  On  section  of  a  limited  portion  of  the  growth, 
it  is  usually  possible  to  distinguish  it  from  a  simple  adenoma 
of  Lieberkiihn's  follicles,  since  in  the  latter  the  alveoli  are  complete 


Fig.  65. — Section  through  Advancing  Margin  of  Columnar  Cancer  of 
Stomach,      x   25.     (Ziegler.) 

d.  Mucosa  ,  b,  submucosa  ;  c,  muscularis  ;  d,  serosa  ;  e,  neoplasm  which,  starting 
from  the  mucosa,  has  invaded  the  other  layers.  Small-celled  infiltration  has 
accompanied  here  and  there  the  formation  of  the  neoplastic  tubules. 

and  regularly  lined  with  a  laySr  of  columnar  epithelium,  whilst  in 
cancer  the  alveoli  vary  in  shape,  and  the  epithelial  elements  are 
less  regularly  arranged.  The  distinction  is  well  seen  in  Fig.  64. 
If  a  large  section,  including  the  whole  thickness  of  the  intes- 
tinal wall,  is  examined,  the  extension  of  the  glandular  tissue  into  and 
between  the  muscular  fasciculi  (Fig.  65)  at  once  indicates  the  malig- 
nant nature  of  the  case.  Ulceration  usually  occurs,  giving  rise  to  a 
typical  sore,  surrounded  in  the  more  chronic  forms  by  indurated  and 
everted  edges.  Neighbouring  lymphatics  are  implicated,  as  in  the  case 
of  all  cancers,  whilst  later  on  the  disease  spreads  to  the  viscera,  and 


2i8  A  MANUAL  OF  SURGERY 

may  be  generally  disseminated.  A  similar  type  of  growth  occurs  in 
the  cervical  portion  of  the  uterus,  and  occasionally  in  the  ducts  of 
glands  such  as  the  liver  and  breast.  It  is  also  met  with  in  the 
superior  maxilla,  originating  in  the  tubular  glands  of  the  mucous 
membrane  lining  the  antrum. 

4.  Colloid  Cancer  results  from  a  degeneration  of  the  epithelial  cells 
of  a  glandular  or  columnar  cancer.  Its  most  frequent  site  is  within 
the  abdominal  cavity,  in  connection  with  cancers  arising  from  the 
stomach,  intestine,  or  omentum. 

To  the  naked  eye  colloid  cancer  presents  an  alveolar  texture,  the 
spaces  being  filled  with  translucent  gelatinous  material  of  varying 
density.  Microscopically,  the  epithelial  cells  are  rarely  distinguish- 
able, being  replaced  by  a  structureless  colloid  substance.  Towards 
the  growing  margin,  however,  the  cells  may  be  seen  in  process  of 
degeneration,  globules  of  the  material  forming  within  them  and 
pressing  the  nucleus  to  one  side. 

The  Treatment  of  Cancer  consists  in  the  removal  of  the  tumour  by 
operation,  together  with  a  wide  margin  of  healthy  tissue  around  it, 
or,  in  some  cases,  of  the  whole  organ  affected,  as  well  as  the  lymphatic 
area  concerned,  and,  if  practicable,  in  one  mass,  so  as  not  to  cut 
across  the  lymphatic  vessels  passing  from  the  growth  to  the  glands. 
If  such  is  conducted  in  a  thorough  manner  and  at  a  sufficiently  early 
date,  a  good  result  may  be  anticipated ;  but,  owing  to  the  tendency 
of  all  cancers  to  spread  along  lymphatics,  its  eradication  is  usually  a 
matter  of  the  greatest  difficulty.  Recurrence  is  therefore  very  liable 
to  ensue. 

In  cases  where  removal  of  the  disease  by  the  knife  is  impracticable, 
owing  to  its  extent,  it  may  sometimes  be  possible  to  remove  a  portion 
of  the  disease,  the  remainder  being  dealt  with  by  the  actual  cautery 
or  by  caustics.  The  former  is  by  some  considered  the  better,  inas- 
much as  it  determines  a  greater  degree  of  fibrosis.  Of  caustics,  the 
most  satisfactory  is  chloride  of  zinc,  which  is  usually  applied  as  a 
paste,  a  little  opium  being  added  to  allay  pain.  In  other  instances 
it  has  been  proposed  to  starve  the  growth  by  tying  the  chief  nutrient 
vessels,  and  to  diminish  pain  by  division  of  sensory  nerves ;  such  can, 
however,  only  give  the  most  temporary  relief. 

There  is  no  question  that  X  rays  have  a  decided  influence  upon 
the  course  and  development  of  malignant  disease.  The  effect  of 
exposure  to  this  agent  is  to  set  up  a  localized  leucocytosis,  and  this 
results  in  the  breaking  down  of  the  neoplastic  tissue  and  its  replace- 
ment in  favourable  cases  by  fibrous  tissue.  The  whole  subject  is 
more  Or  less  experimental,  but  our  present  experience  seems  to 
indicate  that  early  recurrences  in  the  skin  of  the  cuirasse  type, 
ulcerating  and  f ungating  masses,  and  some  forms  of  sarcoma,  benefit 
most  from  this  procedure.  In  the  case  of  epithelioma  the  results 
have  been  most  discouraging,  whilst  deep-seated  foci  of  disease  are 
practically  uninfluenced.  Rodent  ulcer  appears  to  be  favourably 
influenced,  and  many  cures  have  been  reported ;  but  in  some  old- 
standing  cases  X  rays  have  no  effect,  as  also  when  the  bones  are 


TUMOURS  AND  CYSTS  219 

involved.  It  must  not  be  forgotten,  however,  that  X  rays  have  deter- 
mined, the  occurrence  of  cutaneous  cancer  in  several  radiographers, 
and  may  Hght  up  into  activity  more  or  less  latent  foci. 

The  results  gained  thus  far  by  the  use  of  radium  are  practically 
identical  with  those  obtained  by  the  X  rays. 

Perhaps  more  satisfactory  results  may  follow  from  the  routine  treat- 
ment of  patients  with  radium  or  X  rays  after  operation,  with  a  view 
to  destroying  any  minute  foci  of  disease  which  may  have  been  left. 
Treatment  should  begin  ten  or  twelve  days  after  operation,  and  may 
continue  daily  for  three  weeks.  It  may  be  well  to  repeat  the  course 
at  gradually  lengthening  intervals.  The  application  of  the  X  rays 
should  always  be  in  the  hands  of  skilled  radiographers,  who  alone 
can  judge  of  the  strength  of  the  rays,  the  tubes  varying  enormously 
from  time  to  time.  Serious  and  extremely  chronic  burns  result 
from  injudiciously  prolonged  sittings,  and  the  mischief  done  may  not 
become  evident  until  twelve  or  fourteen  days  after  the  particular 
application.  Surrounding  parts  must  be  carefully  guarded  by  lead- 
foil  or  by  the  use  of  a  '  shielded '  tube  which  only  allows  the  rays  to 
act  on  the  required  area. 

High-frequency  currents  have  been  extensively  used  in  this 
direction,  but  per  se  have  no  influence  on  the  disease,  although  they 
may  improve  the  general  health  by  their  tonic  effect.  The  recently 
introduced  '  high  vacuum  electrodes '  give  off"  a  small  quantity  of 
X  rays,  and  may  enable  one  to  apply  these  rays  to  cavities  or  in 
situations  which  would  be  otherwise  inaccessible. 

Much  has  been  written  of  recent  years  concerning  the  treatment  of 
cancer  by  the  pancreatic  ferments,  trypsin  and  amylopsin,  extract  of 
violet-leaves,  and  other  so-called  cancer  cures.  Successes  have  been 
attributed  to  all  of  these,  but  when  they  have  been  thoroughly  tested 
in  a  scientific  manner  in  cases  certainly  cancerous,  the  results  have 
been  equally  disappointing. 

In  hopeless  cases  all  that  can  be  done  is  to  keep  any  ulcerated 
surface  free  from  irritation  and,  if  possible,  aseptic,  whilst  the  general 
health  is  maintained  by  suitable  diet  and  drugs,  and  pain  is  kept  in 
check  by  morphia  or  opium. 

In  some  cases  a  considerable  degree  of  palliation  of  the  symptoms 
and  some  shrinkage  in  the  tumour  may  be  brought  about  by  inocula- 
tions with  a  vaccine  of  dead  staphylococci,  or  (what  appears  to  be 
the  same  thing)  of  M.  Doyen's  Micrococcus  neofovmans,  an  organism 
often  found  in  carcinomata,  and  thought  by  him  to  be  the  cause  of 
the  disease.  It  appears  to  act  by  getting  rid  of  the  septic  element, 
and  is  of  most  value  when  this  is  marked.  Exposure  to  X  rays  even 
in  these  hopeless  cases  will  usually  lessen  the  patients'  pain  and 
make  them  more  comfortable. 

III.  Tumours  of  Endothelial  Origin. 
The  Endotheliomata  form  a  large  and  important  group  of  tumours. 
They  are  by  no  means  rare,  and  as  a  class  are  much  less  malignant 
than  the  sarcom.ata  or  carcinomata,  to  which  they  often  have  a  close 


A  MANUAL  OF  SURGERY 


structural  resemblance  ;   they  are   slow  in    their   development,  but 
often  recur  locally  after  removal,  and  may,  after  a  time,  affect  glands 


Fig.  66. — Endothelioma  of  the  Parotid  Gland.     ( x  120.) 

or  form  secondary  deposits  in  internal  organs.     Their  most  frequent 
seat  is  in  the  parotid  gland,  where  they  form  the  mixed  parotid  tumour 


»^ 


*  'Ml 


^1     • 


Fig.  67. — Perithelioma,     (x-120.) 


of  the  older  surgeons,  but  they  are  common  in  other  parts  in  the 
neighbourhood  of  the  mouth  and  in  the  meninges  of  the  brain  and 


TUMOURS  AND  CYSTS  221 

cord ;  they  may  occur,  however,  in  any  part  of  the  body.  The  cells 
constituting  an  endothelioma  are  derived  from  the  pre-existing  endo- 
thelium of  the  region,  and  they  become  spherical,  cuboidal,  or  even 
columnar  in  shape,  and  take  on  independent  growth.  The  tumour 
may  start  in  the  lymphatic  clefts,  which  then  appear  to  be  injected 
with  cuboidal  cells,  and  form  a  cellular  network  having  a  general 
resemblance  to  a  carcinoma.  The  stroma  between  these  columns  is 
profoundly  altered,  usually  becoming  mucoid  or  converted  into  a 
hyaline  tissue  resembling  cartilage  (Fig.  66) ;  fat  is  often  deposited 
in  it,  and  cystic  degeneration  may  take  place,  the  tumour  thus  formed 
being  of  extraordinary  complexity.  In  other  cases  the  cells  affected 
are  those  lining  the  smaller  lymphatic  vessels,  and  in  some  cases  this 
may  especially  involve  those  occurring  in  the  vascular  sheaths, 
forming  a  cellular  investment  to  the  smaller  vessels  [perithelioma  or 
perithelial  sarcoma,  Fig.  67).  In  a  third  group  the  endothelium  which 
takes  on  morbid  growth  is  that  which  lines  the  bloodvessels  them- 
selves. In*  this  case  it  is  common  for  the  cylinders  of  cells  thus 
formed  to  undergo  a  hyaline  degeneration  [cylindroma). 

The  endotheliomata  which  occur  in  the  brain  are  usually  composed 
of  spindle-shaped  cells,  which  have  a  tendency  to  organize  into 
fibrous  tissue,  and  have  a  curious  arrangement  in  whorls,  something 
like  those  of  a  cell-nest.  The  central  portions  of  these  masses 
frequently  undergo  conversion  into  a  material  resembling  amyloid 
substance,  and  subsequently  become  calcified.  These  tumours  are 
called  Psammomata.  Endotheliomata  of  the  brain  are  not  uncommon, 
and  are  usually  superficial,  readily  shelled  out,  and  do  not  usually 
recur  after  operation. 

IV.  Tumours  formed  by  Inclusion  of  Part  of  another  Embryo. 

Teratomata  are  tumours  derived  from  included  embryos,  or  from 
portions  of  a  second  embryo,  which  are  formed  by  dichotomy,  but 
which  have  remained  rudimentary,  and  partially  or  completely  buried 
in  the  tissues  of  the  host.  The  commonest  example  is  the  so-called 
dermoid  of  the  ovary,  which  is  usually  unilocular  and  often  of  large  size. 
Its  lining  wall  is  more  or  less  obviously  cutaneous  in  nature,  and 
from  it  an  abundant  development  of  cutaneous  appendages — hair, 
nails,  teeth,  nipples,  mammae,  etc. — is  sometimes  observed.  Most 
commonly  the  cyst  is  filled  with  greasy  sebaceous  material  with  an 
abundance  of  hair,  which  is  said  to  be  influenced  in  the  same  way  as 
that  on  the  scalp,  becoming  gray  or  being  shed  at  the  same  time. 
Sometimes  the  tumour  becomes  more  complex,  containing  structures 
such  as  bone,  muscle,  gland  tissue,. etc.,  which  are  formed  from  all 
three  layers  of  the  embryo;  in  some  rare  cases  large  portions  of  an 
embryo  (such  as  a  limb)  are  recognisable.  Similar  dermoids  are 
found  in  the  testis  and  in  other  portions  of  ■  the  body,  though  only  in 
rare  cases.  Teratomata  of  complex  structure  are  often  found  in  the 
sacral  region,  where  they  are  probably  due  to  posterior  dichotomy, 
the  smaller  portion  of  the  embryo  remaining  rudimentary  and 
attached  to  the  larger  twin  in  the  region  of  the  sacrum. 


A  MANUAL  OF  SURGERY 


Cysts. 

By  a  cyst  is  usually  meant  a  more  or  less  rounded  cavity,  with  a 
distinct  lining  membrane,  distended  with  some  fluid  or  semi-solid 
material.  The  term  is  used  very  loosely,  being  applied  to  a  variety 
of  manifestations  which  it  is  difficult  to  classify,  owing  to  the  fact 
that  conditions  which  are  pathologically  similar  in  origin  are  some- 
times termed  cysts  in  one  part  of  the  body,  and  not  so  in  another. 
For  practical  purposes,  however,  they  may  be  grouped  as  follows : 

I.  Cysts  of  embryonic  origin,  or  arising  in  connection  with  embryonic 
remains. 

II.  Cysts  arising  from  the  distension  of  pre-existing  spaces  (distension 
cysts). 

III.  Cysts  of  new  formation. 

IV.  Cysts  of  degeneration. 

I.  Cysts  of  Embryonic  Origin,  or  arising  in  Connection  with 
Emtryonic  Remains. 

I.  The  most  important  cysts  to  be  considered  under  this  heading 
are  those  known  as  Dermoids.  These  are  characterized  by  the 
existence  ip  abnormal  situations   of  cavities  lined  with  epithelium, 

from  which  may  be  developed  such 
f^''-^   —     _  forms  of  cutaneous  appendages  as 

hairs  and  nails,  whilst  the  space 
is  usually  occupied  by  sebaceous 
contents.  The  structure  of  the 
lining  wall  is  very  similar  in 
nature  to  skin  or  mucous  mem- 
brane, consisting  of  stratified 
epithelium,  from  which  a  con- 
siderable growth  of  sebaceous 
glands  and  hair  follicles  often  take 
place.  If  teeth  or  more  complex 
tissues,  such  as  bony  alveoli, 
mammary  glands,  nipples,  etc., 
are  enclosed  in  such  a  cavity,  it 
should  probably  be  looked  on  as 
a  teratoma. 

Several  varieties   of  dermoids 
are  described  : 

[a]  Sequestration  Dermoids  are 
cysts  arising  from  the  incomplete 
disappearance  of  surface  epithe- 
lium in  situations  where,  during 
embryonic  life,  fleshy  segments 
coalesce.  Thus,  in  almost  any  part  of  the  middle  line  of  the  body  such 
tumours  may  develop,  owing  to  the  fact  that  there  is  here  a  union  of 
two  lateral  segments.  Similarly,  they  are  not  uncommon  about  the  face 
and  neck,  occurring  along  the  lines  of  the  facial  and  branchial  clefts. 
Perhaps  the  most  common  position  for  them  in  this  region  is  the 


Fig.  68. — Dermoid  Cyst,  growing  at 
THE  Outer  Angle  of  the  Orbit. 
(Bland  Sutton.) 


TUMOURS  AND  CYSTS 


223 


upper  portion  of  the  orbito-nasal  cleft,  behind,  and  to  the  outer 
side  of  the  eye  (Fig.  68).  It  is  not  unusual  to  find  the  skull  de- 
fective beneath  them,  and  a  pedicle  extending  from  the  deep  side, 
connecting  them  with  the  dura  mater.  Sequestration  dermoids 
appear  as  rounded,  definitely  limited  tumours,  firm  and  elastic  to  the 
touch,  over  which  the  skin  glides  freely,  but  are  usually  somewhat 
adherent  to  the  deeper  parts.  This  form  of  dermoid  may  be  re- 
moved without  difficulty,  but  in  those  occurring  about  the  scalp, 
with  the  bone  hollowed  out  beneath  them,  it  is  perhaps  advisable  to 
delay  operation  till  adult  life,  unless  the  tumours  are  rapidly 
increasing  in  size.  The  reason  for  this  is  that  the  bone  gradually 
g'Ows  up  around  the  pedicle,  and  thus  closes  the  communication 
v/ith  the  cranial  cavity.     In  some  cases  it  may  be  difficult  to  remove 


Hydatid  of 
Morgagni. 


Fig.  Gp.^DiAGRAM  of  Adult  Testicle,  to  show  Relation  of  MESONEniRCS 
AND  ITS  Ducts.     (Bland  Sutton  ) 

the  whole  of  the  lining  membrane  by  dissection,  and  under  these 
circumstances  the  portion  left  behind  should  be  destroyed  with 
cautery  or  caustics :  otherwise,  recurrence  is  almost  certain  to 
follow. 

(b)  Dermoids  may  also  arise  in  connection  with  embryonic  canals 
and  passages,  and  have  then  been  called  Tubulo-Dermoids.  These 
are  chiefly  met  with  in  connection  with  the  thyro-glossal  duct  and 
the  post-anal  gut  (q.v.). 

{c)  For  Ovarian  Dermoids  see  page  221. 

2.  Cysts  occasionally  arise  in  connection  with  the  formation  of  the 
teeth;  such  have  been  already  alluded  to  under  the  terms  follicular 
and  epithelial  odontomes  (p.  207),  the  former  being  also  known  as 
dentigerous  cysts,  the  latter  as  fibro-cystic  disease  of  the  jaw. 


"4 


A  MANUAL  OF  SURGERt 


3.  Various  cysts  develop  in  connection  with  the  remains  of  the 
Wolffian  body,  as  also  from  its  tubules  and  duct.  It  must  be  remem- 
bered that  this  body  arises  in  the  posterior  abdominal  wall  near  to 
the  origin  of  the  kidney  and  testis,  and  that  part  of  it  enters  into 
the  formation  of  the  latter ;  hence  one  is  not  surprised  to  find  chat 
its  remains  are  closely  associated  with  that  organ  in  the  scrotum. 

In  the  male  (Fig.  69)  the  Wolffian  body  atrophies  almost  com- 
pletely, being  represented  by  a  few  blind  tubules,  situated  close  to 
the  epididymis,  and  known  as  the  paradidymis,  or  organ  of  Giraldes. 
Fibro-cystic  disease  of  the  testis  (adenoma  testis)  is  said  to  arise 
from  this  structure.  The  majority  of  the  ducts  of  the  Wolffian 
body  form  the  vasa  efferentia  testis  ;  a  few  of  the  upper  ones,  how- 
ever, contract  no  attachment  to  the  gland,  and  their  free  ends 
(known  as  Kobelt's  tubes)  may  become  dilated,  and  form  small 


Fig.  70. — Diagram  to  represent  the  Cyst  Regions  of  the  Ovary. 
(Bland  Sutton.) 

A,   Oophoron,  or   ovarian    tissue;   B,  paroophoron,  or  tissue  of  the  hilus  ;  C, 
parovarium  ;  K,  Kobelt's  tubes  ;  G,  Gartner's  duct  (  =  main  Wolffian  duct). 

cysts,  situated  close  to  the  hydatid  of  Morgagni,  which  structure 
represents  the  remains  of  the  Miillerian  body  and  duct.  It  is 
possible  that  an  encysted  hydrocele  of  the  epididymis  sometimes  arises 
from  one  of  these  unobliterated  tubules.  The  main  duct  of  the 
Wolffian  body  forms  the  lower  portions  of  the  epididymis  and  vas 
deferens. 

In  the  female  (Fig.  70)  the  remains  of  the  Wolffian  body  are 
sometimes  met  with  as  a  series  of  closed  tubes  (paroophoron)  in  the 
neighbourhood  of  the  ovary.  Pavoophoritic  Cysts  may  arise  in  con- 
nection with  this  structure,  and  are  chiefly  characterized  by  their 
inner  walls  being  the  seat  of  proliferating  papillomata.  The  Wolffian 
tubules  can  almost  always  be  recognised  in  the  broad  ligament, 
constituting  the  parovarium,  or  organ  of  Rosenmiiller.  Parovarian 
Cysts  formed  from  the  distension  of  this  structure  are  usually  uni- 


TUMOURS  AND  CYSTS  225 

locular,  and  filled  with  a  clear  limpid  serous  fluid  ;  they  have  no 
definite  pedicle,  and  strip  up  the  layers  of  the  broad  ligament.  Some 
of  the  terminal  tubes  may  be  converted  into  small  cysts  which 
project  from  the  fimbriated  ends  of  the  Fallopian  tube,  and  are 
known  as  cysts  of  KoheWs  tubes.  The  main  Wolffian  duct  generally 
atrophies,  but  occasionally  runs  down  between  the  layers  of  the 
broad  ligament  close  to  the  uterus,  to  open  in  the  vagina  near  the 
urethral  orifice,  being  then  known  as  Gartner's  duct.  Cysts  may 
occasionally  arise  in  connection  with  this  structure,  projecting  into 
the  lateral  fornix  of  the  vagina. 

4.  The  processus  vaginalis,  or  funicular  process,  is  the  term  applied 
to  the  protrusion  of  peritoneum  which  precedes  the.  testis  to  form  the 
tunica  vaginalis,  and  which  in  the  female  accompanies  the  round 
ligament  (canal  of  Nuck).  Normally  it  becomes  obliterated,  but 
sometimes  portions  remain  patent,  and  are  distended  with  a  clear 
straw-coloured  serous  fluid,  constituting  in  the  male  an  encysted 
hydrocele  of  the  cord,  and  in  the  female  a  hydrocele  of  the  round  ligament. 

5.  Cysts  arise  occasionally  in  connection  with  some  irregular  develop- 
ment of  the  lymphatic  spaces  ;  thus  in  the  neck  the  so-called  cystic 
hygroma  is  in  reality  a  congenital  cavernous  lymphangiectasis. 

II.  Cysts  due  to  the  Distension  of  Pre-existing  Spaces. 

{a)  Exudation  Cysts  arise  from  the  distension  of  cavities  which  are 
unprovided  with  excretory  ducts,  and  are  frequently  of  inflammatory 
origin.  Such  spaces  may  be  lined  with  epithelium  or  endothelium. 
As  illustrations  of  epithelial  cysts  may  be  mentioned  those  which  arise 
in  connection  with  the  thyroid  body,  as  also  conditions  due  to  the 
distension  of  the  central  canal  of  the  nervous  system  (syringo- 
myelocele), and  those  forms  of  ovarian  cysts  which  arise  from 
distension  of  Graafian  follicles. 

Exudation  cysts  lined  by  an  endothelial  wall  are  much  more 
numerous.  Enlargements  of  bursae,  -hydroceles  of  the  tunica 
vaginalis,  funicular  process,  or  canal  of  Nuck,  and  some  forms  of 
ganglia,  are  of  this  nature.  Diverticula  or  hernial  protrusions  of 
the  synovial  membrane  of  joints  also  occur,  and  are  known  as 
Baker's  cysts. 

A  Scrolls  Cyst  is  supposed  to  arise  from  the  distension  of  lymph 
spaces,  giving  rise  to  uni-  or  multi-locular  cavities,  lined  with 
endothelium,  and  containing  a  limpid  straw-coloured  fluid.  They 
are  seen  most  commonly  in  the  neck,  axilla,  or  breast,  and  in  the 
latter  structure  may  be  surrounded  by  a  dense,  sclerosed,  fibrous 
tissue.  It  is  usually  possible  to  dissect  them  out,  but  occasionally 
one  has  to  rely  on  draining  or  packing  them,  so  as  to  insure  healing 
by  granulation. 

Adventitious  Buvs(B  arise  in  a  somewhat  similar  manner. 

(h)  When  a  collection  of  blood  forms  in  a  pre-existing  cavity,  a 
so-called  Cyst  of  Extravasation  is  produced.  Such  is  met  with  in 
the  pelvis  or  tunica  vaginalis  (hsematocele),  and  also  occasionally  on 
the  surface  of  the  brain,  constituting  an  arachnoid  cyst. 

15 


226  A  MANUAL  OF  SURGERY 

{c)  Retention  Cysts  always  arise  from  obstruction  to  the  escape  ol 
some  natural  secretion  from  a  gland  duct  or  tubule.  The  cavity 
thus  formed  is  lined  with  epithelium,  whilst,  owing  to  the  irritation 
produced  by  the  tension,  a  fibro-cicatricial  wall  of  variable  thickness 
is  developed  outside.  There  is  often  a  considerable  formation  of 
intracystic  growths,  especially  in  the  breast,  whilst  the  contents  gener- 
ally consist  of  the  inspissated  secretion,  perhaps  mixed  with  blood. 

Retention  cysts  may  develop  in  connection  with  any  glandular 
tissue.  The  majority  are  described  under  the  appropriate  headings — 
viz.,  mammary  cysts,  renal  cysts,  pancreatic  cysts,  etc. 

III.  Cysts  of  New  Formation  are  such  as  occur  apart  from  any 
embryonic  condition  or  pre-existing  cavity.  The  following  varieties 
may  be  described  : 

{a)  An  Implantation  Cyst  is  one  which  arises  from  the  accidental 
intrusion  into  the  subcutaneous  or  submucous  tissues  of  epithelial 
cells  which  retain  their  vitality,  and  are  enabled  to  develop  a  cyst 
very  similar  in  nature  to  a  dermoid ;  in  fact,  it  may  be  looked  upon 
as  an  Acquired  or  Traumatic  Dermoid.  Such  an  occurrence  is  usually 
brought  about  as  the  result  of  an  injury,  especially  from  punctured 
wounds  ;  thus,  cysts  of  this  nature  have  been  met  with  in  the  fingers 
or  palm  of  the  hand  as  a  consequence  of  the  penetration  of  some 
sharp  instrument,  whilst  they  are  also  occasionally  seen  in  the 
anterior  chamber  of  the  eye,  following  an  iridectomy.  They  are, 
moreover,  observed  in  the  axillae  of  cattle,  as  a  result  of  goading 
them  with  a  sharp  implement.  The  clinical  signs  and  treatment  are 
similar  to  those  of  a  dermoid  cyst. 

(b)  Cysts  may  form  around  foreign  bodies,  which  thus  become 
encapsuled.  They  are  lined  with  granulation  tissue  or  endothelium, 
surrounded  by  a  variable  amount  of  fibro-cicatricial  tissue. 

(c)  Blood  Cysts  are  of  variable  origin.  Some  certainly  arise 
from  extravasation  of  blood,  and  are  then  filled  with  coagulated 
blood,  or  a  thin  serous  fluid  with  a  varying  amount  of  laminated 
fibrin.  In  many  cases  a  so-called  blood  cyst  is  really  a  soft  sarcoma, 
into  which  haemorrhage  has  occurred  ;  but  a  few  instances  are  on 
record  in  which  a  thin-walled  cavity  existed,  occupied  by  blood, 
and  readily  refilling  after  it  had  been  tapped,  and  with  no  evidence 
of  any  growth.  Such  conditions  have  been  most  frequently  observed 
in  the  neck  (see  Chapter  XXXI.). 

{d}  Parasitic  Cysts  are  produced  by  the  irritation  caused  by  the 
growth  within  the  tissues  of  certain  living  organisms.  Thus,  in  the 
disease  known  as  trichinosis,  derived  from  eating  unsound  pork,  the 
Trichina  spiralis,  a  small  round  worm,  develops  in  large  numbers  in 
the  voluntary  muscles,  and  becomes  surrounded  by  a  capsule  which 
is  subsequently  calcified. 

The  most  important  of  these  parasitic  cysts  is  that  caused  by  the 
development  within  the  body  of  the  scolex  stage  of  the  Tienia  echino- 
coccus,  giving  rise  to  what  are  known  as  Hydatid  Cysts.  This 
disease  is  much  more  common  in  Australia  than  in  this  country, 


TUMOURS  AND  CYSTS 


227 


The  Tania  echinococciis  (Fig.  71)  is  a  minute  tapeworm,  less  than  half 
an  inch  in  length,  which  inhabits  the  intestinal  canal  of  dogs  ;  it 
consists  of  four  segments,  the  posterior  one  being  larger  than  the 
rest  of  the  body,  and  containing  the  genital  organs.  When  mature, 
this  last  segment  becomes  filled  with  ova,  which 
are  discharged,  and  these  find  their  way  into  the 
human  stomach  by  the  media  of  water  or  uncooked 
vegetables,  such  as  watercress,  which  have  been 
contaminated  with  the  dog's  excreta.  The  process 
of  digestion  sets  the  embryo  free,  and  by  means 
of  a  crown  of  little  hooks  which  it  possesses,  as 
well  as  four  suckers,  it  is  enabled  to  bore  its  way 
through  the  walls  of  the  stomach,  and  thence 
travels  by  the  bloodvessels  to  the  liver  or  some 
other  part  of  the  body.  As  a  result  of  the  irrita- 
tion caused  by  its  presence,  a  sac  forms,  which 
originally  consists  of  three  layers  ;  externally,  a 
fibro-cicatricial  layer,  then  an  intermediate  lamel- 
lated  layer  of  chitinous  material  (true  ectocyst),  and 
finally  the  cyst  is  lined  by  a  protoplasmic  germinal 
layer  {endocyst),  from  which  may  be  developed 
solitary  taenia  heads  or  scolices,  also  provided  with 
four  suckers  and  a  circlet  of  hooks,  whilst  some- 
times groups  of  them,  known  as  brood-capsules, 
may  arise  in  the  same  way  (Fig.  72).  Daughter- 
cysts  are  not  unfrequently  formed  from  the 
scolices,  and  they  in  their  turn  may  pass  through 
the  same  changes,  although  as  a  rule  they  are 
barren.  Occasionally  even  the  main  cyst  may 
be  sterile  {acephalocyst),  and  in  such  cases  the  walls 
become  very  definitely  laminated.  The  fluid  con- 
tained in  the  cyst  varies  much  in  amount,  but  is 
always  of  low  specific  gravity,  not  more  than  1007  ; 
it  is  colourless,  but  slightly  opalescent,  limpid,  and 
contains  but  a  trace  of  albumen,  although  a  con- 
siderable amount  of  chloride  of  sodium  is  present. 
On  examining  the  fluid  microscopically,  the  char- 
acteristic hooklets  are  observed.  The  organs 
usually  affected  by  hydatid  disease  are  the  liver,  kidneys,  and  brain, 
but  any  part  of  the  body  may  be  attacked.  Occasionally  in  the 
liver,  and  usually  in  bone,  multiple  cysts  develop  quite  distinct  from 
each  other,  and  with  no  general  cyst-wall  {exogenous  multiplication). 
This  can  only  occur  when  the  ectocyst  is  thin,  allowing  the  scolices, 
which  always  have  a  retractile  neck,  to  push  through  and  '  swarm 
off" '  into  surrounding  tissues. 

Hydatid  cysts  give  rise  to  no  special  symptoms,  except  those 
caused  by  their  size  and  situation,  and  they  are  likely  to  go  on  grow- 
ing until  operative  treatment  becomes  imperative  on  account  of  some 
complication,  or  from  the  size  of  the  mass.     At  any  time  the  cyst 


7 


^i 


Fig.     71. — T^NiA 

ECHINOCOCCUS. 
X    ABODT   20. 


228 


A  MANUAL  OF  SURGERY 


may  rupture,  either  spontaneously  or  as  the  result  of  some  injury  ;  if 
into  a  serous  cavity,  such  as  the  peritoneal  or  pleural,  this  becomes 
infected,  and  an.  abundant  development  of  scolices  and  cysts  ensues, 


-^ 


Fig.    72 — Hydatid    Cyst  (Diagrammatic),    showing    Daughter-Cysts    and 
Brood-Capsules  growing  from  the  Walls.     (After  Bland  Sutton.) 


Fig.  73. — Diagrammatic  Section  of  Wall  of  Cyst. 

a,  Fibrocellular  capsule,  here  somewhat  exaggerated;  b,  lamellated  chitinous 
layer,  or  ectocyst ;  c,  brood-capsules  developing  from  the  protoplasmic  layer, 
or  endocyst ;   d,  scolex,  or  separate  head,  enlarged. 

giving  rise  to  considerable  localized  inflammatory  reaction  ;  moreover, 
the  escape  of  the  cyst  fluid  may  cause  serious  toxaemia,  or,  at  any 
rate,  urticaria,  owing  to  the  presence  therein  of  some  toxic  substance. 


TUMOURS  AND  CYSTS  229 

Occasionally  the  organisvadies  spontaneotisly,  and  then  the  cyst  shrivels 
up,  and  the  laminated  walls  and  daughter-cysts  form  a  firm  leathery 
mass,  perhaps  infiltrated  with  lime  salts  and  of  the  consistency  of 
wet  mortar  ;  a  thick  fibro-cic'atricial  capsule  encloses  the  whole.  At 
other  times  suppuration  takes  place  within  the  cyst,  and  an  abscess 
results.  If  acute,  it  bursts  either  externally,  or  may  open  into  some 
serous  cavity  or  hollow  viscus ;  in  the  last  case,  the  cyst  may 
evacuate  itself,  and  a  spontaneous  cure  result.  Sometimes  the  abscess 
becomes  chronic  and  encapsuled,  and  may  then  remain  quiescent  for 
years. 

For  the  diagnosis  and  treatment  of  hydatid  cyst  of  the  liver,  see 
Chapter  XXXIV.  In  other  regions,  if  the  tumour  cannot  be  removed 
by  dissection,  reliance  must  be  placed  on  drainage,  where  the  situa- 
tion of  the  growth  renders  this  practicable,  or  aspiration,  since  it  is 
usually  found  that  removal  of  the  fluid  contents  causes  death  of  the 
organism,  probably  by  altering  the  intracystic  tension. 

IV.  Cysts  of  Degeneration  arise  in  connection  with  tumours, 
especially  those  where  the  blood-supply  is  not  very  abundant.  Thus, 
mucoid  degeneration  is  not  uncommon  in  fibromata,  fibro-myomata, 
chondromata,  and  even  in  the  harder  forms  of  cancer.  Occasionally 
cysts  form  in  the  sarcomata  from  this  cause,  but  more  frequently  as 
a  result  of  haemorrhage. 


CHAPTER   IX. 
WOUNDS. 

A  WOUND  has  been  defined  as  the  forcible  solution  of  continuity  of  any 

of  the  tissues  of  the  body  ;  but  the  term  is  more  commonly  limited  to 
injuries  of  the  soft  parts,  involving  the  skin  or  mucous  membranes. 
Lesions  in  which  the  skin  does  not  participate,  and  in  which  the 
deeper  structures,  such  as  bones,  ligaments,  etc.,  are  not  involved, 
are  spoken  of  as  contusions. 

A  Contusion  is  any  subcutaneous  wound  or  injury  due  to  the 
agency  of  external  violence,  causing  laceration  of  the  cellular  tissue, 
without  necessarily  involving  such  deeper  structures  as  muscles, 
tendons,  nerves,  or  bones.  The  signs  are  usually  very  obvious,  viz., 
pain,  bruising,  or  discoloration  of  the  part,  and  swelling.  These  are 
readily  explained  by  the  injury  inflicted  on  the  subcutaneous  tissues, 
which  in  the  worst  cases  may  be  entirely  disorganized  and  separated 
from  the  skin.  The  amount  of  bruising  varies  with  the  part  injured 
and  the  severity  of  the  lesion ;  thus,  in  the  eyelids,  scrotum,  and 
vulva,  where  the  tissues  are  lax,  the  ecchymosis  will  be  very  extensive 
and  of  a  black  colour ;  on  the  scalp  there  is,  on  the  other  hand,  but 
little  swelling,  if  the  injury  does  not  include  bleeding  beneath  the 
aponeurosis  of  the  occipito-frontalis.  Again,  the  condition  of  the 
patient's  general  health  influences  the  amount  of  blood  effused ; 
a  strong  man  in  good  training  does  not  bruise  nearly  as  much  as 
those  of  a  languid  temperament  and  relaxed  tissues.  Blebs  and 
bullae  may  form  over  the  injured  spot,  especially  in  connection  with 
fractures.  The  changes  that  occur  in  a  bruise  are  well  known,  the 
colour  passing  from  a  blackish-purple  through  various  shades  of 
brown  and  green  to  a  yellow,  which  gradually  fades  and  disappears  ; 
this  is  due  to  the  disintegration  of  the  red  corpuscles,  and  staining  of 
the  tissues  by  the  haemoglobin  thus  set  free,  or  by  the  products 
formed  during  its  removal.  When  haemorrhage  has  taken  place 
into  the  deeper  parts  or  under  dense  fasciae,  it  is  often  some  days 
before  the  bruise  '  comes  out,'  and  this  may  occur  at  some  distant 
spot,  e.g.,  in  the  eyelids  after  a  blow  on  the  scalp,  whilst  it  may 
travel  along  the  muscular  and  fascial  planes  under  the  influence 
of  gravity. 

230 


WOUNDS  231 

In  a  bruise  or  ecchymosis,  the  tissues  are,  as  a  rule,  merely 
infiltrated  with  blood,  but  occasionally  the  extravasation  is  more 
localized,  collecting  in  a  cavity  formed  by  the  laceration  of  the 
tissues,  and  remaining  as  a  fluid  swelling,  or  Hsematoma.  It  some- 
what resembles  an  abscess  to  the  touch,  but  differs  from  it  in  its 
history,  having  supervened  immediately  after  an  injury,  and  having 
appeared  without  any  heat  or  other  sign  of  inflammation  ;  moreover, 
though  at  first  fluid  and  soft,  it  soon  becomes  harder,  whereas  an 
abscess  is  preceded  by  a  stage  of  brawny  infiltration,  and  the 
softening  occurs  later.  The  subsequent  history  of  a  haematoma 
varies  somewhat  according  to  circumstances,  (a)  A  deposit  of  fibrin 
may  be  formed  peripherally,  leaving  for  a  time  a  fluid  centre,  which 
gradually  disappears,  and  the  whole  is  finally  absorbed.  This  is  well 
exemplified  in  a  subpericranial  cephalhsematoma,  where  the  contrast 
between  the  peripheral  fibrinous  deposit  and  the  fluid  centre,  through 
which  the  skull  can  be  felt,  is  sometimes  so  accentuated  as  to  give 
the  impression  of  a  depressed  fracture,  {b)  The  fluid  portion  of  the 
blood  may  be  absorbed  almost  entirely,  and  the  solid  fibrinous 
residuum  may  become  organized  into  a  firm  fibroid  tumour  which 
persists  indefinitely  ;  the  mass  is  more  or  less  laminated,  and  not 
unfrequently  pigmented,  (c)  The  fibrin  may  be  entirely  absorbed, 
and  a  slightly  pigmented  fibrous  capsule  formed  containing  serous 
fluid,  and  constituting  a  definite  cyst ;  such  is  best  seen  in  connection 
with  the  cerebral  tunics  [avaclmoid  cyst),  (d)  Suppuration  may  ensue 
owing  to  auto-infection  from  within  the  body,  or  from  an  invasion  of 
organisms  through  abraded  skin. 

In  forming  an  opinion  as  to  the  gravity  of  a  subcutaneous 
injury,  one  must  be  guided  by  the  part  injured,  the  extent  of  tissue 
involved,  the  amount  of  blood  extravasated,  and  the  age  and  vitality 
of  the  individual.  In  the  less  severe  cases,  though  there  may 
be  a  good  deal  of  bruising,  recovery  will  ensue,  but  under  less 
favourable  conditions  sloughing  and  death  of  the  injured  tissues  may 
result. 

The  Treatment  of  a  bruise  usually  consists  in  keeping  the  part 
at  rest,  and  applying  cold  or  evaporating  lotions.  The  skin  should 
be  washed  and  rendered  aseptic,  and,  if  need  be,  wrapped  in  an 
aseptic  dressing,  especially  when  much  bruised,  or  if  bullae  have 
formed.  When  a  tense  and  painful  haematoma  exists,  as  under  the 
fascia  lata  of  the  thigh,  recovery  can  be  hastened  and  pain  relieved 
by  an  aseptic  puncture,  followed  by  careful  compression.  In  general 
bruising  of  the  body  from  a  fall  or  extensive  injury,  pain  can  often 
be  relieved  by  applying  fomentations  or  by  a  hot  bath.  There  is 
usually  a  certain  amount  of  fever  and  constitutional  disturbance  for 
a  few  days,  and  these  are  dealt  with  by  purgatives  and  a  suitable 
limitation  of  diet. 

Open  Wounds. 

An  open  wound  may  be  defined  as  a  solution  of  continuity  of  any 
superficial  part  of  the  body,  including  skin  or  mucous  membrane. 


232  A  MANUAL  OF  SURGERY 

Various  kinds  of  wounds  are  described,  such  as  the  incised,  lacerated, 
contused,  punctured,  poisoned,  and  gunshot ;  but,  of  course,  the  most 
important  distinction  to  draw  is  between  the  infected  and  the  non- 
infected. 

I.  Incised  Wounds. — An  incised  wound  is  one  made  by  any  sharn 
cutting  instrument,  but  occasionally  one  not  produced  in  this  manner 
may  be  characterized  by  similar  appearances  ;  e.g.,  the  skin  of  the 
knee  or  elbow  may  be  cleanly  split  open  from  falling  on  it  with  the 
limb  flexed,  and  occasionally  a  policeman's  truncheon  will  lay  open 
the  scalp  almost  as  evenly  as  if  a  knife  had  been  employed. 

The  special  features  of  an  incised  wound  are  as  follows : 

1.  The  hsemorrhage  is  free,  from  the  fact  that  the  vessels  are 
cleanly  divided.  The  amount  necessarily  depends  on  the  size  of 
the  vessels  involved,  and  the  vascularity  of  the  part ;  its  continu- 
ance, upon  the  density  of  the  structures  allowing  or  not  of  con- 
traction and  retraction  of  the  severed  ends. 

2.  Separation  of  the  lips  of  the  wound  also  occurs,  the  amount 
depending  upon  the  elasticity  and  character  of  the  parts  involved. 

3.  Bruising  of  the  margins  of  the  incision  is  absent,  so  that  under 
ordinary  circumstances  rapid  healing  (by  first  intention)  should 
obtain.  The  surfaces,  to  begin  with,  are  lined  by  a  microscopic 
layer  of  damaged  tissue,  some  of  which  may  be  actually  dead ;  but 
if  suitable  precautions  are  taken,  this  is  absorbed,  and  in  no  way 
interferes  with  satisfactory  union. 

Treatment  of  Incised  Wounds. — Seven  essentials  must  be  attended 
to  if  healing  by  first  intention  is  to  be  obtained,  viz. : 

(i.)  The  Arrest  of  all  Bleeding. — If  there  is  general  oozing, 
exposure  to  the  air  is  often  quite  sufficient ;  or  sometimes  it  may 
be  supplemented  by  pressure  for  a  few  minutes  with  an  aseptic 
swab.  Arteries  and  veins  will  need  a  ligature,  but  if  situated  close 
to  the  skin,  they  may  sometimes  be  secured  by  passing  under  the 
bleeding  spot  the  needle  used  for  the  suture.  The  importance  ol 
complete  haemostasis  in  limiting  or  hindering  bacterial  developments 
has  been  already  alluded  to  (p.  4). 

(ii.)  Sterilization  of  the  Wound  and  its  Surroundings.— This  will 
be  considered  in  extenso  in  Chapter  X.  In  casualty  work  asepsis 
cannot  be  always  assured,  as  the  wound,  though  cleanly  cut,  is  made 
through  dirty  skin,  and  portions  of  clothing,  dirt,  and  splinters  of 
wood  or  glass  may  be  carried  in.  Under  these  circumstances  the 
wound  and  its  surroundings  must  be  thoroughly  purified,  according 
to  the  rules  given  on  p. '272,  and  a  free  use  of  i  in  20  carbolic  lotion, 
or  even  of  Lister's  '  strong  mixture  '  (5  per  cent,  of  carbolic  acid  with 
o'2  per  cent,  of  corrosive  sublimate),  is  advisable,  or  the  iodine 
method  may  be  applied. 

(iii.)  The  coaptation  of  the  opposed  surfaces  by  means  of  sutures 
may  now  be  undertaken.  Many  substances  are  employed  for  this 
purpose,  but  amongst  the  best  are  fine  silver  wire,  silk,  horsehair, 
silkworm  gut  and  catgut.  In  casualty  work,  and  for  parts  of  the 
body  where  but  little  scar  is  subsequently  desirable,  as  in  the  face, 


WOUNDS  233 

horsehair  and  silkworm  gut,  being  non-absorbent,  are  perhaps  the 
best  materials  to  employ  ;  but  in  ordinary  operative  work,  which  will 
be  more  certainly  aseptic,  and  where  the  after-treatment  is  more 
efHcient,  fine  catgut  or  silk  may  be  used.  There  are  three  chief 
varieties  of  sutures,  viz.,  the  buried,  the  deep,  and  the  superficial. 

Buried  sutures  are  now  largely  employed,  since  a  foreign  body  may 
be  safely  inserted  into  the  tissues,  if  both  it  and  the  wound  are 
aseptic.  Some  discrimination  must  be  employed  in  the  selection  of 
the  material  chosen  for  a  buried  stitch,  according  to  whether  or  not 
it  is  desirable  that  it  should  persist  or  be  absorbed.  If  a  part  is  not 
very  strong  and  the  cicatrix  is  exposed  to  a  certain  amount  of  tension, 
as  in  the  abdominal  wall  after  a  laparotomy,  non-absorbent  material 
such  as  silk  or  silkworm-gut  may  be  employed,  and  the  incorporation 
of  the  suture  in  the  cicatrix  will  prove  a  source  of  strength.  At  the 
same  time  it  must  be  remembered  that,  if  drawn  too  tight,  the  tissues 
within  its  grasp  may  be  strangled,  and  suppuration  at  a  later  date 
determined  even  apart  from  external  infection.  In  other  cases  all 
that  is  required  of  a  buried  stitch  is  to  hold  certain  tissues  in  contact 
until  a  natural  bond  of  union  has  developed,  and  then  the  sooner  the 
stitch  disappears  the  better — e.g.,  in  building  up  the  tissues  of  the 
neck  after  the  remova.1  of  a  goitre  or  in  re^^uniting  a  divided  nerve ; 
for  such  a  purpose  fine  catgut  slightly  chromicized  answers  admirably. 

Deep  stitches,  or  sutures  of  relaxation,  are  required  in  cases  where 
there  is  difficulty  in  bringing  the  edges  of  the  wound  together,  in 
order  to  transfer  the  tension  from  the  healing  margin  to  tissues 
further  away,  the  edges  being  thereby  relaxed.  For  this  purpose 
thick  silver  wire  may  be  employed,  inserted  i  or  ij  inches  from  the 
margins,  and  tied  directly,  or  lead  buttons  may  be  interposed  next  to 
the  skin,  and  the  ends  of  the  wire  fastened  round  the  projecting 
edges,  thus  diffusing  the  pressure  over  a  greater  space.  They  are 
generally  removed  at  the  end  of  two  or  three  days. 

Stiperficial  stitches,  or  sutures  of  coaptation,  must  be  so  inserted  as  to 
bring  the  edges  of  the  wound  into  contact  without  undue  pressure, 
and  without  any  folding  in  of  the  skin.  Various  methods  are  em- 
ployed, viz.  :  I.  The  interrupted  suture  (Fig.  74,  A),  in  which  each 
stitch  is  separately  finished  off,  the  knot  lying  well  to  one  side  of  the 
incision.  This  is  generally  utilized  for  wounds  which  are  of  irregular 
shape  or  in  which  there  is  tension.  2.  The  glover's  stitch  ,(Fig.  74,  B) 
is  a  continuous  one,  in  which  the  thread  is  carried  on  from  point  to 
point,  and  only  fastened  at  the  ends ;  it  is  not  to  be  recommended. 
3.  The  blanket  or  buttonhole  stitch  (Fig.  74,  C)  is  the  form  of  con- 
tinuous suture  which  should  be  employed  for  extensive  wounds  or 
incisions.  In  it  the  needle,  after  traversing  the  lips  of  the  wound,  if 
carried  under  the  slack  of  the  thread,  so  that  the  loop  of  each  stitch, 
as  it  is  tightened,  is  maintained  at  right  angles  to  the  edge  of  the 
wound,  whilst  the  intermediate  portion  lies  parallel  to  it.  To  fasten 
it  off,  the  needle  is  passed  in  the  opposite  direction  through  the  edges 
of  the  incision,  with  the  free  end  long  enough  to  prevent  it  coming 
through,  and  so  enable  it  to  be  tied  to  the  double  portion  carried 


234 


A  MANUAL  OF  SURGERY 


through  by  the  needle.  4.  Halstead's  intvade/mic  or  subcuticular  stitch 
(Fig.  74,  D)  may  be  employed  when  very  exact  coaptation  is  desir- 
able, and  a  minimum  of  visible  scar  required,  as  in  the  face  or  neck. 
The  deeper  tissues  must  first  be  carefully  built  up  by  a  series  of 
buried  sutures,  so  that  the  margins  of  the  wound  are  nearly  in  apposi- 
tion. Fine  silkworm-gut  or  silver  wire  is  employed,  and  a  short 
straight  needle.  The  needle  is  introduced  in  the  substance  of  the 
skin  beneath  the  cuticle  and  passed  parallel  with  the  surface,  to 
emerge  on  the  same  level  less  than  a  centimetre  from  the  point  of  intro- 
duction, thereby  taking  up  a  semicircle  of  tissue ;  it  is  then  introduced 


I 
A 


Fig.   74. — Various  Forms  of  Suture. 

A,  interrupted  suture;  B,  continuous  suture;  C,  blanket  stitch.  At  the  lower  end 
the  needle  has  just  been  passed,  and  the  way  in  which  it  catches  up  the  loop 
is  indicated.  At  the  upper  end  the  method  of  finishing  off  (originally 
suggested  by  the  late  Mr.  Maunsell)  is  shown  ;  viz. ,  the  needle  is  passed  in 
the  opposite  direction  to  all  the  other  stitches,  the  free  end  being  left  long,  so 
as  to  enable  it  to  be  tied  into  a  knot  with  the  double  thread  which  the  needle 
has  carried  through ;  D,  Halstead's  intradermic  or  subcuticular  stitch. 


in  a  similar  way  on  the  opposite  side  of  the  incision,  and  the  process 
is  repeated  from  one  end  of  the  wound  to  the  other.  The  suture  is 
finally  pulled  tight  at  each  end,  and  left  long.  To  remove  it,  one  end 
is  cut  short,  and  then  a  sharp  pull  on  the  other  end  draws  out  the 
remainder  quickly  and  without  pain.  5.  In  the  quilled  suture  the 
stitches  are  tied  round  a  quill  or  portion  of  catheter  on  either  side  of 
the  wound,  so  that  the  deep  surfa.ces  may  be  maintained  in  apposi- 


WOUNDS  235 

tion,  whilst  the  superficial  portions  are  left  clear  for  additional 
sutures.  The  only  conditions  under  which  it  is  now  used  are  in  the 
operations  for  ruptured  perineum,  or  for  extensive  perineal  or 
urethral  fistulae.  6.  Metallic  clips  (e.g.,  Michel's)  are  used  by  some 
surgeons  instead  of  sutures,  but  they  have  no  real  advantage. 

Adhesive  plaster  is  sometimes  employed,  but  the  wounds  must  be 
very  small  and  insignificant  which  only  require  such  treatment.  A 
fine  aseptic  suture  is  in  most  cases  preferable. 

(iv.)  Drainage  must,  if  necessary,  be  provided,  in  order  to  guard 
against  the  irritation  and  tension  caused  by  retained  blood  or  exuda- 
tions. In  casualty  wounds,  where  there  is  doubt  as  to  the  complete- 
ness of  the  asepsis  or  hsemostasis,  or  where  there  has  been  much 
tearing  or  laceration  of  tissues,  it  is  often  wise  to  insert  a  tube  for 
twenty-four  or  forty-eight  hours. 

When  drainage  is  required,  the  indiarubber  tube  introduced  by 
Chassaignac  answers  well ;  the  end  should  be  cut  flush  with  the 
surface,  and  stitched  to  the  edges  of  the  wound,  so  as  to  prevent  it 
slipping  in  or  out.  For  small  wounds,  a  strand  of  horsehair  or  a 
strip  of  gauze  or  protective  will  usually  suffice. 

(v.)  All  fresh  sources  of  irritation  and  infection  of  the  wound  must 
be  -excluded  by  some  form  of  antiseptic  or  aseptic  dressing. 

(vi.)  Rest  to  the  injured  part  must  be  secured  by  such  an  arrange- 
ment of  splints,  slings,  or  bandages  as  may  be  necessary. 

(vii.)  The  general  health  of  the  patient  is  a  most  important  item 
to  attend  to.  In  an  operation  case  the  bowels  should,  if  possible, 
be  previously  opened,  and  the  patient's  diet  carefully  regulated ;  in 
casualty  work  a  good  purge  should  be  administered  as  soon  as 
convenient,  and  the  food  and  drink  limited. 

Under  ordinary  circumstances  an  aseptic  incised  wound  heals  in 
about  five  to  seven  days,  but  the  actual  time  when  it  is  safe  to 
remove  the  stitches  varies  with  the  age  and  vigour  of  the  individual, 
the  part  of  the  body,  and  the  amount  of  tension  required  to  draw 
the  lips  of  the  wound  together.  In  ordinary  aseptic  operation 
wounds  one  usually  removes  the  stitches  on  the  eighth  day ;  but  in 
the  face  it  is  often  possible  and  advisable  to  take  them  out  earlier, 
partly  because  the  healing  process  is  quickly  accomplished  in  such 
a  vascular  region,  partly  in  order  to  minimize  the  amount  of  scarring. 

Many  conditions  may  arise  to  prevent  the  healing  of  an  incised 
wound  by  first  intention,  and  they  may  be  epitomized  as  essentially 
the  reverse  of  the  seven  conditions  mentioned  above— viz.,  (i.)  Non- 
arrest  of  the  bleeding,  causing  separation  of  the  lips  or  deeper 
portions  of  the  wound ;  (ii.)  the  presence  of  impure  foreign  bodies  or 
other  septic  material;  (iii.)  the  edges  not  being  brought  into  contact; 
(iv.)  imperfect  drainage,  leading  to  tension  on  the  stitches ;  (v.) 
infection  of  the  wound  from  various  causes ;  (vi.)  lack  of  rest  to  the 
part;  and  (vii.)  constitutional  conditions,  such  as  deficient  general 
vitality  from  disease  or  other  causes. 

When  blood  collects  in  the  deeper  parts  of  the  wound,  the  skin 
incision  may  heal  satisfactorily,  but  there  may  be  some  local  tender- 


236  A  MANUAL  OF  SURGERY 

ness,  and  a  little  swelling,  and  some  slight  fever,  the  temperature 
running  up  at  night  to  about  ioo°.  In  such  cases  it  usually  suffices 
partially  to  open  the  incision,  squeeze  or  press  out  the  fluid,  and 
insert  a  small  tube  or  gauze  drain.  (For  Sepsis  of  Wounds,  see  p.  8i  •) 
II.  Lacerated  or  Contused  Wounds. — Such  injuries  are  caused  by 
blunt  instruments,  by  machinery,  missiles,  the  wheels  of  a  vehicle, 
etc.     They  are  characterized  by  the  following  signs : 

1.  The  haemorrhage  is,  as  a  rule,  but  slight,  since  the  vessels  are 
torn  across  irregularly,  and  not  cut  cleanly;  the  middle  and  inner 
coats,  which  give  way  first,  are  curled  up  within  the  contorted  outer 
coat,  forming  a  barrier  sufficient  to  prevent  loss  of  blood.  The 
vessels,  being  elastic,  may  be  pulled  out  of  their  sheaths,  and  are 
sometimes  seen  pulsating  upon  the  surface. 

2.  The  lips  gape  less  than  in  an  incised  wound,  and  are  irregular, 
torn,  and  bruised.  More  or  less  extensive  portions  of  dead  tissue 
have  to  be  disposed  of  before  repair  can  take  place,  and  hence  this 
form  of  wound  usually  heals  by  granulation.  When  a  limb  is  torn 
completely  off,  the  tendons  are  often  left  long,  and  the  muscular 
bellies  project  from  their  fascial  sheaths  as  flabby  congested  masses, 
since  the  skin  gives  way  at  a  higher  point  than  the  subjacent 
structures. 

The  Progress  of  the  case  depends  largely  upon  the  question  whether 
the  wound  is  or  is  not  aseptic. 

In  an  Aseptic  lacerated  wound  it  may  be  possible  to  bring  the 
edges  together  by  suture  or  otherwise,  and,  even  though  they  are  a 
little  bruised,  healing  by  a  slightly  delayed  first  intention  is  possible,  if 
drainage  is  provided.  When  the  wound  remains  open,  the  dead  tissue 
is  absorbed  or  separated,  and  an  aseptic  granulating  surface  results. 
There  may  be  some  simple  traumatic  fever  for  a  day  or  two,  but  it  is 
of  little  consequence. 

If  the  wound  is  Septic,  however,  inflammatory  phenomena  super- 
vene, resulting  finally  in  a  granulating  surface.  Three  stages  may 
be  described  in  the  course  of  the  case,  viz. : 

(a)  The  stage  of  injury,  resulting  in  shock. 

(b)  The   stage   of    inflammation   and   sloughing,   associated   with 

septic  traumatic  fever. 

(c)  The  stage  of  repair  by  granulation,  or  prolonged  suppuration, 

with  exhaustion  and  hectic  fever  in  the  worst  cases. 
The  inflammatory  period  lasts  a  week,  ten  days,  or  more,  according 
to   circumstances,  and   during  this  period   the  patient   is   liable  to 
various  forms  of  septic  trouble,   including  secondary  haemorrhage, 
toxaemia,  pyaemia,  and  traumatic  gangrene. 

The  Treatment  of  contused  and  lacerated  wounds  varies  with  their 
character,  and  no  absolute  rule  of  practice  can  be  laid  down  to  suit 
all  cases.     The  following  routine  is  that  usually  adopted : 

(a)  Immediate  Treatment. — The  great  desideratum  in  all  these 
cases  is  to  render  the  wound  aseptic.  To  accomplish  this  in  severe 
injuries,  it  is  wise  to  anaesthetize  the  patient,  and  then,  after  shaving 
the  skin,  if  necessary,  the  wound  and  its  surroundings  are  scrubbed 


WOUNDS  237 

with  soap  and  carbolic  lotion  (i  in  20)  by  means  of  a  sterilized  nail- 
brush. Foreign  bodies  are  removed,  and  dead  or  doubtful  tissues  cut 
away,  if  unimportant,  whilst  bleeding  vessels  are  secured  by  ligature. 
Ample  provision  must  be  made  for  drainage,  since  the  carbolic 
irrigation  of  itself  causes  much  exudation ;  occasionally  it  is  desirable 
to  make  a  counter-opening  for  this  purpose.  Ragged  or  torn  frag- 
ments of  skin  are  removed  by  knife  or  scissors,  and  then,  if  sufficient 
tissue  remains,  the  wound  may  be  loosely  closed  by  a  few  interrupted 
sutures,  and  an  antiseptic  dressing  of  the  usual  type  applied.  If, 
however,  the  skin  is  scanty  and  asepsis  not  assured,  it  is  better  to 
leave  the  wound  open,  or,  at  any  rate,  only  to  close  it  -partially, 
packing  it  carefully  with  gauze  impregnated  with  iodoform. 

(b)  Subsequent  Treatment  depends  on  whether  or  not  the  measures 
adopted  to  obtain  asepsis  have  been  successful.  If  the  wound  re- 
mains free  from  infection,  nothing  special  is  required.  If  it  becomes 
septic,  cellulitis  associated  with  a  certain  degree  of  sloughing  will 
follow,  and  necessitate  free  incisions.  When  the  suppuration  has 
ceased  and  the  sloughs  have  separated,  healing  by  granulation  will 
occur.  It  must  be  remernbered  that  secondary  haemorrhage  may 
occur  when  the  dead  tissues  are  finally  detached.  During  this 
period  inflammatory  fever  continues,  and  the  patient's  general  health 
must  be  closely  watched.  When  once  a  clean  granulating  surface  is 
obtained,  it  is  treated  in  the  same  way  as  any  healing  wound,  skm- 
grafting  possibly  being  needed  in  the  more  extensive  cases. 

The  question  of  Amputation  will  necessarily  arise  in  dealing 
with  the  graver  forms  of  lacerated  wounds,  although  many  limbs 
are  now  saved  which  would  inevitably  in  former  days  have  been 
sacrificed.  Hard-and-fast  rules  cannot  be  laid  down  as  to  when  to 
amputate  and  when  not  to  do  so  ;  each  case  must  be  treated  on  its 
own  merits.  Apart  from  the  local  lesion,  the  following  points  must 
be  carefully  considered  :  (a)  The  age  and  vitality  of  the  patient.  An 
old  person  has  less  recuperative  power  than  a  young  one,  and  hence 
a  damaged  limb  may  often  be  left  in  a  youth  which  one  would 
certainly  remove  in  an  elderly  person.  The  vitality  of  the  individual 
is  perhaps  even  more  important  than  the  age,  for  some  men  at  sixty 
are  in  a  much  more  healthy  and  resistant  state  than  others  at  forty. 
The  habits,  as  to  temperance,  etc.,  must  also  be  taken  into  considera- 
tion, and  the  existence  of  general  diseases,  such  as  diabetes  or 
albuminuria,  might  induce  one  to  resort  to  radical  rather  than  con- 
servative measures,  (b)  The  vitality  of  the  extremity  injured.  A 
leg  has  to  be  sacrificed  more  frequently  than  an  arm,  since  the 
vitality  and  reparative  power  of  the  latter  are  so^  much  greater. 
(c)  The  presence  or  not  of  sepsis  is  of  the  greatest  significance, 
since,  if  infection  can  be  prevented,  the  chances  of  preserving  the 
limb  are  greatly  improved,  and  operation  may  thus  be  delayed, 
whereas  sepsis  would  turn  the  scale  in  favour  of  radical  interference. 

The  local  conditions  which  suggest  or  determine  the  performance 
of  an  amputation  may  be  conveniently  divided  into  two  groups — viz., 
where  amputation  is  essential,  or  where  it  is  doubtful. 


^38  A  MANUAL  OF  SURGERY 

A,  Amputation  is  certainly  called  for — 

1.  To  trim  up  the  stump  of  a  limb  torn  off  by  machinery,  or  cut  off 
by  a  railway  train,  or  blown  off  in  an  explosion. 

2.  When  the  whole  limb  or  one  complete  segment  of  it  his  been 
totally  disorganized,  or  crushed  to  pulp,  though  still  retaining  its 
connection  with  the  body. 

3.  In  cases  where  gangrene  is  imminent  or  has  supervened, 
especially  if  it  is  of  the  spreading  type. 

4.  When  severe  septic  symptoms  develop  in  a  case  where  an 
attempt  is  being  made  to  save  a  limb,  the  retention  of  which  was 
from  the  first  doubtful ;  or  when  exhaustion  supervenes  from  pro- 
longed suppuration. 

5.  In  severe  compound  lacerations  of  the  foot  in  old  people,  involv- 
ing the  bones  and  laying  open  the  common  synovial  cavity.  Septic 
arthritis  and  necrosis  are  then  very  apt  to  ensue,  whilst  the  distance 
of  the  foot  from  the  centre  of  the  circulation  increases  the  likelihood 
of  gangrene. 

B.  Amputation  is  doubtful  in  the  following  conditions : 

1.  Compound  comminuted  fractures  in  parts  other  than  the  foot 
do  not  per  se  require  amputation,  even  if  neighbouring  joints  are 
implicated.  By  careful  attention  to  antisepsis,  free  drainage,  and 
the  removal  of  detached  fragments  of  bone  and  foreign  bodies,  which 
should  usually  be  accomplished  under  an  anaesthetic,  limbs  formerly 
condemned  to  amputation  can  not  only  be  preserved,  but  also  restored 
to  a  considerable  degree  of  functional  usefulness.  The  final  decision 
will  mainly  depend  on  the  age,  condition,  and  previous  habits  of  the 
individual. 

2.  When  the  soft  parts  have  borne  the  brunt  of  the  injury,  and 
have  been  extensively  stripped  from  the  bones — e.g.,  when  the 
muscles  of  the  forearm  have  been  torn  up  in  a  machine  accident — 
amputation  is  by  no  means  an  essential,  provided  that  they  can  be 
restored  to  their  original  position,  that  there  is  a  reasonable  prob- 
ability of  their  vitality  being  maintained,  and  that  the  utility  of  the 
limb  will  not  be  hopelessly  impaired,  as  a  result  of  lesions  to  the 
nerves,  after  the  wound  has  healed.  The  surgeon  has  here  to  balance 
carefully  the  risk  run  if  an  attempt  is  made  to  save  the  limb,  and  the 
value  that  the  limb  if  saved  will  subsequently  be  to  the  patient. 

3.  Laceration  of  the  main  artery  of  a  limb  need  not  in  itself 
determine  amputation ;  but  if  in  addition  to  this  the  bones,  veins,  or 
nerves  are  hopelessly  injured,  and  especially  in  the  lower  extremities 
of  old  people,  amputation  should  be  undertaken  without  delay.  In 
this  connection  ,it  may  be  pointed  out  that  in  all  probability  tissue- 
grafting  will  be  more  extensively  used  in  the  future  than  it  has  been 
hitherto,  and  that  already  some  astonishing  results  of  this  process 
have  been  attained. 

III.  Punctured  Wounds  and  Stabs. — These  may  be  brought  about 
by  any  form  of  penetrating  instrument,  from  a  pin  or  needle  to  a 
sword,  bayonet,  or  pickaxe.     The  external  opening  may  be  in  itself 


Fig.  75. — Skiagram  of  Wrist  with  Portion  of  Needle  Embedded  in 
Palmar  Aspect. 


Fig.  76. — Skiagram  of  Hand  with  Splinters  of  Glass  Embedded  close  to 
THE  Metacarpal  Bone  of  the  Index  Finger. 

It  will  bft  noted  that  the  glaso  casts  quite  as  dense  a  shadow  as  the  bone. 


WOUNDS  241 

insignificant,  the  chief  danger  arising  from  the  damage  to  deep 
structures — bloodvessels  or  nerves  being  divided,  and  serous  cavities 
or  viscera  opened,  or  even  the  skull  penetrated.  The  subsequent 
symptoms  depend  almost  entirely  upon  the  question  of  sepsis ;  there 
is  alvi^ays  considerable  difficulty  in  efficiently  draining  the  depths  of  a 
long  and  narrov/  wound,  and  therefore  collections  of  pus  readily  form 
and  burrow  in  all  directions. 

Wounds  resulting  from  the  modern  sword-bayonet,  though  very 
serious  from  their  size  and  depth,  are  not  so  difficult  to  heal  as  those 
inflicted  by  the  old  triangular  blade.  They  should  be  effectively 
purified,  well  drained,  and  the  skin  opening  not  allowed  to  close 
until  all  discharge  has  ceased  ;  if  necessary,  a  counter-opening  is 
made  at  a  dependent  spot.  Serious  haemorrhage  or  paralysis,  in- 
dicating that  important  vessels  or  nerves  have  been  divided,  calls  for 
immediate  opening  up  of  the  wound,  so  as  to  expose  and  deal  with 
the  injured  structures. 

The  commonest  punctured  wounds  met  with  in  civil  practice  are 
those  produced  by  needles,  which  are  frequently  broken  off  short  in 
the  body,  especially  in  the  hands,  feet,  knees,  or  nates.  If  seen  soon 
after  the  injury,  it  is  advisable  to  undertake  their  immediate  removal, 
a  proceeding  sometimes  very  simple,  but  occasionally  necessitating 
a  deep  and  difficult  dissection.  Should  the  needle  not  be  removed, 
it  may  travel  about  the  body  along  the  muscular  and  fascial  planes, 
and  there  is  no  knowing  where  it  may  lodge  or  come  to  the  surface, 
or  how  long  it  may  remain  in  the  body.  It  has  been  known  to  find 
its  way  into  the  pelvis  of  the  kidney,  and  constitute  the  nucleus  of  a 
renal  calculus. 

One  of  the  most  troublesome  and  painful  forms  of  penetrating 
wound  is  that  caused  by  a  fish-hook,  since  the  barbed  end  catches  in 
the  tissues,  and  it  is  impossible  to  withdraw  it  without  increasing  the 
size  of  the  wound  considerably.  The  simplest  plan  of  treatment  is 
to  push  on  the  hook  and  make  it  protrude  through  the  skin  else- 
where to  such  an  extent  as  to  enable  the  barb  to  be  cut  away,  when 
the  remainder  of  the  hook  will  be  set  free. 

For  the  detection  of  penetrating  foreign  bodies  of  a  metallic 
nature,  or  of  splinters  of  glass  or  stone,  the  X  rays  of  Rontgen  are 
exceedingly  valuable  (Figs.  75,  76),  but  one  need  scarcely  point  out 
that  such  plates  are  useless  as  means  of  localizing  the  foreign  body ; 
thus  one  could  not  even  say  on  which  side  of  the  bones  (dorsal  or 
palmar)  the  substance  is  located.  It  is,  therefore,  always  neces- 
sary to  take  the  skiagram  from  two  directions,  and  if  the  antero- 
posterior one  is  taken  stereoscopically,  so  much  the  better.  Even 
with  such  assistance,  it  is  often  difficult  to  find  a  foreign  body,  such 
as  a  needle,  and  it  is  advisable  to  undertake  the  operation  for  its 
removal  under  the  rays  with  the  assistance  of  a  screen.  These  are 
now  made  in  a  sterilizable  form,  so  that  full  asepsis  can  be  maintained. 

The   employment   of   complicated   methods  of   localizing  foreign 

bodies — e.g.,  the  cross-thread  localizer — are  not  necessary  except  in 

ophthalmic  work. 

16 


242  A  MANUALOF  SURGERY 

IV.  Gunsliot  Wounds. — It  is  impossible  in  a  work  such  as  this  tc 
go  minutely  into  the  subject  of  gunshot  wounds,  but  it  is  essential 
to  indicate  their  most  important  features,  and  in  what  respect  they 
differ  from  other  forms  of  injury  already  described.  The  character 
of  a  gunshot  wound  varies  according  to  the  nature  of  the  projectile, 
the  arm  employed,  the  velocity  of  the  missile,  the  distance  from  the 
body  at  which  the  firearm  was  discharged,  the  part  of  the  body 
struck,  and  the  direction  of  the  shot. 

The  wounds  inflicted  by  the  modern  small-bore  rifle  {e.g.,  the  Lee- 
Metford,  Mauser,  or  Krag-Jorgenson)  are  very  different  to  those 
produced  in  former  days.  The  desiderata  that  have  been  considered 
in  the  evolution  of  the  modern  rifle  have  been  to  secure  great  muzzle 
velocity,  a  low  trajectory,  and  clean  and  hard  hitting.  To  this  end 
the  barrel  has  been  rifled  so  as  to  cause  the  bullet  to  rotate  on  its 
own  longitudinal  axis  (without  such  rifling  the  bullet  would  rotate 
on  its  short  axis),  and  the  bullet  has  been  greatly  modified,  whilst 
the  old  form  of  gunpowder  has  given  way  to  more  highly  explosive 
substances. 

The  modern  bullet  is  a  long,  thin,  conical  body,  consisting  of 
a  core  of  lead  hardened  by  the  addition  of  2  per  cent,  of  antimony, 
enclosed  in  a  cover,  jacket  or  mantle  of  some  smooth,  hard  metal — 
e.g.,  80  per  cent,  of  copper  and  20  per  cent,  of  nickel  (Lee-Metford 
and  Mauser).  The  muzzle  velocity  is  very  high,  amounting  to 
2,000  feet  per  second  for  a  Lee-Metford  rifle,  and  2,300  feet  per 
second  for  a  Mauser.  The  traiectory  is  nearly  flat ;  anything  within 
500  yards  may  be  fired  at  point-blank,  whilst  in  a  range  of  2,000 
yards  the  bullet  only  rises  194  feet,  as  compared  with  866  feet  with 
the  Snider  bullet. 

The  effect  of  these  arms  varies  to  some  extent  with  the  range,  but 
not  nearly  so  much  so  as  was  formerly  maintained ;  and  although 
the  worst  wounds  are  usually  produced  at  a  short  range,  say  500  or 
750  yards,  yet  quite  simple  wounds  with  no  disruptive  phenomena 
may  also  be  caused  at  a  similar  distance.  One  of  the  best-marked 
features  of  these  wounds  is  that  the  bullet  travels  straight  and  direct, 
without  lateral  deviation  or  deflection,  as  was  so  commonly  the  case 
in  the  old  days.  Simple  flesh  wounds  are  of  no  great  importance 
per  se,  granted  that  important  vessels  and  nerves  are  not  injured. 
The  aperture  of  entry  is  small,  and  looks  somewhat  '  like  a  bug- 
bite  '  (Treves)  ;  the  aperture  of  exit  is  slightly  larger,  and  tends  to  be 
a  little  more  slit-like.  A  certain  amount  of  extravasation  occurs  into 
the  tissues  around  the  track,  but  the  external  bleeding  is  often  slight. 
There  is  but  little  tendency  to  carry  in  portions  of  clothing  or  septic 
material,  and  the  wound  heals  by  first  intention  if  reasonable  pre- 
cautions are  taken.  The  external  cicatrices  finally  look  very  similar 
to  those  produced  by  bad  acne  pustules.  Vessels  and  nerves  are 
not  likely  to  be  injured  unless  they  are  actually  in  the  line  of  the 
bullet ;  the  accurate  limitation  of  the  damage  to  this  line  is  evident 
when  one  hears  of  a  bullet  passing  between  the  abdominal  aorta  and 
the  vena  cava  without  either  being  injured.     If  a  large  artery   is 


WOUNDS  243 

cleanly  hit,  the  patient  bleeds  freely,  and  may  die  of  haemorrhage, 
unless  it  can  be  controlled  by  a  tourniquet.  If  the  artery  is  button- 
holed, a  traumatic  aneurism  may  result,  whilst  arterio-venous  wounds 
were  common  in  the  South  African  campaign.  There  has  been  some 
difference  of  opinion  as  to  the  character  of  the  injuries  to  bones  ;  that 
large  masses  of  cancellous  tissue  (e.g.,  the  lower  end  of  the  femur) 
can  be  drilled  cleanly  without  fracture  is  certain ;  but  such  woundg 
are  sometimes  associated  with  much  splintering  and  involvement  of 
neighbouring  joints,  possibly  as  a  result  of  a  short  range,  or  of 
expansion  of  the  bullet  from  the  tearing  down  of  the  mantle.  If  a 
bullet  hits  cleanly  the  compact  shaft  of  a  long  bone,  it  may  smash 
the  whole  bone  into  small  fragments,  or  the  force  may  be  more 
localized  in  its  action,  though  always  severe.  Such  comminuted 
fractures  are  very  likely  to  become  septic,  if  there  is  a  long  transport 
to  the  field  hospital,  and  then  fragments  undergo  necrosis  and  serious 
inflammatory  phenomena  follow. 

Head  wounds  are  much  less  fatal  than  might  be  imagined  from 
the  experimental  work  that  has  been  undertaken.  At  close  range 
frightful  disruptive  effects  are  produced,  which  are  almost  certain  to 
be  fatal ;  at  a  longer  range  comparatively  little  mischief  is  done, 
except  along  the  line  of  the  missile.  The  inner  table  is  always  more 
splintered  than  the  outer,  and  of  course  a  certain  amount  of  brain 
substance  may  escape.  Abdominal  wounds  are  also  much  less 
serious  than  formerly,  a  mortality  of  90  per  cent.  (American  Civil 
War)  being  replaced  by  one  of.  40  per  cent,  in  the  South  African 
campaign,  and  that  without  operation  (Treves).  The  mere  penetra- 
tion of  one  or  more  coils  of  intestine  is  not  sufficient  to  cause  general 
peritonitis ;  the  wound  is  very  small,  and  peristalsis  seems  to  come 
to  an  end  entirely  as  soon  as  the  patient  is  struck,  so  that  neighbour- 
ing coils  of  intestine  or  the  omentum  suffice  to  prevent  faecal 
extravasation ;  indeed,  many  of  the  patients  suffer  but  little  con- 
stitutional or  local  disturbance  Of  course  an  empty  intestinal  canal 
is  a  favourable  condition,  and  this  is  not  unfrequently  present  on  the 
field  of  battle.  Bloodvessels  may  be  wounded  in  the  mesentery,  and 
death  result  from  haemorrhage;  solid  viscera,  such  as  the  liver  or 
spleen,  are  often  damaged  but  little,  granting  a  fairly  long  range. 
(Dn  the  whole,  the  effect  of  these  modern  bullets  is  to  disable  without 
killing,  unless  a  vital  part  is  struck. 

Soft-nosed  Bullets  {e.g.,  the  Dum-Dum)  are  characterized  by  the 
mantle  being  absent  at  the  top,  whilst  the  lead  core  is  usually  free 
from  antimony.  The  result  of  this  is  that  as  soon  as  the  bullet 
strikes,  the  lead  core  mushrooms  out,  and  terrible  mutilation  or 
destruction  of  surrounding  tissues  ensues,  whilst  bones  are  com,- 
minuted  and  solid  viscera  pulped.  A  similar  result  follows  from 
rubbing  or  cutting  off  the  top  of  the  Lee-Metford  or  Mauser  bullet, 
or  even  from  incising  the  cover  in  two  or  three  places. 

Martini-Henry  and  Snider  Bullets  produce  wounds  which  are  inter- 
mediate in  their  severity  between  the  preceding  two.  The  aperture 
of  entry  is  usually  small,  that  of  exit  large  and  with  everted  edges. 


244  ^   MANUAL  OP  SURGERV 

Portions  of  clothing  are  frequently  carried  in  by  these  missiles,  and 
add  to  the  risks  of  sepsis. 

Shell  Wounds  have  no  special  peculiarities  beyond  their  severity 
and  the  ghastly  nature  of  the  injuries  which  may  be  inflicted  by 
them,  depending  on  the  irregular  shape  of  the  fragments  into  which 
the  shell  bursts. 

Revolver  Wounds  are  more  likely  to  be  seen  in  civil  practice  than 
any  other  form  of  gunshot  injury.  They  may  be  suicidal  or  acci- 
dental in  origin.  Suicidal  wounds  are  usually  directed  to  the  temple, 
the  base  of  the  skull  through  the  mouth,  or  the  heart.  In  the 
temporal  region  (right  side  for  right-handed  individuals)  there  is 
usually  a  small  wound,  surrounded  by  an  area  in  which  the  skin  and 
hair  are  singed,  and  perhaps  stained  by  the  powder.  The  bullet 
pierces  the  bone  and  traverses  the  brain,  but  in  the  majority  of  cases 
does  not  emerge  from  or  even  fracture  the  other  side.  It  may  be 
found  either  embedded  in  the  brain  substance  or  loose  under  the  dura 
mater.  Death  is  not  always  instantaneous,  as  no  large  vessel  may 
be  torn.  When  the  revolver  is  discharged  upwards  through  the 
mouth,  the  base  of  the  skull  is  penetrated,  and  death  is  more  likely 
to  be  instantaneous ;  the  bullet  in  some  cases  may  dislodge  a  portion 
of  the  top  of  the  cranium,  but  without  penetration.  Accidental 
revolver  wounds  may  present  any  variety  of  lesion,  but  the  apertures 
of  entry  and  exit  are  distinctl}'  recognisable  as  a  rule. 

Dangerous  wounds  may  be  inflicted  by  small  shot,  as,  for  instance, 
when  one  of  the  pellets  enters  the  eye,  whilst  the  wads  or  other 
portions  of  the  cartridge  may  also  be  carried  into  the  body ;  a  horse- 
hair wad  may  produce  tetanus.  A  blank  cartridge,  if  discharged  at 
a  short  distance,  may  produce  a  severe  wound,  and  under  such 
circumstances  the  skin  around  is  likely  to  be  burned  and  blackened, 
leaving  a  permanent  bluish- black  tattooing  of  the  tissues. 

The  Treatment  of  gunshot  wounds  is  conducted  in  accordance 
with  general  surgical  principles,  although  it  may  have  to  be  some- 
whkt  modified  by  the  patient's  environment  and  by  the  fact  that 
after  a  battle  the  pressure  of  work  may  be  such  that  all  lengthy 
operative  procedures  have  to  be  discarded.  The  first  essential  is  to 
protect  the  wound  from  infection,  and  for  this  purpose  the  small 
packet  of  antiseptic  dressing  carried  by  all  our  soldiers  is  admirable. 
Bleeding  is  controlled  by  a  tourniquet,  and  splints  must  be  impro- 
vised for  broken  limbs.  As  soon  as  the  wounded  man  reaches  the 
field  hospital,  the  wound  is  more  thoroughly  explored  and  cleansed  ; 
foreign  bodies  are  removed,  bleeding-points  secured,  and  if  the  bullet 
has  not  escaped  and  can  be  readily  detected,  it  should  be  extracted. 
When  lodged  deeply,  its  positon  may  be  determined  by  skiagraphy, 
or  by  such  appliances  as  Nelaton's  porcelain- ended  probe,  or  more 
complicated  electrical  contrivances,  such  as  the  telephone  probe. 
Comminuted  fractures  are  carefully  investigated,  detached  fragments 
of  bone  are  removed,  and  if  an  attempt  is  made  to  save  the  limb, 
splints,  etc.,  are  carefully  applied.  Primary  amputations  for  bullet 
wounds  are  not  very  common  at  the  present  day,  except  when  great 


WOUNDb  245 

comminution  of  bone  or  hopeless  involvement  of  vessels  and  nerves 
has  occurred.  Wounds  of  the  skull  always  demand  the  most  careful 
attention  ;  even  when  the  bullet  has  penetrated  cleanly  and  escaped, 
each  opening  must  be  trephined  so  as  to  allow  of  the  removal  of 
depressed  splinters  of  the  inner  table.  This  rule  holds  good  even 
when  a  bullet  has  merely  ploughed  a  groove  or  track  along  the 
calvarium  without  penetration.  The  results  of  such  treatment  have 
been  most  admirable. 

The  treatment  of  abdominal  wounds  produced  by  small-bore  rifle 
fire  is  generally  one  of  expectancy.  It  has  now  been  abundantly 
proved  that  patients  can  recover  in  the  most  astonishing  fashion 
from  bullet  wounds  which  have  traversed  the  abdomen  from  side 
to  side  or  from  front  to  back,  and  therefore  unless  there  is  some 
very  clear  indication,  operation  is  better  avoided.  Moreover,  the 
practical  difficulties  connected  with  abdominal  sections,  the  frequent 
lack  of  sterilized  water,  of  towels,  and  the  dirty  condition  in  which 
the  patient  is,  owing  to  the  exigencies  of  the  campaign,  together 
with  the  length  of  time  that  such  an  operation  takes — all  these 
constitute  reasons  for  not  interfering  unnecessarily.  Abdominal 
distension  from  haemorrhage  is  one  of  the  chief  indications  for 
laparotomy. 

For  revolver  wounds  very  similar  rules  of  treatment  hold  good. 
As  a  general  rule,  careful  antisepsis  to  the  external  wound  is  all  that 
is  required  ;  the  bullet  may  be  disregarded,  and  there  is  no  need 
to  attempt  its  removal,  unless  it  is  superficial  or  doing  some 
mischief.  Wounds  in  the  limbs  should  not  be  explored  unless 
special  indications  (haemorrhage,  paralysis,  etc.)  suggest  that  vessels 
or  nerves  have  been  injured.  On  the  other  hand,  cranial  injuries 
always  demand  exploration  of  the  aperture  of  entry  and  a  limited 
search  for  the  bullet.  Abdominal  wounds  should  also  be  opened  up 
and  investigated,  if  it  is  thought  likely  that  some  hollow  viscus  has 
been  injured  or  internal  haemorrhage  is  proceedmg. 

V.  Poisoned  Wounds. — The  great  majority  of  poisoned  wounds  are 
due  to  some  definite  micro-organism,  and  we  have  discussed  their 
nature  and  characteristics  elsewhere.  A  few  only  remain  to  be  dealt 
with  here. 

Stings  of  Insects,  such  as  bees  and  wasps,  may  be  exceedingly 
irritating  and  painful,  but  are  not  dangerous,  unless  some  local 
complication,  such  as  erysipelas,  supervenes,  or  the  stings  are  very 
numerous,  as  when  a  swarm  of  angry  bees  settles  on  a  person, 
or  the  part  involved  is  such  as  to  lead  to  serious  swelling,  as  in  the 
pharynx  or  tongue,  oedema  of  the  glottis  possibly  arising  under  such 
circumstances.  All  that  is  usually  needed  is  the  application  of  a 
weak  alkaline  lotion,  whilst  a  common  and  efficient  domestic  remedy 
is  a  sliced  fresh  onion  applied  to  the  part.  Care  must  also  be 
exercised  to  ascertain  that  the  sting  and  poison  sac  are  not  left  in 
the  body. 

Some  varieties  of  flies  and  spiders  are  also  extremely  virulent,  and 


246  A  MANUAL  OF  SURGERY 

it  is  now  certain  that  several  forms  of  disease  are  conveyed  by  the 
former.  Thus,  if  a  fly  bites  a  person  after  feeding  on  putrid  carrion, 
some  form  of  septic  inflammation  may  be  originated  ;  anthrax  may 
also  be  spread  in  this  way.  Mosquitoes,  too,  play  an  important  role 
in  the  development  of  malaria  and  filariasis. 

Snake-bites  require  but  little  notice  here,  as  they  are  exceedingly 
rare  in  this  country,  the  common  adder  [Pelias  herus)  being  the  only 
venomous  one  likely  to  be  met  with,  and  even  with  this  the  poison 
is  not  sufficiently  virulent  to  do  much  harm  unless  the  individual 
attacked  is  a  child  or  a  person  in  a  very  bad  state  of  health.  The 
poison  is  conveyed  to  the  wound  from  the  glands  and  poison  sac 
situated  on  either  side  of  the  upper  jaw  through  fine  canals  in  the 
specialized  teeth,  which  open  at  their  apices  ;  these  teeth  are  so 
delicate  in  some  snakes  that  it  may  be  difficult  to  find  the  wounds 
produced  by  them.  The  effects  of  an  adder's  bite  are  not,  as  a  rule, 
noticed  immediately,  but  come  on  in  the  course  of  an  hour  or  so  ; 
extreme  prostration  supervenes,  with  a  weak  pulse,  cold  clammy 
perspiration,  dilatation  of  the  pupils,  and  perhaps  delirium  in  bad 
cases,  merging  into  coma. 

The  Treatment  consists  in  preventing  the  absorption  of  the  virus 
by  tying  a  ligature  firmly  above  the  wound,  which  should  then  be 
laid  open  so  as  to  allow  of  free  bleeding,  and  the  surface  excised  or 
cauterized.  The  collapse  resulting  from  absorption  of  the  poison  is 
best  remedied  by  the  administration  of  stimulants  or  the  hypodermic 
injection  of  strychnine. 

In  India  and  other  countries  many  varieties  of  poisonous  snakes 
are  met  with,  and  wounds  are  frequently  fatal ;  indeed,  in  India  it 
is  stated  that  12,000  individuals  are  yearly  destroyed  in  this  way. 
The  symptoms  come  on  rapidly,  and  are  extremely  severe,  although 
they  are  modified  according  to  the  variety  of  snake.  Treatment  con- 
sists in  the  immediate  application  of  a  ligature  round  the  limb  above 
the  wound,  which  is  squeezed  or  sucked  after  incising,  so  as  to  enlarge 
it.  The  wound  is  then  packed  with  crystals  of  permanganate  of 
potash,  or  soaked  in  a  concentrated  solution  of  the  same.  If  the 
patient  survive,  the  ligature  is  removed  from  the  limb  after  a 
few  hours.*  Calmette's  antivenene,  if  obtainable,  may  also  be 
employed ;  it  consists  of  the  blood-serum  of  a  horse  that  has  been 
immunized  by  the  injection  of  gradually  increasing  doses  of  cobra 
venom.  The  dose  required  varies  with  the  size  of  the  snake — from 
10  to  40  c.c.  or  more — and  to  be  beneficial  must  be  injected  within 
an  hour  of  the  bite. 

The  Anatomical  Tubercle,  or  Butcher's  Wart  {Verruca  necrogenica), 
consists  in  a  papillomatous  development  usually  on  the  knuckles  or 
wrists  of  those  who  are  exposed  to  wounds  either  in  the  deadhouse 
or  slaughter-house.  It  is  in  all  probability  a  manifestation  of  tuber- 
culous infection,  and,  indeed,  resembles  somewhat  closely  the  appear- 
ance of  lupus  when  it  develops  on  the  hands.     Treatment  consists 

*  Leonard  Rogers,  Brit,  Med.  Jour.,  November  11,  1905. 


WOUNDS  247 

in  the  application  of  a  powerful  caustic,  whilst  in   bad  cases  it  is 
necessary  to  scrape  the  surface  before  cauterizing. 

Dissection  or  Post-mortem  Wounds  have  obtained  an  unenviable 
notoriety  in  the  production  of  serious  inflammatory  disturbance. 
It  is  well  known  that  bodies  are  most  virulent  within  a  few 
hours  of  death,  and  hence  the  post-mortem  room  is  more  frequently 
responsible  for  these  affections  than  the  dissecting  room,  although 
the  use  of  rubber  gloves  has  reduced  the  dangers  due  to  this 
source.  Inflammatory  disturbances  may  arise  from  several  distinct 
causes : 

1.  The  presence  of  strong  antiseptics,  such  as  arsenic,  often 
irritates  abrasions,  and  causes  tenderness  and  congestion  of  the 
matrices  of  the  nails. 

2.  The  organisms  occurring  in  actual  putrid  material  have  no 
power  of  attacking  living  tissues,  although  some  irritation  may  be 
caused  by  them  if  small  sores  or  abrasions  are  present. 

3.  Pathogenic  organisms  are  frequently  found  in  bodies  soon  after 
death,  and  are  especially  virulent  when  developing  in  the  exudations 
from  serous  membranes,  such  as  the  peritoneum  ;  hence  both  the 
surgeon  who  operates  on  the  living  subject,  and  the  pathologist  who 
examines  the  body  after  death,  are  alike  exposed  to  serious  risk 
either  from  an  accidental  puncture  or  from  the  infection  of  some 
abraded  surface.  It  is  even  possible  for  infection  to  occur  through 
the  hair  follicles  of  an  unbroken  skin. 

The  resultant  lesions  necessarily  vary  much  in  their  nature.  In 
the  simpler  cases  all  that  ensues  is  a  limited  irritation  of  some 
abrasion  or  scratch,  which  rapidly  disappears  on  the  application  of 
some  sedative  or  antiseptic  lotion.  Suppurative  folliculitis,  or  even 
boils,  arise  from  infection  of  the  hair  follicles,  and  in  worse  cases 
the  various  forms  of  onychia,  paronychia,  or  diffuse  cellulitis,  with 
or  without  suppuration  in  the  nearest  lymphatic  glands.  Severe 
toxaemic  symptoms  usually  accompany  the  last-named  conditions, 
and  even  acute  septicaemia  may  develop. 

The  immediate  treatment  indicated  for  a  dissection  wound  is  to 
tie  a  ligature  or  handkerchief  around  the  base  of  the  wounded  finger, 
so  as  to  encourage  bleeding  and  prevent  the  absorption  of  toxic 
materials ;  the  part  is  then  well  washed  under  a  tap  of  cold  water, 
inrmersed  in  an  antiseptic  solution,  and  sucked  for  some  minutes  ; 
an  antiseptic  dressing  must  then  be  applied.  Any  inflammation 
which  arises  subsequently  must  be  treated  according  to  the  general 
rules  of  surgery. 

Poisoned  wounds  of  the  fingers,  whatever  their  origin,  frequently 
result  in  inflammation  of  the  nail  matrix,  or  of  the  tissues  of  the 
fingers,  constituting  a  whitlow.  The  former  will  be  described  in 
Chapter  XVI. 

A  Whitlow  {Paronychia  or  Panaritium)  occurs  in  four  difierent  forms, 
of  which  one  is  a  localized  inflammation  of  the  skin,  another  a  true 
cellulitis,  a  third  is  a  teno-synovitis,  and  the  fourth  involves  the 
terminal  phalanx. 


248 


A  MANUAL  OF  SURGERY 


la)  The  Subcuticular  whitlow  consists  merely  in  a  development  of  pus  beneath 
the  cuticle  which  separates  it  from  the  cutis  vera.  It  is  very  painful,  but  other- 
wise of  little  importance.  A  boracic  poultice,  preceded  by  the  removal  of  the 
loose  cuticle,  is  all  that  is  needed  in  its  treatment. 

(b)  The  Subcutaneous  whitlow  is  a  true  cellulitis,  commencing  in  the  pulp  of  a 
finger,  but  often  spreading  upwards  to  involve  the  palm.  The  finger  becomes 
swollen  and  painful,  the  pain  being  increased  by  pressure  or  by  hanging  down 
the  arm.  Gradually  both  these  symptoms  increase  in  amount,  the  back  of  the 
finger  becoming  oedematous,  and  the  pulp  more  or  less  red.  The  swelling  is  at 
first  hard  and  brawny,  and  even  when  pus  is  present  it  may  be  difficult  to  detect 
fluctuation  unless  the  abscess  is  nearly  pointing.  Constitutional  symptoms  are 
not,  as  a  rule,  very  severe,  though  the  intensity  of  the  pain  may  exhaust  the 
patient.  The  hand  should  be  elevated,  and  the  finger  fomented  or  poulticed,  or 
treated  by  Bier's  cupping-glass.  When  pus  has 
formed,  a  free  longitudinal  incision  in  the  middle 
line  should  be  early  adopted  ;  but,  though  free,  it 
must  not  extend  too  deeply,  or  the  tendon  sheath 
may  be  opened  and  infected.  Occasionally  the  pus 
forms  at  one  or  other  side  of  the  finger,  and  the 
incisions  must  then  be  suitably  modified.  Antiseptic 
fomentations  constantly  changed  and  baths  must  be 
utilized  after  such  an  incision,  the  constant  moisture 
adding  greatly  to  the  patient's  comfort.  Bier's  plan 
of  treatment  may  advisably  be  repeated  after  in- 
cision. 

(c)  The  Thecal  form  of  whitlow  is  really  a  suppu- 
rative teno-synovitis  of  the  flexor  sheaths.  The 
signs  are  much  the  same  as  in  the  former  variety, 
only  more  severe,  because  the  process  is  often  more 
extensive.  As  special  features  may  be  mentioned 
the  inability  of  the  patient  to  bend  the  finger,  and 
the  extreme  pain  caused  on  attempting  to  do  so, 
owing  to  the  involvement  of  the  tendon.  The 
swelling  also  is  more  marked,  and  usually  extends 
to  the  dorsum  of  the  hand.  The  arrangement  of 
the  synovial  sheaths  in  the  fingers  and  palm  is 
indicated  in  the  accompanying  diagram  (Fig.  77), 
from  which  it  is  obvious  that  whitlows  of  the  thumb 
and  little  finger  are  more  dangerous  than  those  of  the  intervening  fingers.  In 
the  last  case  suppuration  ceases  at  the  level  of  the  heads  of  the  metacarpal 
bones  ;  but  occasionally  it  oversteps  this  limit,  and  involves  the  palm  in  the  same 
way  as  in  the  thumb  and  little  finger.  Free  and  early  longitudinal  incision  in 
the  mid-line  of  the  finger  must  be  made  to  anticipate  such  extension,  and  also  to 
limit  as  far  as  possible  the  adhesions  which  the  tendons  are  liable  to  contract,  or 
to  prevent  them  from  sloughing  owing  to  the  acuteness  of  the  inflammation.  In 
neglected  cases  the  pus  may  burrow  to  the  dorsum  of  the  fingers,  necessitating 
counter-openings ;  or  the  periosteum  may  be  affected,  leading  to  disease  or  death 
of  the  phalanges;  the  interphalangeal  joints  may  also  be  disorganized.  If  the 
palm  is  involved,  one  usually  endeavours  to  spare  the  superficial  palmar  arch  and 
its  branches,  but  in  bad  cases  an  incision  is  made  down  the  centre  of  the  palm 
irrespective  of  vessels,  inasmuch  as  the  superficial  arch  is  easily  picked  up  and 
tied.  The  incision  should  be  made  alon,g  the  middle  of  the  metacarpal  bones 
involved,  and  not  higher  than  the  centre  of  the  palm  ;  but  an  opening  may  also 
be  necessary  close  to  the  level  of  the  wrist-joint,  and  this  can  be  made  in  the 
middle  line  without  danger. 

{d)  The  Subperiosteal  whitlow  may  be  merely  a  complication  of  the  thecal 
variety  ;  but  it  occasionally  starts  as  an  acute  necrosis  of  the  terminal  phalanx, 
arising  either  idiopathically  or  as  a  result  of  infection  from  the  nail  matrix.  The 
inflammation  may  be  limited  to  the  end  of  the  finger,  or  may  spread  to  the  palm. 
Free  incisions,  and  the  removal  of  the  bone,  if  dead,  are  necessary,  followed  by 
antiseptic  fomentations  pr  baths. 


Fig.     77.  —  Diagram  of 

Synovial    Sheaths  of 

Flexor     Tendons  of 
Hand. 


WOUNDS  24$ 

Repair  of  Wounds. 

When  any  of  the  tissues  or  sohd  organs  have  been  divided  or 
injured,  the  reparative  activities  of  the  body  early  assert  themselves 
in  order  to  make  good  the  defect,  unless  they  are  for  a  time  diverted 
by  the  necessity  of  overcoming  an  invasion  of  bacteria,  and  even 
then  the  means  employed  by  Nature  to  conquer  the  microbes  are 
useful  in  determining  the  early  stages  of  repair.  It  matters  little 
what  tissue  of  the  body  is  involved,  for  in  all  the  reparative  process 
is  one  and  the  same,  although  it  may  be  modified  somewhat  by  the 
condition  of  the  wound,  and  the  final  outcome  may  also  differ  in 
measure.  In  the  majority  of  cases  the  ultimate  result  is  a  production 
of  cicatricial  or  scar  tissue,  which  ser\'es  as  the  bond  of  union  between 
the  divided  structures,  and  varies  in  amount  with 'the  closeness  of 
approximation,  the  maintenance  or  not  of  rest  to  the  part,  and  the 
degree  of  inflammatory  disturbance  in  the  wound.  In  a  few  tissues 
a  further  stage — viz.,  that  of  regeneration  of  the  injured  parts — is 
reached ;  in  this  there  is  a  preliminary  formation  of  granulation 
tissue,  which  is  subsequently  invaded  and  replaced  by  a  development 
from  the  parenchyma  of  the  affected  tissue  or  organ.  Striped  muscle, 
bone,  tendon,  nerves,  and  some  glandular  structures  may  thus  be 
regenerated ;  the  skin  and  subcutaneous  tissues,  rarely ;  the  spinal 
cord,  never. 

The  general  facts  as  to  the  process  of  repair  may  be  stated  as 
follows  :  The  margins  of  the  wound  are  always  bounded  by  an  area 
of  tissue  in  a  state  of  lowered  vitality,  even  if  no  bruising  or  sloughing 
of  the  parts  is  present.  The  divided  vessels  are  in  a  condition  of 
thrombosis  as  far  as  the  next  patent  branches,  which  in  their  turn 
are  slightly  dilated,  partly  as  a  result  of  this  obstruction  and  partly 
from  the  reflex  irritation  of  the  injury.  The  surface  of  the  wound  is 
generally  covered  with  a  film  of  lymph  or  blood-clot,  whilst  any  spaces 
left  in  the  interstices  of  the  tissues  are  similarly  occupied. 

(a)  The  first  stage  in  the  process  consists  in  an  abundant  exudation 
of  small  round  cells,  presumably  leucocytes,  whose  function  is  to  remove 
all  dead  or  damaged  tissue,  as  well  as  to  break  up,  disintegrate,  and 
finally  absorb,  any  blood-clot  which  is  present.  These  cells  are 
derived  from  the  surrounding  vessels,  and  are  accompanied  by  a 
certain  amount  of  plasma,  so  that  the  early  manifestations  of  a 
slight  inflammatory  reaction  are  simulated,  and  this,  if  it  does  not 
extend  beyond  certain  limits,  is  a  beneficial  proceeding.  Should  it, 
however,  become  excessive,  as  when  bacterial  invasion  is  present, 
injurious  results  may  follow. 

(b)  The  exudation  of  leucocytes  is  soon  followed  by  the  appearance 
of  a  number  of  large  oval  cells  with  abundant  protoplasm  and  large 
vesicular  nuclei  (Fig.  78) ;  these  are  termed  fibroblasts,  and  are  the 
cells  which  undergo  organization  to  form  fibrous  tissue  and  blood- 
vessels. (^Formerly  it  was  supposed  that  these  cells  were  migrated 
leucocytes,  but  this  idea  was  abandoned  in  favour  of  the  theory 
that  they  are  derived  from  the  cells  composing  the  tissues  of  the 


250 


A  MANUAL  OF  SURGERY 


part,  either  from  the  connective-tissue  corpuscles  or  the  endothehal 
cells  lining  the  capillaries,  lymphatics,  or  lymph-spaces.  1  The 
ingenious  researches  of  Zeigler  and  his  school,  who  inserted  into 
the  peritoneal  cavity  glass  chambers  composed  of  two  pieces  ot 
thin  cover-glass,  cemented  a  short  distance  apart,  and  watched  the 
process  of  organization  in  this  narrow  space,  have  shown  definitely 
that  some  at  least  of  the  fibroblasts  are  wandering  cells  derived  from 
the  blood  :  it  is  possible  that  these  cells  are  in  their  turn  derived 
from  the  endothelium,  and  that  the  endothelial  cell  is  the  fibroblastic 
cell  par  excellence.  Whatever  their  origin,  they  soon  form  a  layer  of 
cellular  tissue  which  lies  upon  or  between  the  surfaces  or  lips  of  the 
wound,   whilst   the   previously  effused   leucocytes   disappear,  some 


Fig.  78. 


-Granulation  Tissue  from  the  Base  of  an  Ulcer. 


(x  60.) 


finding  their  way  back  into  the  circulation,  and  others  serving  as 
pabulum,  for  the  nutrition  of  the  fibroblasts. 

(c)  The  vascularization  of  this  cellular  layer  forms  the  next  stage  in 
the  process.  This  is  brought  about  by  the  outgrowth  from  the 
walls  of  the  nearest  capillaries  of  soHd  rods  of  protoplasm  (Fig.  79,  a), 
which  appear  first  as  minute  buds,  but  rapidly  increase  in  length, 
and  may  be  single  or  double.  They  soon  bend  over  to  unite  with 
similar  threads  growing  out  from  other  capillaries,  or  with  the  wall 
of  another  vessel  (Fig.  79,  h),  or  occasionally  they  unite  with  the 
vessel  from  which  they  started.  The  connective-tissue  cells  may 
also  become  spindle-shaped,  and  send  out  branching  processes  to 
unite  with  the  offshoots  from  the  vessel  walls.  After  a  time  these 
protoplasmic  threads  become  canalized  (Fig.  79,  c),  and  a  com- 
munication is  established  between  them  and  the  mother  vessel,  so 


WOUNDS  ^\ 

that  blood  passes  into  them.  The  new  capillary  wall,  at  first 
homogeneous,  soon  becomes  lined  with  definite  endothelial  cells, 
and  strengthened  by  the  connective  tissue  which  forms  around  it. 
By  this  means  a  soft  vascular  tissue  is  produced,  known  as  granula- 
tion tissue  (Fig.  78),  consisting  of  loops  of  capillaries  supported  by 
large  nucleated  cells  with  a  varying  amount  of  intercellular  substance, 
which  soon  becomes  fibrillated  in  texture.  The  capillary  loops  arise 
in  leashes  from  small  terminal  arterioles,  and  it  is  to  this  arrange- 
ment that  the  granular  appearance  of  the  developing  tissue  is  due. 
Each  granulation,  as  it  arises,  is  about  the  size  of  a  pin's  head. 

(d)  The  transformation  of  this  granulation  tissue  m\.o  fibvo-cicatricial 
tissue  is  next  proceeded  with.     The  fibroblasts  become  spindle-shaped, 


Fits.   79.— New  Vessel  Formation.     (After  Tillmanns.) 
a,  A  small  bud-like  projection  from  the  wall  of  a  capillary  ;  b,  the  union  of  puch 
buds  one  with  another,  or  with  the  branching  processes  of  connective-tissue 
cells  ;  f ,  the  canalization  of  these  processes. 


and  finally  long  and  narrow,  with  pointed  extremities,  which  often 
branch  (Fig.  80) ;  the  nuclei  also  become  long  and  narrow,  and  lose 
their  vesicular  appearance.  /  The  next  stage  of  the  process  is  open 
to  doubt.  The  most  probable  view  is  that  the  periphery  of  the  cell 
becomes  converted  into  collagen,  and  is  then  split  off"  from  the 
mother-cell  to  form  a  fibril  of  connective  tissue  ;  this  process  is 
repeated  until  almost  the  whole  of  the  protoplasm  is  used  up,  the 
nucleus  and  a  small  area  of  protoplasm  remaining  as  a  connective- 
tissue  cell,  or  as  an  endothelial  cell  lining  a  lymph-cleft.  An 
alternative  theory  is  that  these  fibrillae  are  formed  as  an  inter- 
cellular exudation.  By  the  contraction  of  these  fibres  the  cells 
become  flattened  out  and  compressed,  and  the  newly-formed  vessels 


A  MANUAL  OF  SURGERY 


constricted,  so  that  as  time  passes  the  scar  tissue  becomes  less  and 
less  vascular,  and  consequently  firmer  and  denser,  as  well  as  smaller. 


Fig.    So. -Granulation  Tissce  in  the  Early  Stage  o? 
Organization.  (  X  250.  j 

(e)  Whilst  this  last  stage  is  in  progress,  the  surface  of  the  wound 
is  covered  over  with  cuticle,  which  spreads  inwards  from  healthy 


^A(<^i 


^ ;  ^  ^  ^yCZ/  '^-^  ^4.  -  ^^'  C" 


Fig.  81.— Diagram  of  Healing  by  First  Intention.     (After  Billroth.) 
The  wound  is  occupied  by  a  fibro-cellular  growth,  into  which  loops  of  capillaries 
extend,   constituting  granulation    tissue,    whilst  the   epithelium   has  united 
across  the  surface. 

epithelium  in  the  neighbourhood  of  the  wound,  and  especially  from 
the  deeper  layers  of  the  rete  Malpighii. 


WOUNDS  253 

As  already  stated,  the  general  process  of  repair  sketched  above 
is  modified  according  to  the  character  and  condition  of  the  wound. 
Four  chief  modifications  are  met  with  in  surgery  : 

I.  Healing  by  First  Intention  or  Primary  Union  occurs  in  cleanly- 
cut  aseptic  wounds  where  the  lips  are  unbruised  and  brought 
together,  so  that  no  extensive  collection  of  blood  or  discharge 
between  them  is  possible.  A  thin  layer  of  blood-clot  lies  between 
the  surfaces  of  the  wound  and  penetrates  into  their  irregularities,  and 
the  contraction  of  this  clot  is  at  first  the  chief  means  of  keeping  the 
deeper   parts    in   apposition.     There  is  but   a   microscopic   line   of 


Fig.  82. — Section  of  a  Wouxd  Healed  by  First  Intention  Ten  Days 
AFTER  ITS  Infliction. 

The  epithelium  is  drawn  in  to  form  a  V-shaped  notch,  and  beneath  is  a  mass  of 
fibro-cicatricial  tissue  with  comparatively  few  cells  or  vessels  evident. 

damaged  tissue,  which,  together  with  the  blood-clot,  is  easily 
absorbed,  and  the  process  runs  a  typical  course,  as  sketched  out 
above,  union  being  effected  in  five  to  seven  days.  (See  Figs.  81 
and  82). 

2.  Healing  by  Granulation,  or  Second  Intention,  as  it  used  to  be 
termed,  is  met  with  [a)  in  cases  where  there  has  been  definite  loss 
of  substance,  so  that  the  lips  of  the  wound  are  not,  or  cannot  be, 
approximated ;  as  also  {b)  when  the  surface  of  the  wound  is  bruised 
or  damaged  so  that  portions  of  tissue  have  to  separate  by  sloughing ; 
or  {c)  when  the  advent  of  sepsis  has  prevented  the  occurrence  of 
primary  union. 


2S4 


A  MANUAL  OF  SURGERY 


When  a  small  amount  of  aseptic  dead  tissue  is  present,  it  is 
removed,  as  previously  described  (p.  loi),  by  an  invasion  of  leucocytes 
from  the  surrounding  vessels,  which  disintegrate  and  gradually 
absorb  it.  These  are  followed  by  the  fibroblasts,  which  form  a  layer 
of  granulation  tissue  on  the  surface  of  the  wound  (Fig.  83).  If 
there  is  much  slough  to  be  dealt  with,  the  vitality  of  the  granulation 
tissue  cannot  be  maintained  beyond  a  certain  distance  from  its 
source  of  nutrition,  and  so  by  a  process  of  simple  anaemic  ulceration 
the  unabsorbed  dead  portion  is  cast  off  and  a  granulating  surface 
remains.  If  the  slough  is  septic,  inflammation  occurs  in  the  adjacent 
living  tissue,  and  this  brings  about  a  similar  result,  though  accom- 
panied by  suppuration  and  septic  fever. 

When,  however,  there  is  a  simple  loss  of  substance,  with  no  bruis- 
ing or  damage  to  the  tissues,  the  course  of  events  is  as  follows :  The 


Fig.  83. — Diagrammatic  Representation  of  Healing  by  Granulation. 
(After  Billroth.) 


blood-stream  in  the  superficial  capillaries  having  been  arrested,  adjacent 
vessels  become  dilated,  and  from  these  an  exudation  of  plasma  and 
leucocytes  results.  The  plasma  coagulates  on  the  surface  and  forms 
a  layer  of  fibrin,  entangled  in  the  meshes  of  which  are  a  number  of 
white  corpuscles,  so  that  the  wound  becomes  covered  with  a  film  of 
whitish-yellow  material  known  as  lymph.  This  gradually  increases 
in  amount  and  thickness,  and  is  vascularized  from  below  into 
granulation  tissue,  this  process  occupying  from  four  to  seven  days. 

The  healing  of  a  granulating  wound  is  brought  about  by  the 
conversion  of  the  granulations  into  fibro-cicatricial  tissue,  and  by 
the  surface  becoming  covered  with  cuticle.  The  contractile  tendency 
inherent  in  all  cicatricial  tissue  produces  two  results  from  its  presence 
in  the  base  of  the  wound  beneath  the  superficial  layer  of  granula- 
tions :  (i.)  The  surface  area  of  the  wound  is  diminished  in  all 
directions,  a  most  important  element  in  the  healing  process,  since  if 


tVOUMDS 


iS5 


the  base  is  inherent  to  some  dense  resisting  structure  repair  is  slow 
and  difficult,  and  the  wound  may  remain  open  as  a  so-called  chronic 
ulcer.  When  the  granulating  surface  is  very  extensive,  contraction 
may  proceed  to  such  a  degree  as  to  obliterate  many  of  the  vascular 
channels,  and  by  thus  depriving  the  superficial  tissues  of  their 
adequate  nutrition,  the  healing  process  may  be  indefinitely  pro- 
longed, (ii.)  The  depth  of  the  wound  is  diminished,  partly  by  the 
continuous  growth  of  granulation  tissue  from  below  upwards,  but 
also  by  the  contractile  base  lifting  the  deeper  structures  to  the 
surface.     If  the  base  of  the  wound  cannot  be  raised,  the  superficial 


Fig.  84.— Scar  from  a  Recently  Healed  Superficial  Wodnd.(Low  Power.) 
The  epithelial  surface  is  regular  and  devoid  of  papillae ;  the  scar  tissue  has  an 

abundance  of  cells  scattered  through  it,  as  well  as  some  very  obvious  vessels, 

which  would  almost  entirely  disappear  at  a  later  date. 


parts  are  drawn  down,  and  the  cicatrix  is  usually  depressed  and 
adherent  to  the  underlying  parts. 

During  the  process  of  repair  the  wound  takes  on  the  appearances 
already  described  as  characteristic  of  a  healing  ulcer  (p.  96). 

3.  Healing  under  a  Scab  is  a  proceeding  that  can  only  take  place 
in  very  small  wounds,  such  as  superficial  grazes  and  abrasions,  and 
is  practically  identical  with  the  granulating  process,  except  that, 
instead  of  an  artificial  dressing  applied  by  the  surgeon,  the  lesion  is 
covered  by  a  scab  which  consists  of  clotted  blood  or  dried  exudation. 
Should  sepsis  be  present,  pus  is  likely  to  aibcumulate  beneath  the 
scab  and  give  trouble. 


256  A  MANUAL  OP  SURGERY 

4.  Healing  by  Organization  of  Blood-clot  is  only  observed  in  strictly 
aseptic  wounds  where  there  is  definite  loss  of  substance,  as  in  the 
deep  channels  made  in  the  treatment  of  bones  thickened  by  chronic 
osteitis.  Blood  is  allowed  to  collect  and  coagulate  so  as  to  fill  the 
cavity,  and  the  surface  is  covered  with  protective  to  prevent  irritation 
from  the  dressings.  The  dark  coagulum  shows  no  trace  of  change 
for  some  days,  but  gradually  the  peripheral  portions  become  granular 
and  yellowish-white  in  colour  ;  these  are  gradually  vascularized  and 
transformed  into  granulation  tissue,  which  in  time  spreads  over  the 
whole  surface  from  periphery  to  centre,  and  then  healing  occurs  as 
described  above.  The  clot  is  absolutely  passive  in  this  process, 
being  infiltrated  by  leucocytes  and  removed  by  degrees,  and  thus 
merely  serves  as  a  basis  of  support  or  scaffolding  for  the  building  up 
of  the  granulation  tissue  which  replaces  it.  A  similar  result  may  be 
obtained  by  filling  a  cavity  with  grafts  of  sterile  sponge  or  decalcified 
bone. 

A  Scar  is  a  m.ass  of  fibroid  tissue  covered  by  epithelium,  which 
has  been  form^ed  in  the  repair  of  a  wound  (Figs.  82  and  84).  It  is 
at  first  vascular,  and  contains  cells  of  the  connective-tissue  type ; 
but  after  a  time,  as  contraction  continues,  the  cell  elements  become 
flattened  out,  fewer  in  number  and  less  obvious,  the  intercellular 
fibrous  tissue  more  abundant,  and  the  vessels  constricted,  so  that 
finally  a  scar  becomes  well-nigh  bloodless.  Where  superficial,  its 
colour  changes  from  red  to  white,  and  if  of  small  size  it  may  almost 
disappear,  but  never  absolutely,  unless  the  subcutaneous  tissue  has 
not  been  involved.  When  the  parts  around  become  injected  by  any 
cause,  such  as  sharp  friction,  the  anaemic  scar  tissue  again  becomes 
evident  by  contrast.  Lymphatics,  nerves,  hairs,  and  cutaneous 
glands  are  all  absent,  except  perhaps  at  the  periphery,  and  the 
epithelial  covering  itself  is  merely  a  uniform  layer  without  papillae. 
The  Pathological  Phenomena  connected  with  scars  are  as  follows  : 
I,  Excessive  Contraction,  which  may  lead  to  great  deformity, 
especially  when  the  wound  has  occurred  in  the  flexure  of  any  of 
the  joints.  A  web-like  mass  of  fibroid  tissue  then  forms,  limiting 
movement,  and  requiring  operative  interference.  A  seriously  burned 
hand  may  by  cicatricial  contraction  be  fused  into  an  unsightly  mass, 
rendering  the  fingers  of  little  use  ;  similarly,  the  chin  may  be  draA\Ti 
down  and  practically  fixed  to  the  sternum,  and  the  lower  lip  everted, 
as  the  result  of  a  burn  on  the  front  of  the  neck.  The  Treatment  of 
such  conditions  consists  in  dividing  or  excising  the  cicatrix,  and  thus 
freeing  the  parts,  during  which  process  it  must  be  remembered  that 
deeper  structures  of  importance,  such  as  the  main  vessels  and 
nerves,  may  be  adherent  to  the  under  surface,  and  thus  be  endangered. 
When  once  the  scar  has  been  divided,  there  is  often  no  difficulty  in 
restoring  the  parts  to  their  normal  positions,  although  when  the 
contraction  has  existed  for  any  length  of  time  it  may  be  advisable  to 
do  this  slowly,  even  by  gradual  extension  with  a  weight  and  pulley, 
so  as  to  avoid   the  risk  of  lacerating  the  deeper   parts,   which  are 


WOUNDS  nyt 

usually  contracted  secondarily.  The  raw  surface  formed  by  the 
opening  out  of  the  contraction  is  covered  with  epithelium  by  Thiersch's 
method  or  Wolfe  grafts. 

Of  recent  years  it  has  been  proposed  to  treat  such  cases  by  injec- 
tions of  thiosinamin  or  fibrolysin,*  administered  hypodermically.  A 
solution  of  lo  parts  of  the  drug  in  20  parts  of  glycerine  and  70  of 
distilled  water,  is  apparently  the  best,  and  in  the  adult  the  dose  may 
range  upwards  from  \  c.c.  Interesting  results  have  been  published 
of  cures  of  many  different  conditions  due  to  developments  of  scar 
tissue,  and  it  is  supposed  that  they  are  due  to  an  active  leucocytosis 
induced  by  the  drug.  Possibly  the  internal  administration  of 
iodolysin  (an  ethyl-iodide  of  thiosinamin)  may  be  even  more  useful. 

2.  Overgrowth  of  the  scar  tissue  is  sometimes  met  with,  con- 
stituting what  is  known  as  the  false  or  Alibert's  Keloid.  This  most 
frequently  occurs  in  the  scars  of  burns  or  of  wounds  in  tuberculous 
patients,  but  may  arise  from  any  cicatrix,  presenting  itself  as  a 
fibroid  indurated  mass  of  a  dusky  red  colour,  with  perhaps  a  number 
of  dilated  vessels  coursing  over  it,  which  occupies  the  region  of  the 
old  scar,  and  may  possibly  send  claw-like  processes  into  neighbouring 
healthy  structures.  It  consists  merely  of  a  hyperplasia  of  the  scar 
tissue,  but  as  to  its  aetiology  nothing  is  known.  With  the  exception 
of  somewhat  severe  pruritus  or  itching,  its  presence  entails  no  incon- 
venience, although  if  it  occurs  on  exposed  parts  it  may  be  very 
disfiguring.  Removal  is  useless,  since  the  keloid  almost  always 
recurs  in  the  new  cicatrix  and  in  the  stitch  holes.  After  a  longer  or 
shorter  interval  it  often  disappears  spontaneously.  Exposure  to 
X  rays  or  to  radium  will  often  be  beneficial  in  these  cases,  although 
the  treatment  may  be  of  long  duration. 

3.  Ulceration  of  Scars  usually  results  from  defective  nutrition, 
or  from  pressure,  either  from  without  or  from  within — t.g.,  adhe- 
sions of  a  scar  to  an  underlying  bone.  It  is  always  of  a  chronic 
nature,  and  difficult  to  heal.  Stimulating  applications  and  general 
tonic  treatment  are  required,  and  any  harmful  pressure  must  be 
mitigated. 

4.  Painful  Scars  arise  from  either  the  implication  of  a  nerve  terminal 
in  the  cicatrix,  or  the  pressure  of  a  contracting  scar  upon  the  bulbous 
end  of  a  divided  nerve,  as  in  amputation  stumps.  In  each  case 
further  operation  is  necessary  ;  in  the  former  the  cicatrix,  or  at  any 
rate  the  painful  portion  of  it,  is  excised,  whilst  in  the  latter  the  stump 
must  be  opened  up,  and  the  enlarged  end  of  the  affected  nerve 
removed. 

5.  Malignant  Disease  of  Scars,  or  of  old  chronic  sores  but  partially 
healed,  is  of  an  epitheliomatous  type,  and  appears  as  a  hard  ulcerated 
tumour  with  everted  edges,  a  thickened  base,  and  usually  a  good 
deal  of  foetid  discharge  [Mavjolin's  ulcer).  The  progress  is  very  slow, 
since  the  vascularity  of  the  tissue  is  slight.  It  is  painless,  from  the 
absence  of  nerves,  and  as  long  as  the  disease  is  limited  to  the  scar, 

•  Thiosinamin  is  prepared  by  warming  oil  of  mustard  with  an  alcoholic  solution 
of  ammonia.     Fibrolysin  is  a  mixture  of  thiosinamin  with  salicylate  of  soda. 

17 


258  A  MANUAL  OF  SURGERY 

no  tymphatic  implication  will  be  noted.  As  soon,  however,  as  the 
malignant  growi:h  invades  healthy  tissues,  the  usual  phenomena  show 
themselves.  The  diseased  tissues  may  be  freely  dissected  out, 
having  regard  to  subjacent  structures,  and  the  wound  closed  by  some 
plastic  method,  or  amputation  may  be  required. 

General  Conditions  connected  with  Wounds. 

I.  Shock.— By  the  term  '  shock '  is  meant  a  general  depressed 
condition  of  the  nervous  system,  resulting  from  some  energetic 
stimulus,  which  is  either  transmitted  to  the  vital  centres  in  the 
medulla  from  the  peripheral  sensory  or  sympathetic  nerves  of  an 
injured  part,  or  may  descend  to  them  from  a  disturbance  of  the 
emotional  centres  through  the  nerves  of  special  sense.  Local  Shock 
is  a  curious  condition  of  insensibility  to  pain  on  handling,  which  is 
sometimes  present  after  severe  injuries,  and  is  especially  seen  in 
gunshot  wounds.  Possibly  it  is  due  to  some  temporary  paralysis  of 
the  sensory  nerves. 

The  term  collapse  is  applied  to  a  condition  very  similar  in  nature  to  shock,  but 
differing  from  it  mainly  in  its  onset,  which  is  gradual,  and  often  preceded  by 
some  exhausting  disease,  and  by  the  fact  that  muscular  relaxation  is  more  com- 
plete. The  collapse  of  cholera  is  one  of  the  most  typical  manifestations,  but  any 
condition  associated  with  loss  or  derivation  of  fluids  from  the  vessels  may  give 
rise  to  it — e.g.,  prolonged  vomiting  or  serious  haemorrhage.  If  at  the  same  time 
septic  absorption  is  taking  place,  the  symptoms  are  still  more  marked ;  thus  in 
acute  peritonitis  the  two  factors,  removal  of  fluid  from  the  circulation  and 
toxaemia,  are  proceeding  concurrently.  Shock  usually  tends  to  recovery,  unless 
the  lesion  is  of  a  serious  nature,  and  then  collapse  may  supervene  and  prove 
fatal ;  thus,  after  rupture  of  the  intestine  the  immediate  symptoms  are  the  result 
of  shock,  but  they  are  quickly  followed  by  the  collapse  due  to  acute  peritonitis. 

The  degree  of  shock  experienced  in  any  particular  case  is  mainly 
influenced  by  the  following  factors  : 

(a)  The  severity  and  extent  of  the  injury.  Speaking  generally,  the 
amount  of  shock  varies  directly  with  the  depth  of  the  wound,  since 
the  deeper  the  wound,  the  greater  the  violence  which  has  produced 
it ;  but  in  some  cases  extensive  superficial  wounds  produce  a  more 
severe  effect  than  limited  deep  ones,  owing  to  the  larger  number  of 
nerves  involved,  along  which  stimuli  can  be  carried  to  the  centres  ; 
thus,  an  extensive  superficial  burn  is  more  likely  to  produce  fatal 
shock  than  the  complete  incineration  of  an  extremity.  Clean  division 
of  tissues  causes  less  shock  than  crushing  or  tearing. 

(h)  The  site  of  the  injury.  The  more  essential  and  sensitive  the 
organ  injured,  and  the  more  closely  it  is  connected  with  the  chief 
sympathetic  or  cerebral  centres,  the  greater  will  be  the  shock,  but 
much  depends  on  the  character  of  the  injury,  and  as  to  whether  the 
wound  is  accidental  or  operative.  In  the  latter,  when  the  patient  is 
carefully  protected  or  guarded,  operations  involving  division  of,  or 
prolonged  traction  on,  important  nerve  trunks,  or  the  exposure  to 
the  chilling  influences  of  the  air  on  internal  viscera,  will  be  the  most 
productive  of  serious  shock.     Operations  on  the  head  or  brain  are 


[ROUNDS  259 

followed  by  comparatively  little  shock,  whilst  the  upper  part  of  the 
abdomen  is  more  susceptible  to  depressing  influences  than  the  lower. 
Operations  on  the  kidney  and  urinary  passages  are  associated  with 
little  shock. 

{c)  The  nervous  susceptibility  of  the  patient  is  a  most  important 
element,  for  the  more  highly  organized  the  nervous  system,  the  greater 
is  the  amount  of  shock  experienced,  and  vice  versa. 

[d)  The  expectation  or  not  of  the  injury.  When  the  whole  nervous 
system  is  maintained  in  a  state  of  tension,  anxiously  expecting  the 
receipt  of  some  painful  impression,  the  effect  produced  will  naturally  be 
increased;  whilst  if  the  attention  is  diverted,  and  interest  actively 
aroused  in  other  things,  the  shock  at  the  time  is  much  diminished, 
though  its  effects  may  be  subsequently  greater.  Thus,  in  the  keen 
excitement  and  nervous  tension  of  a  battle,  soldiers  have  often  been 
wounded  severely,  and  yet  not  known  it  at  the  time ;  whilst  the  pain 
of  the  most  trifling  Cut  may  produce  deep  shock  when  the  patient 
is  in  a  state  of  dread  and  anticipation. 

The  Symptoms  vary  with  the  injury  inflicted,  from  a  slight 
momentary  giddiness  and  faintness  (known  ordinarily  as  an  attack  of 
syncope  or  a  fainting  fit)  to  immediate  and  complete  prostration, 
insensibility,  and  even  death.  The  pulse  is  at  first  small,  slow,  and 
weak,  but  soon  becomes  irregular,  extremely  rapid,  and  often  im- 
perceptible ;  the .  countenance  is  pallid  and  shrunken,  and  the  brow 
covered  with  cold  sweat ;  the  respirations  are  slow  and  shallow,  whilst 
the  temperature  is  usually  subnormal. 

After  an  interval,  the  length  of  which  depends  on  the  severity  of 
the  lesion  and  the  treatment  adopted,  reaction  occurs,  being  introduced 
by  increased  depth  and  frequency  of  the  respirations ;  the  pulse 
becomes  slower  and  fuller,  the  surface  warmer,  whilst  consciousness 
and  muscular  power  are  gradually  restored.  During  this  period  it  is 
not  unusual  for  an  attack  of  vomiting  to  supervene,  probably  due  to 
hyperaemia  of  the  brain  following  the  anaemia  which  has  been  re- 
sponsible for  most  of  the  preceding  symptoms. 

When  serious  loss  of  blood  has  also  occurred,  the  phenomena  of 
haemorrhage  are  associated  with  those  of  shock  ;  the  palse  is  some- 
times of  the  haemorrhagic  type  (p.  277) ;  the  blood  is  altered  in  its 
characters,  and  great  restlessness  may  be  present. 

Sometimes  reaction  is  accompanied  by  irritability,  either  of  the 
mental  or  muscular  systems,  in  the  one  case  leading  to  traumatic 
delirium,  which  is  always  of  grave  import,  and  in  the  other  to  intense 
restlessness,  as  in  the  shock  which  follows  extensive  burns.  It  is 
possible  that  in  both  these  conditions  a  toxic  element  has  been 
introduced.  The  term  erethitic  shock  is  sometimes  applied  to  these 
manifestations. 

Occasionally  the  evidences  of  shock  are  delayed  in  their  appearance 
for  some  time  after  the  injury,  and  come  on  gradually.  Especially  is 
this  the  case  after  railway  accidents  when  no  great  injury  has  been 
experienced ;  for  a  time  the  anxiety  and  excitement  are  such  that  no 
depression  is  noticed,  but  as  the  mental  perturbation  passes  off,  the 


26o  A  MANUALOP  SURGERY 

individual  experiences  symptoms  very  similar  to  the  above,  but 
probably  rather  of  the  nature  of  neurasthenia  than  of  real  shock  (see 
Chapter  XXIII.).  When  an  accident  occurs  to  a  person  in  a  state 
of  intoxication,  it  is  not  unusual  for  the  phenomena  of  shock  to  be 
delayed  for  some  time,  only  showing  themselves  when  the  effect  of 
the  alcohol  has  passed  away. 

Pathology. — The  post-mortem  evidences  are  not  at  all  characteristic, 
and  consist  merely  in  anaemia  of  the  brain  and  superficial  parts  of 
the  body,  and  enormous  engorgement  of  the  abdominal  viscera,  lungs, 
and  great  venous  trunks ;  the  heart  contains  practically  no  blood, 
although  it  is  probable  that  the  right  side  is  much  distended  at  the 
time  of  death,  especially  when  due  to  sudden  injury,  and  subsequently 
empties  itself  by  post-mortem  contraction.  The  explanation  of  the 
phenomena  of  shock  is  by  no  means  simple,  and  several  factors  are 
probably  needed  to  produce  the  complex  result,  i.  Reflex  inhibition 
of  the  heart's  action  through  the  cardio-inhibitory  centre  in  the 
medulla  explains  the  early  syncope  with  slow  pulse.  It  is  well  known 
that  if  a  frog's  abdomen  is  opened  and  the  exposed  intestine  sharply 
struck,  the  heart  stops  in  a  condition  of  diastole,  whilst  if  the  vagi 
are  previously  divided,  no  effect  is  produced.  Any  severe  peripheral 
injury  may  lead  to  such  a  result,  especially  those  directed  to  the  great 
sympathetic  centres  in  the  abdomen  which  are  closely  connected  with 
the  vital  centres  in  the  medulla.  In  this  way  sudden  death  may  be 
produced  by  a  severe  blow  in  the  epigastrium,  or  by  drinking  a  glass 
of  very  cold  water,  when  hot ;  but,  as  a  rule,  this  inhibition  of  the  heart's 
action  is  never  prolonged  in  mammals.  2.  The  causation  of  the  shock 
which  follows  lengthy  operations  is  still  a  matter  of  discussion.  Crile,* 
who  has  studied  this  subject  experimentally,  shows  that  stimulation 
of  the  central  end  of  a  divided  sensory  nerve  causes  a  rise  of  blood- 
pressure  at  first ;  but  if  the  stimulation  is  repeated  often,  this  rise 
gradually  diminishes,  disappears,  and  in  time  is  represented  by  a  fall. 
This  he  attributes  to  exhaustion  of  the  vasomotor  centre  in  the 
medulla ;  the  blood  collects  in  the  splanchnic  area  as  a  result  of 
paralytic  distension,  and  hence  the  supply  to  the  brain  and  surface 
of  the  body  is  diminished  to  a  dangerous  degree.  Obviously,  any 
considerable  haemorrhage  will  aggravate  the  symptoms.  This  explana- 
tion has  been  recently  questioned  by  Malcolm,!  who  points  out  that 
in  lengthy  abdominal  operations  with  much  shock  this  portal  engorge- 
ment does  not  become  obvious,  and  suggests  that  the  cause  of  the 
shock  is  not  paralysis  or  exhaustion  of  the  vasomotor  mechanism, 
but  a  gradually  ascending  contraction  of  the  arteries  from  the  surface 
towards  the  centre,  which  keeps  the  blood  more  and  more  in  the 
central  parts  of  the  body,  and  deprives  the  periphery,  and,  finally, 
the  brain  itseli,  of  its  necessary  blood-supply. 

Diagnosis. — i.  From  the  general  results  of  hemorrhage.  Restless- 
ness and  thirst  are  then  prominent  signs,  together  with  a  sense  of 

*  'An  Experimental  Research  into  Surgical  Shock,'  by  G.  W.  Crile.  J.  B, 
Lippincott  Co.,  1899. 

t  '  Remarks  on  Shock,'  Bi^u.  Med.  /our.,  December  c^.  1905. 


WOUNDS  261 

dyspnoea,  causing  rapid  respiratory  efforts  ;  the  mental  condition, 
moreover,  is  less  affected,  and  the  patient  is  generally  sensible ;  the 
surface  is  exceedingly  blanched,  and  the  pulse  may  have  a  marked 
haemorrhagic  wave.  2.  In  concussion  of  the  brain  there  are  superadded 
to  the  symptoms  of  shock  those  more  particularly  connected  with  the 
region  affected,  i.e.,  the  intellectual  centres,  so  that  unconsciousness 
is  the  predominant  feature,  whilst  loss  of  memory  of  the  accident  and 
of  the  events  which  followed  is  often  noticed.  3.  When  vomiting  is 
approaching  under  the  influence  of  an  anasthetic,  the  patient's  pulse 
usually  becomes  weak  and  rapid,  and  the  countenance  pale.  This 
condition  closely  simulates  shock,  and  is  often  distinguished  from  it 
only  by  the  progress  of  the  case.  Under  such  circumstances,  if 
vomiting  is  plainly  imminent,  it  is  sometimes  wise  to  increase  the 
amount  of  anaesthetic,  as  the  patient  is  usually  not  fully  under  its 
influence. 

Treatment. — In  slight  cases  very  little  is  needed  beyond  resting 
quietly  for  a  few  minutes,  or  the  exhibition  of  some  aromatic  stimulant 
to  the  nostrils,  such  as  ammonia  or  smelling-salts.  In  the  more 
severe  cases  the  patient  is  laid  recumbent,  with  the  head  low;  hot 
bottles,  well  protected,  and  blankets  are  applied  to  the  trunk  and 
extremities  to  maintain  and  increase  the  bodily  temperature.  If  able 
to  swallow,  a  little  warm  tea  or  stimulant  may  be  administered  ;  but 
if  unconscious,  a  hot  coffee  or  brandy  enema,  small  in  bulk,  or  a 
hypodermic  injection  of  ether  or  strychnine  (1T<_  v.-x.  of  the  B.P. 
injection)  is  necessary.  It  must  be  borne  in  mind  that  the  patient 
has,  in  most  cases,  only  to  be  tided  over  a  certain  period  of  depression 
before  reaction  naturally  follows,  so  that  it  is  important  to  economize 
vital  power,  and  not  to  waste  it  by  over-stimulation.  A  very  simple, 
but  successful,  plan  of  raising  the  bodily  temperature  is  to  place 
under  the  bedclothes,  which  are  supported  on  a  cradle,  one  or  more 
electric  lamps  of  such  strength  as  to  bring  the  temperature  of  the  air 
around  the  body  to  100°  to  105°  F.  This  has  proved  of  much  value  in 
combating  the  severe  shock  following  burns  in  children. 

The  injection  of  hot  saline  fluid  (i  drachm  of  chloride  of  sodium  to 
I  pint  of  water)  into  a  superficial  vein,  the  rectum,  or  the  subcutaneous 
tissues  (submammary  or  gluteal,  for  choice),  has  been  employed  with 
considerable  success  of  recent  years.  The  modus  operandi  of  intra- 
venous infusion  is  described  at  p.  278;  the  fluid  should  be  introduced 
at  a  temperature  between  105°  and  110°  F.  Two  or  three  pints  may 
be  injected  to  begin  with,  the  exact  amount  being  governed  by  the 
reaction  of  the  patient.  If  after  a  few  hours  symptoms  of  depression 
again  supervene,  the  injection  should  be  repeated. 

According  to  Crile,  a  most  valuable  remedy  for  shock  is  the  intra- 
venous injection  of  a  solution  of  adrenalin  (i  in  50,000  or  100,000  parts 
of  normal  saline  solution),  a  few  cubic  centimetres  being  allowed  to 
enter  the  circulation  each  minute.  Pituitary  extract  also  has  a 
powerful  effect  in  raising  the  blood-pressure,  and  slowing  the  too 
rapid  action  of  the  heart  in  shock. 

An  important  question  is  often  raised  as  to  the  advisability  of 


262  A  MANUAL  OF  SURGERY 

performing  an  operation  during  shock.  As  a  general  rule,  it  may 
be  stated  that  operation  should  be  deferred  until  reaction  has  come 
on,  unless  the  presence  of  the  injured  organ,  such  as  a  badly  crushed 
limb,  is  evidently  prolonging  the  condition.  Under  these  circum- 
stances a  hypodermic  injection  of  morphia  may  improve  matters 
by  relieving  pain ;  otherwise  the  local  lesion  should  be  at  once  dealt 
with,  and  it  will  be  often  found  that,  as  the  patient  passes  under  the 
influence  of  the  anaesthetic,  the  pulse  improves,  and  the  state  of 
shock  disappears,  the  anaesthetic  shielding  the  medullary  centres 
from  the  painful  afferent  stimuli. 

Shock  may  to  a  large  extent  be  prevented  during  operation  by  a 
careful  attention  to  such  details  as  keeping  the  patient  well  covered 
and  as  warm  as  possible,  by  perhaps  operating  on  a  hot-water 
table,  by  minimizing  haemorrhage,  and  by  rapidity  and  cleanness  of 
execution.  A  hypodermic  injection  of  strychnine,  or  a  brandy  and 
beef-tea  enema,  given  just  before  the  operation,  is  also  useful ;  and 
it  must  be  remembered  that  incomplete  anaesthesia  tends  to  increase 
the  shock  rather  than  to  prevent  its  occurrence,  although  as  little 
anaesthetic  should  be  administered  as  possible.  In  any  operation, 
where  shock  is  likely  to  be  severe,  its  development  may  often  be  pre- 
vented by  commencing  intravenous  infusion  before  the  operation 
begins,  and  continuing  it  slowly  throughout. 

II.  Traumatic  Fever. — Traumatic  fever  is  that  which  follows  the 
receipt  of  an  injury,  whether  simple  or  compound,  or  after  an  opera- 
tion.    Two  main  varieties  are  described : 

{a)  Aseptic  Traumatic  Fever  occurs  after  subcutaneous  injuries, 
such  as  sprains,  contusions,  fractures,  etc.,  and  after  aseptic  operation 
wounds  or  compound  injuries,  where  micro-organisms  are  absent  or 
impotent.  The  cause  is^  the  absorption  of  fibrin  ferment  or  some 
other  chemical  substance,  which  has  a  stimulating  effect  upon  the 
thermogenic  centres.  Probably  the  use  of  irritating  antiseptics  in 
the  wound,  the  retention  of  serous  discharge,  and  the  accumulation 
of  blood,  are  the  chief  causes  of  the  pyrexia.  Occasionally  fever  is 
observed  in  cases  where  we  have  no  grounds  for  supposing  that 
absorption  is  taking  place ;  it  may  then  be  due  to  some  peripheral 
irritation,  e.g.,  a  badly-fitting  splmt,  and  disappears  immediately  on 
the  removal  of  the  cause. 

The  symptoms  are  those  of  slight  pyrexia,  reaching  ioo°  or  ioi°  F. 
within  twenty-four  or  forty-eight  hours  of  the  injury,  with  coated 
tongue,  loss  of  appetite,  etc.,  gradually  passing  off  in  three  or  four 
days.     If  thus  limited,  it  is  of  no  prognostic  importance. 

(b)  Symptomatic  Traumatic  Fever  is  caused  either  by  the  absorption 
of  the  products  of  putrefaction,  resulting  from  the  vital  activity  of 
organisms  in  discharges,  blood-clot,  or  dead  tissue;  or  from  the 
absorption  of  the  toxins  connected  with  a  development  of  parasitic 
organisms  in  the  wound  or  its  surroundings  ;  or  from  the  supervention 
of  some  general  infective  disorder.  All  these  different  conditions 
have  been  dealt  with  elsewhere  (p.  8i). 


WOUNDS  ■  263 

III.  Traumatic  Delirium. — Although  delirium  is  merely  a  symptom, 
it  is  occasionally  of  so  pronounced  a  character  as  to  demand  special 
attention.     Three  forms  are  described  : 

(a)  The  Active  Delirium  which  accompanies  severe  injuries,  par- 
ticularly in  plethoric,  and  often  in  previously  healthy  individuals, 
whose  environment  has  been  suddenly  changed  from  that  of  everyday 
life  to  a  sick-bed  in  a  hospital  ward.  Septic  contamination  of  the 
wound  is  usually  present,  and  the  delirious  state  is  associated  and 
runs  a  parallel  course  with  the  traumatic  fever.  It  is  not  usually  of 
a  violent  type,  although  the  patient  may  be  irrational  and  restless ; 
he  moves  the  injured  part  without  any  evident  appreciation  of  the 
pain  which,  if  conscious,  he  must  suffer,  but  he  is  easily  restrained 
by  the  exhibition  of  firmness  and  tact  on  the  part  of  the  attendant. 
The  symptoms  are  most  marked  at  night,  and  commence  at  the  end 
of  forty-eight  hours,  lasting,  as  a  rule,  for  two  or  three  days.  There 
is  a  distaste  for  food,  which,  however,  can  be  overcome  by  gentle 
persuasion. 

Treatment. — Patients  in  this  condition  must  never  be  left ;  the  diet 
should  be  light,  but  nourishing ;  the  bowels  are  thoroughly  opened, 
and  an  icebag  to  the  head  may  be  useful.  The  wound  should  be 
freed  from  any  septic  accumulation. 

(b)  Delirium  of  a  Low  Muttering  Type  is  met  with  in  individuals 
of  low  vitality,  exhausted  by  dissipation,  drink,  disease,  or  faulty 
hygienic  surroundings.  It  is  commonly  associated  with  fever  of  an 
asthenic  type,  such  as  is  seen  towards  the  end  of  septic  or  infective 
diseases.  The  patient  usually  lies  on  his  back,  staring  vacantly 
upwards,  is  incoherent,  takes  no  notice  of  surrounding  objects,  and 
is  observed  to  pick  at  the  bedclothes  and  mutter  to  himself  unintel- 
ligibly. There  is  often,  in  addition,  an  involuntary  escape  of  urine 
or  faeces.  The  mouth  is  generally  open,  the  tongue  dry,  brown  and 
cracked,  and  viscid  mucus  collects  about  the  teeth  (sordes). 

The  Treatment  should  be  directed  to  careful  nursing  and  feeding, 
as  by  that  means  alone  can  the  patient  be  saved. 

(c)  Nervous  Traumatic  Delirium  is  observed  in  individuals  who, 
previously  of  intemperate  habits,  have  suffered  some  serious  injury, 
such  as  a  compound  fracture.  The  violent  symptoms  do  not  set  in 
till  about  the  third  day,  but  are  usually  preceded  by  some  amount 
of  sleeplessness  and  wandering  at  night,  or  the  patient  may  have 
short  snatches  of  sleep,  from  which  he  awakes  semi-delirious.  This 
gradually  increases,  and  is  followed  by  violent  delirium  of  the  worst 
type  {delinimi  tremens),  in  which  the  patient  is  haunted  by  terrifying 
visions  of  reptiles,  horrible  insects,  and  the  like,  from  which  he  tries 
in  vain  to  escape.  During  this  stage  of  excitement  he  is  with 
difficulty  restrained  from !  jumping  out  of  bed ;  in  many  instances 
these  patients  are  remarkably  cunning,  and,  managing  to  elude  the 
vigilance  of  their  attendants,  will  succeed  in  escaping  from  the  room 
by  the  door  or  window,  and  may  inflict  serious,  and  even  fatal, 
injuries  upon  themselves  or  others.  There  is  always  a  tremulous 
condition  of  the  extremities  and  of  the  tongue,  which  is  white  and 


264  ^  MANUAL  OF  SURGERY 

coated,  whilst  the  bowels  are  obstinately  confined.  The  pulse  and 
temperature  vary  considerably,  and  the  skin  is  often  moist  and 
clammy.  The  violent  stage  is  always  followed  by  profound  ex- 
haustion, in  which  the  patient  may  gradually  sink  into  a  state  of  coma 
and  die.  In  the  case  of  a  fractured  leg,  the  struggles  of  the  patient 
will  cause  considerable  displacement  of  the  limb,  and  necessitate 
constant  attention  to  prevent  further  mischief.  The  limb  should 
never  be  fixed  to  the  bed,  but  slung  in  a  Salter's  swing  or  immobilized 
in  plaster  of  Paris. 

Treatment. — In  cases  where  an  attack  of  delirium  tremens  is  con- 
sidered imminent,  either  from  the  previous  history  of  the  patient,  the 
tremulous  state  of  his  hands  and  tongue,  or  his  sleeplessness,  the 
best  treatment  to  adopt  is  to  support  the  strength  by  suitable  food 
and  a  medium  dose  of  stimulant,  combined  with  free  purging  and,  if 
need  be,  soporifics  (chloral,  bromide,  paraldehyde,  or  morphia)  ; 
under  such  a  regimen  the  symptoms  usually  soon  disappear.  In 
the  acute  maniacal  attacks  the  patient  must  be  fully  controlled  and 
guarded,  but  with  as  little  manifestation  of  restraint  as  possible; 
hyoscin  in  doses  of  -g-Jjj-  to  J^y  grain  is  useful  in  this  condition. 
Nourishing  food  (possibly  of  a  fluid  type),  with  a  certain  amount  of 
stimulant,  should  be  administered  during  the  quiet  intervals,  and 
sleep  obtained  by  drugs,  especially  morphia  hypodermically ;  a 
quarter  of  a  grain  should  be  given  at  first,  and  more  if  necessary. 
Free  purging  is  of  course  essential. 


CHAPTER  X. 

THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY. 

No  one  who  has  been  brought  up  in  the  modern  school  of  antiseptic 
or  aseptic  surgery  can  have  any  idea  of  the  horrors  that  were  per- 
petrated under  the  name  of  surgery  by  our  ancestors.  Anaesthesia 
was  unknown,  and  perhaps  this  was  an  advantage  rather  than  other- 
wise, as  it  Hmited  the  number  and  the  scope  of  operations.  Patients 
had  to  be  forcibly  restrained  during  the  procedure ;  haemostatic 
forceps  were  not  in  existence,  and  the  operating  theatre  was  not  the 
quietly  decorous  spot  that  it  now  is,  but  rather  resembled  the 
shambles.  The  wards  were  a  hotbed  of  surgical  fever,  and  erysipelas, 
pyaemia,  and  other  manifestations  of  pyogenic  infection  led  to  an 
appalhng  post-operative  death-rate.  Hospital  gangrene,  wound 
phagedena,  and  other  affections  now  happily  extinct,  were  common 
enough,  and  not  unfrequently  wards  had  to  be  entirely  closed  in 
order  to  limit  the  ravages  of  such  diseases.  The  almost  synchronous 
discovery  of  anaesthesia  and  antisepsis  has  transformed  surgery,  and 
from  being  an  art  dangerous,  barbarous,  and  almost  repulsive,  it  has 
been  changed  into  a  scientific  procedure,  beautiful  in  its  details  and 
beneficent  in  its  results.  In  this  connection  the  names  of  Simpson, 
who  fought  the  battle  of  anaesthesia,  of  Spencer  Wells,  who 
popularized  the  use  of  haemostatic  forceps,  and  of  Lister,  who  first 
applied  to  surgery  the  principles  that  were  being  taught  by  Pasteur 
as  to  the  microbic  origin  of  disease,  will  ever  stand  out  as  three  of 
the  greatest  benefactors  of  the  human  race. 

The  Antiseptic  plan  of  treating  wounds,  as  originally  introduced 
by  Lord  Lister,  is  an  outcome  of  the  germ  theory  of  putrefaction. 
It  has  for  its  object  the  prevention  of  bacterial  development  in 
wounds  by  the  use  of  chemical  agents,  some  of  which  are  true 
germicides,  capable  of  destroying  the  bacteria,  whilst  others  merely 
prevent  or  inhibit  their  growth.  Amongst  the  multifarious  antiseptic 
agents  which  have  been  used,  the  most  prominent  are  carbolic  acid, 
corrosive  sublimate,  bmiodide  of  mercury,  iodine,  iodoform,  formalin, 
boric  acid,  salicylic  acid,  etc. 

Carbolic  Acid,  the  first  antiseptic  introduced  by  Lister,  has  a  direct  germicidal 
action  in  strong  solutions,  and  an  inhibitory  effect  in  weaker  ones.  The  crystals, 
when  heated  with  lo  per  cent,  of  water,  constitute  an  oily  fluid  known  as  pure 

2.55 


266  A  MANUAL  OF  SURGERY 

or  liquefied  carbolic  acid,  which  is  a  powerful  though  superficial  caustic,  and 
may  be  applied  without  much  fear  to  infected  living  tissues— «.^.,  to  tuberculous 
sinuses  or  wounds — after  scraping  them,  in  order  to  destroy  any  portions  of  tuber- 
culous material  which  may  have  escaped  the  spoon.  Excess  of  the  acid  may  be 
washed  away  with  absolute  alcohol,  which  quickly  dissolves  it.  The  liquid 
carbolic  dissolves  in  water  on  the  application  of  warmth,  and  the  i  in  20  and 
I  in  40  solutions  are  those  mainly  employed ;  the  former  is  an  efiicient  and 
potent  antiseptic,  but  must  be  used  carefully  on  delicate  skins.  It  is  most  im- 
portant to  insure  the  complete  solution  of  the  acid,  as  otherwise  globules  of  it 
may  be  deposited  on  the  hands  or  in  the  wound,  and  may  do  much  harm. 
Carbolic  acid  is  frequently  somewhat  crude  and  impure,  and  many  of  the 
irritative  and  toxic  phenomena  are  due  to  cresylic  acid  and  other  substances 
which  should  not  be  present.  General  absorption  of  this  reagent  leads  to 
darkening  of  tht  urine,  which  may  become  olive-green  or  even  black  in  colour, 
and  this  carboluna  is  often  associated  with  a  rise  in  temperature  and  some 
intestinal  irritation,  whilst  diseased  kidneys  may  be  seriously  affected.  Weaker 
solutions  are  more  readily  absorbed  than  the  liquefied  or  pure  acid.  It  must  be 
remembered  that  children  and  some  adults  are  peculiarly  susceptible  to  its  action, 
and  its  application  to  large  wounded  surfaces,  e.g.,  burns,  is  inadvisable.  On  the 
other  hand,  its  great  affinity  for  all  greasy  and  oily  substances  renders  it  a 
valuable  antiseptic  for  emergency  work,  as  it  penetrates  into  the  skin  more  readily 
than  other  agents.  A  solution  in  olive  oil  (i  in  20)  or  vaseline  is  frequently  used 
as  a  lubricant  for  catheters,  etc.,  but  is  not  very  satisfactory. 

Corrosive  Sublimate  is  usually  employed  in  solutions  of  i  in  2,000,  i  in  1,000, 
or  I  in  500.  Occasionally  the  last  of  these  three  solutions  has  5  per  cent,  of 
carbolic  acid  added  to  it,  constituting  what  is  known  as  Lister's  strotig  mixture. 
Sublimate  solutions  are  inhibitory  in  action  rather  than  germicidal,  but  are  potent 
and  reliable.  They  have  less  power  of  penetration  than  carbolic  acid,  and  have 
less  hardening  or  roughening  influence  on  the  skin.  If,  however,  a  dressing 
soaked  in  a  sublimate  solution  (i  in  2,000)  is  kept  for  long  in  contact  with  the  skin, 
it  acts  as  a  direct  irritant,  and  may  lead  to  an  abundant  formation  of  pustules, 
owing  to  the  activity  of  the  germs  in  the  deeper  parts  of  the  cutis  which  have  not 
been  destroyed  by  the  antiseptic.  Instruments  should  not  be  placed  in  sublimate 
solutions,  as,  even  if  plated,  they  soon  lose  their  bright  appearance.  It  must  be 
remembered  that  individuals  very  sensitive  to  the  action  of  mercury  may  be 
salivated  by  this  agent,  and  especially  when  used  frequently  for  irrigating  cavities 
to  which  a  free  exit  is  not  provided. 

Biniodide  of  Mercury  is  a  potent  antiseptic,  which  has  been  chiefly  employed 
in  the  form  of  a  i  in  500  solution  in  70  per  cent,  methylated  spirit  for  the  purifica- 
tion of  the  hands  or  of  the  skin  of  the  patient.  It  is,  of  course,  extremely  toxic. 
A  I  in  2,000  aqueous  solution  is  also  employed  for  the  hands,  and  is  less  harmful 
to  instruments  than  the  perchloride. 

Boric  or  Boracic  Acid  is  a  mild  and  weak  antiseptic,  which  may  be  utilized 
when  stronger  remedies  might  prove  harmful — e.g.,  in  plastic  operations  and  for 
infants.  It  is  also  useful  when  antiseptic  fomentations  are  required  in  treating 
inflammatory  phenomena,  and  in  ophthalmic  surgery. 

Iodoform  is  a  yellow  powder  of  characteristic  and  unpleasant  odour,  which 
probably  acts  by  being  decomposed  in  the  tissues  and  slowly  giving  off  iodine. 
Commercial  iodoform  is  usually  contaminated  with  a  variety  of  germs,  as  may 
be  shown  by  dusting  it  over  a  film  of  nutrient  gelatine  and  allowing  them  to 
develop.  It  is  therefore  wise  to  wash  the  iodoform  before  use  in  i  in  20  carbolic 
lotion.  Its  chief  value  is  in  septic  or  tuberculous  wounds,  and,  indeed,  it  seems 
to  have  a  specific  inhibitory  action  upon  the  development  of  the  B.  tuberculosis. 
It  may  be  suspended  in  glycerine  (10  per  cent.),  and  after  steriUzation  by 
immersing  the  vessel  in  which  it  is  contained  in  boiling  water  for  half  an  hour, 
this  can  be  injected  into  tuberculous  tissues,  joints,  or  abscesses ;  or  if  open 
wounds  exist,  gauze  soaked  in  this  emulsion,  as  it  is  incorrectly  termed,  may  be 
packed  into  them  with  advantage.  Toxic  efl'ects  of  very  variable  type  may 
follow  from  undue  absorption  of  the  drug.  Gastro-intestinal  disturbances, 
vomiting,  diarrhoea,  colic,  etc.,  may  be  the  chief  symptoms,  but  delirium  and 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY        267 

collapse  often  supervene.  There  is  always  an  abundance  of  iodine  in  the  urine. 
Various  substitutes  have  been  proposed  in  order  to  avoid  the  unpleasant  smell — 
e.g.,  aristol,  orthoform,  etc. — but  they  are  of  doubtful  value. 

Chinosol  is  a  yellow  substance,  harmless  and  free  from  toxic  qualities  ;  it  is 
freely  soluble  in  water,  and  possesses  powerful  antiseptic  properties. 

Lysol  is  another  useful  antiseptic  derivative  of  coal-tar.  It  is  freely  soluble 
in  water,  and  as  a  2  per  cent,  solution  may  be  used  in  syringing  out  cavities, 
such  as  the  vagina,  external  ear,  etc.  One  of  its  great  advantages  is  that  the 
solution  is  somewhat  soapy,  and  tends  to  cling  to  the  tissues  and  prolong  its 
action. 

Permanganate  of  Potash,  Sanitas,  and  Peroxide  of  Hydrogen,  all  act  in  the  same 
way  as  oxidizing  agents  ;  they  are  necessarily  unstable  and  cannot  be  utilized  for 
dressings,  and  are  therefore  chiefly  employed  in  the  disinfection  of  cavities  or 
wounds  already  contaminated.  The  most  potent  of  these  is  peroxide  of  hydrogen, 
which  is  sold  as  a  fluid  capable  of  setting  free  10  to  20  times  its  volume  of  nascent 
oxygen.  It  is  quite  unirritating,  and  may  be  poured  directly  into  a  septic  wound, 
or  even  into  the  peritoneal  cavity  ;  forthwith  it  commences  to  effervesce,  liberating 
its  oxygen,  and  forming  a  frothy  foam,  which  is  likely  to  bring  to  the  surface  any 
loose  foreign  bodies.  Its  use  is  particularly  indicated  in  the  treatment  of  septic 
ulcers,  carbuncles,  sloughy  abscess  cavities,  and  the  like.  Sanitas  and  per- 
manganate of  potash  are  used  in  solutions  of  varying  strength,  and  act  more 
slowly ;  the  latter  has  the  disadvantage  of  staining  the  tissues  with  which  it  is 
brought  in  contact. 

Formalin  is  a  powerful  antiseptic,  and  consists  of  a  40  per  cent,  aqueous 
solution  of  formic  aldehyde.  It  is  decidedly  toxic,  even  in  a  i  per  cent,  solution. 
It  blackens  steel  instruments,  gives  off  an  irritating  vapour,  and  hardens  the  skin 
to  an  unpleasant  degree. 

The  Aseptic  Method  of  treating  wounds  consists  in  the  elimination 
of  chemical  antiseptics  as  far  as  possible,  and  the  substitution  of 
heat,  dry  or  moist,  as  a  sterilizing  agent.  Every  efficient  antiseptic 
is  more  or  less  toxic  and  irritating,  and  there  can  be  no  question  that, 
from  an  ideal  standpoint,  the  less  they  are  introduced  into  wounds, 
the  better.  No  more  satisfactory  germicide  can  be  imagined  than 
heat,  in  the  form  either  of  boiling  water  or  of  steam  under  pressure, 
and  it  is  claimed  that  if  everything  brought  in  contact  with  the 
wound  is  aseptic,  then  no  antiseptics  need  be  employed.  Dressings, 
swabs,  towels,  aprons  or  coats,  and  caps,  are  sterilized  in  drums  or 
kettles  by  means  of  steam  at  ordinary  pressure,  or  by  superheated 
steam  at  high  pressure.  The  latter,  of  course,  is  the  more  satisfactory, 
owing  to  its  greater  penetrative  power,  but  the  former  can  be  effective 
if  the  drums  are  so  constructed  as  to  permit  a  free  passage  of  steam 
through  the  articles  to  be  sterilized,  and  if  the  latter  are  packed  loosely 
and  not  tightly.  The  drum  is  first  lined  with  a  layer  of  lint  or  gauze, 
and  a  similar  covering  must  be  placed  over  the  contents  beneath  the 
lid.  A  sliding  shutter  uncovers  the  perforations  through  which 
steam  enters  the  drum.  When  the  drum  is  removed  from  the 
sterilizer,  this  shutter  is  closed,  and  the  contents  may  be  expected  to 
remain  sterile  for  some  days.  For  small  establishments  a  Schimmel- 
busch's  low-pressure  dressing  sterilizer  or  a  small  high  -  pressure 
(from  5  to  15  pounds)  steam  sterilizer  answers  excellently;  but  for 
hospitals  an  extensive  and  expensive  plant  must  be  installed,  and 
probably  some  variety  of  the  Washington-Lyon  sterilizer  is  the  best. 

Of  course,  there  are  two  elements  in  an  operation  which  can  never 
be  sterilized  apart  from  chemical  antiseptics — viz.,  the  skin  of  the 


26S  A  MANUAL  OF  SURGERY 

patient  and  the  surgeon's  and  assistants'  hands — and  thus  the  most 
complete  aseptic  precautions  can  never  entirely  eliminate  chemical 
agents.  Moreover,  it  must  not  be  forgotten  that  the  air  itself  holds 
numberless  germs  which  cannot  be  excluded  from  the  wound,  and  that 
such  germs  are  more  numerous  in  crowded  cities  and  in  places  where 
sick  people  are  likely  to  congregate.  To  obviate  this,  most  elaborate 
precautions  have  often  been  taken  in  order  to  filter  the  air  admitted 
to  the  'operating  theatre,  and  also  as  to  the  cleanliness  and  dress  of 
the  surgeon  and  his  assistants.  Unsterilized  persons,  and  there- 
fore students,  are  frequently  banished  from  the  operating  theatre,  or 
placed  behind  a  glass  screen,  as  every  additional  onlooker  must 
increase  the  risk  in  purely  aseptic  conditions.  Then,  too,  the  surgeon 
ought  to  be  able  to  rely  on  assistants  and  nurses  who  are  not  changing 
every  six  or  twelve  months,  as  there  is  no  second  line  of  defence  in 
the  presence  of  antiseptics  to  make  good  errors  in  technique.  More- 
over, away  from  hospital,  surgeons  are  not  always  able  to  command 
aseptic  conditions,  but  may  have  to  operate  in  very  unsuitable  sur- 
roundings. Hence,  in  a  large  teaching  hospital,  devoted  to  the  training 
of  students  and  nurses  (and  such,  we  believe,  can  only  be  carried 
out  effectively  by  their  active  participation  in  the  work,  it  is  quite  a 
question  whether  it  is  desirable  to  maintain  a  purely  aseptic  clinique. 

The  actual  details  of  operative  technique  vary  somewhat  with  different 
surgeons,  but  the  main  principles  which  govern  modern  operative 
surgery  are  much  the  same  in  all,  and  the  following  sketch  of  the 
preparations  required  and  of  the  routine  usually  practised  in  under- 
taking an  operation  may  be  considered  more  or  less  typical  of 
modern  methods : 

I.  The  Operating  Theatre  or  Room. — The  arrangement  of  this  neces- 
sarily depends  upon  considerations  of  space  and  finance.  It  should 
not  be  unnecessarily  large,  and  the  old-fashioned  theatre  with  tiers  of 
seats  overlooking  the  central  area  is  not  desirable.  Onlookers  should 
have  a  low  gallery  provided  for  them,  but  little  raised  above  the  iioor- 
space  and  shut  off  from  it  not  merely  by  a  rail,  but  by  an  effective 
barrier  breast-high.  It  may  with  advantage  be  placed  between  the 
operating  area  and  the  source  of  light,  but  clear  of  the  window,  and 
should  be  entered  by  a  separate  pfessage  and  not  through  the  theatre, 
A  north  light  is  desirable,  and  it  should  come,  not  from  the  top,  but 
from  the  side,  in  the  form  of  what  is  known  as  a  '  studio  light.  The 
walls  should  be  free  from  ledges  on  which  dust  may  accumulate,  and 
lined  with  white  tiles,  glazed  bricks,  marble  or  alabaster,  or  at  least 
painted  with  white  enamel,  which  can  be  washed  down  with  a  hose  ; 
of  course  all  corners  should  be  rounded.  The  floor  must  be  imper- 
meable, and  slope  towards  an  open  channel  on  one  side  of  the 
theatre,  so  as  to  allow  of  suitable  flushing  with  a  hose.  All  shelves 
must  be  made  of  glass,  but  the  fewer  fixtures  in  the  actual  theatre 
the  better.  The  heating  arrangements  should  be  such  that  the 
temperature  can  be  raised,  if  necessary,  to  75°  or  80°  F.  Attached 
to  the  theatre  should  be  a  suitable  series  of  smaller  rooms  for  the 
anaesthetist,  for  sterilizing  purposes,  etc. 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY        269 

In  a  private  house  the  room  must,  if  possible,  be  carefully  pre- 
pared beforehand.  The  carpet  should  be  taken  up  and  curtains 
removed.  The  walls  should  be  wiped  over  with  an  antiseptic  solu- 
tion, and  the  floor  thoroughly  scrubbed  ;  all  unnecessary  furniture  is 
removed.  Should  the  operation  be  an  emergency  one,  without  time 
for  such  complete  preparation,  it  is  often  wiser  to  leave  things 
alone,  and  not  stir  up  dust  and  dirt  by  a  hurried  attempt  to 
make  things  look  a  little  better  than  they  really  are.  A  suitable 
supply  of  hot  and  cold  boiled  water  must  be  secured  beforehand, 
and  basins  and  dishes,  etc.,  should,  if  possible,  be  previously 
boiled. 

2.  The  Surgeon  and  Ms  Assistants  must  remember  the  extremely 
grave  responsibility  that  rests  upon  them  in  undertaking  many  of  the 
modern  operations,  and  must  be  willing  and  ready  to  submit  them- 
selves to  the  strictest  regime.  The  coat  must  be  removed,  and  the 
sleeves  of  the  shirt  and  vest  turned  well  up  above  the  elbows,  and 
retained  there,  if  need  be,  by  safety-pins,  or  suitable  clutches.  A 
mackintosh  apron  may  then  be  donned,  and  over  it  a  sterilized  gown 
or  overall,  reaching  to  the  wrist  or  elbow,  as  may  be  desired.  It 
must  be  remembered  that  these  coats  remain  sterile  for  but  a  short 
time,  and  care  must  be  taken  to  prevent  them  being  touched  by 
instruments,  etc.  Opinions  differ  considerably  as  to  whether  it  is 
necessary  to  wear  caps  or  masks.  The  former  should  always  be 
worn,  as  it  is  not  always  possible  to  prevent  the  surgeon  and 
assistant  from  rubbing  heads  over  an  open  wound.  Masks,  covering 
the  whole  face  except  the  eyes,  should  always  be  worn  if  nasal 
catarrh  or  oral  sepsis  is  present,  and  some  surgeons  not  inadvisably 
employ  them  always.  Unnecessary  talking  during  the  operation  is 
forbidden,  and,  whenever  possible,  directions  should  be  given  by 
signs.  If  one  has  to  cough  or  sneeze,  the  head  must  be  turned  aLiide 
completely. 

The  same  rules  hold  good  in  regard  to  the  nurses,  whose  arms 
should  be  bare  to  the  elbows,  and  who  should  wear  sterilized  coats. 
The  hair  should  be  covered  in  by  a  sterilized  cap  or  mask. 

Much  of  the  success  of  an  operative  clinique  depends  upon  the 
methodical  and  effective  organization  of  the  same.  It  is  desirable 
that  all  unnecessary  hands  should  be  eliminated,  and  therefore  every- 
thing likely  to  be  needed  should  be  laid  out  within  reach  of  the 
surgeon  and  his  assistant  on  suitable  side-tables,  so  that  they  may  be 
able  to  take  up  instruments,  ligatures,  sutures,  etc.,  without  being 
touched  by  others. 

3.  The  hands  are  scrubbed  thoroughly  with  soft  or  ether  soap  and 
hot  water  (preferably  sterilized)  ;  the  nails  are  cut,  if  need  be,  and 
cleansed,  special  attention  being  directed  to  the  semilunar  folds  of 
skin  at  the  base,  where  septic  material  is  so  apt  to  collect.  For  this 
purpose  a  purified  nail-brush  is  employed  with  advantage.  The 
hands  are  then  immersed  in  an  efficient  antiseptic  lotion — e.g.,  a  i  in 
500  solution  of  biniodide  of  mercury  in  70  per  cent,  methylated  spirit 
for  one  minute,  and  then  in  i  in  40  carbolic  or  i  in  2,000  sublimate 


270  A  MANUAL  OF  SURGERY 

solution.  The  hands,  once  purified,  should  not  be  dried  (except  on 
a  sterilized  towel),  but  kept  moist,  and  redipped  from  time  to  time 
during  the  operation  either  in  the  i  in  40  carbolic  or  i  in  2,000 
biniodide  of  mercury  or  sublimate  solution,  and  in  intraperitoneal 
work  in  sterilized  salt  solution  (3i.  to  i  pint).  Another  plan  consists 
in  immersing  the  hands  and  forearms  in  a  saturated  solution  of 
permanganate  of  potash,  after  thorough  washing  with  soft  soap  and 
water,  until  they  become  a  deep  mahogany-red  colour.  They  are 
then  placed  in  a  warm  saturated  solution  of  oxalic  acid  until 
completely  decolourized,  and  are  finally  washed  over  with  sub- 
limate solution.  This  method  is  apt  to  cause  a  certain  amount 
of  irritation  of  the  skin  of  the  forearms.  It  is  possible  that  in  many 
instances  complete  sterilization  of  the  hands  is  not  effected,  but  the 
surgeon  must  always  keep  complete  asepsis  of  his  hands  before  him 
as  an  ideal  to  be  attained.  On  several  occasions  when  our  hands  and 
those  of  our  assistants  were  tested  bacteriologically  after  the  use  of 
the  biniodide  of  mercury  and  sublimate  solutions,  they  were  found  to 
be  sterile,  even  scrapings  from  beneath  the  nails  giving  no  reaction. 

The  majority  of  surgeons,  however,  nowadays  use  thin  rubber 
gloves,  which  can  be  sterilized  by  boiling.  They  are  made  so  thin 
that  the  delicacy  of  touch  is  but  little  impaired,  especially  when  the 
use  of  such  gloves  has  become  habitual,  and  can  be  slightly  roughened 
on  the  exterior,  so  that  even  slippery  structures  such  as  intestine 
can  be  held.  They  should  fit  accurately,  and  extend  well  above 
the  wrist.  The  use  of  such  gloves  must  not  in  any  way  lead  to 
diminished  care  of  the  hands,  as  a  small  puncture  made  during  the 
operation  may  lead  to  escape  of  the  fluid  always  contained  within. 
To  put  on  the  gloves,  the  fingers  and  hand  should  be  anointed 
with  sterilized  glycerine,  or  the  glove  itself  filled  with  sterilized 
water.  Cotton  gloves  are  used  by  some  surgeons,  and  several 
pairs  may  be  required  during  a  single  operation  ;  they  do  not  appear 
to  be  so  satisfactory  as  the  former.  Assistants  and  nurses  taking 
any  part  in  the  operation  should  also  wear  gloves,  especially  if  the 
handling  and  wringing  out  of  swabs  is  entrusted  to  them. 

4.  instruments  are  sterilized  by  boiling  in  a  weak  solution  of 
bicarbonate  of  soda  (i  per  cent.)  for  five  or  ten  minutes,  or  more  if 
they  have  been  previously  used  for  a  dirty  case.  To  prevent  them 
from  rusting,  they  should  be  carefully  plated,  and  the  water  ought  to 
boil  for  some  minutes  before  they  are  immersed,  in  order  that  the 
suspended  air  may  be  driven  off.  After  boiling  they  may  be  laid  out 
on  a  sterilized  dry  towel  and  covered  over  with  a  similar  towel  till 
they  are  required,  or  kept  in  a  weak  antiseptic  solution — e.g.,  carbolic 
lotion,  I  in  60.  Mercurial  solutions  should  be  avoided,  as  they  spoil 
the  instruments.  If  during  an  operation  an  instrument  which  has  not 
been  previously  sterilized  is  required,  it  may  be  quickly  purified  by 
immersing  it  for  half  a  minute  in  liquefied  carbolic  acid,  the  excess  of 
which  is  removed  by  washing  thoroughly  in  alcohol  or  hot  sterilized 
water.  The  same  process  or  re-boiling  must  be  adopted  for  any 
instrument  which  falls  on  the  floor  or  becomes   otherwise  soiled. 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY        271 

Special  care  must  be  directed  towards  the  forceps,  to  see  that  the 
serrations  are  freed  from  dried  blood-clot  and  other  dirt.  Haemostatic 
forceps  must  be  opened  before  boiling. 

5.  Swabs  have  now  so  completely  taken  the  place  of  sponges  in 
surgery  that  it  is  unnecessary  to  consider  the  preparation  of  the  latter. 
Swabs  are  made  of  absorbent  wool  wrapped  in  a  single  square  layer 
of  gauze  the  corners  of  which  are  tied  across  and  tucked  in ;  or  they 
may  be  composed  of  gauze  alone,  folded  over,  and  perhaps  stitched 
so  as  to  leave  no  free  edge  which  may  fray  out ;  or  they  may  be 
formed  of  larger  squares  of  absorbent  material,  such  as  Gamgee 
tissue.  A  sufficiency  of  these,  suited  in  size  and  shape  to  the 
requirements  of  the  case,  is  provided  before  the  operation.  They 
are  sterilized  in  a  suitable  autoclave  or  sterilizer,  and  kept  in  the 
drum  until  required,  when  they  are  removed  by  sterile  hands  01 
instruments  to  a  sterile  receptacle,  being  used  dry  or  after  immersion 
in  lotion.  In  case  of  need,  where  a  sterilizer  is  not  available,  they 
may  be  boiled  and  then  kept  either  in  boiled  water,  covered  over  till 
required  with  a  sterilized  cloth,  or  in  an  antiseptic  solution  ;  or  may 
be  dried  in  an  oven  after  being  enclosed  m  a  suitable  cloth. 

Cloths  and  gauze  strips  for  abdominal  operations  are  prepared  in 
a  similar  manner.  In  these  cases  a  careful  record  must  be  kept  of 
the  numbers  used,  so  that  all  may  be  accounted  for  afterwards  ; 
indeed,  it  is  wise  always  to  have  swabs,  etc.,  done  up  in  packets  or 
bags  containing  a  known  number,  such  as  a  dozen. 

6.  The  Ligatures  and  Sutures  demand  very  thorough  purification, 
which  varies  with  the  material  used.  Silkworm-gut,  horsehair,  and 
silver  wire,  which  do  not  imbibe  fluids  or  become  absorbed,  merely 
require  to  be  boiled,  but  silk  and  catgut  need  much  more  care  if 
stitch  suppuration  is  to  be  avoided.  Silk  must  be  boiled  for 
twenty  or  thirty  minutes,  and  should  be  wound  loosely  on  reels  or 
winders,  so  that  the  deeper  strands  may  become  sterile  as  well  as  the 
superficial.  It  may  be  used  at  once  or  after  being  kept  in  antiseptic 
lotion,  and  preferably  in  a  solution  of  sublimate  (i  in  1,000),  for  a 
week  or  until  required,  so  that  its  strands  may  become  well  impreg- 
nated with  the  salt.  An  important  precaution  in  the  use  of  silk  is 
that  it  should  never  be  used  with  ungloved  hands;  the  strands  cut 
through  the  epidermis  and  become  contaminated  by  germs  lying  in 
the  deeper  layers  of  the  skin,  and  stitch  suppuration  may  result. 

Catgut  is  still  more  difficult  to  purify,  inasmuch  as  boiling  in  water 
is  out  of  the  question.  Lister  claims  that  catgut,  prepared  according 
to  his  directions  (p.  286),  remains  actively  antiseptic  for  an  indefinite 
period,  and  that  all  that  is  needed  subsequently  is  to  immerse  it  for 
a  quarter  of  an  hour  in  a  i  in  20  solution  of  carbolic  acid.  The 
majority  of  surgeons,  however,  prefer  to  sterilize  it  before  use,  and 
especially  so  if  they  use  non-chromicized  gut,  or  catgut  which  has 
been  hardened  in  a  5  per  cent,  solution  of  formalin  for  twenty-four 
hours.  Many  diff'erent  processes  have  been  recommended,  but 
perhaps  the  simplest  and  most  effective  is  that  known  as  the  '  iodine  ' 
method.     The  catgut  is  wound  loosely  on  a  glass  spool  or  winder, 


^72  A  MANUAL  OF  SURGERY 

and  immersed  in  a  solution  containing  iodine,  i  part  ;  iodide  of 
potassium,  i  part ;  and  distilled  water,  loo  parts.  It  is  kept  thus  in 
the  dark  for  seven  to  ten  days,  and  then  removed  and  kept  dry, 
wrapped  in  sterile  gauze.  Before  use  it  is  placed  for  a  few 
minutes  in  spirit  (rectified  or  methylated),  so  as  to  dissolve  out  a 
little  of  the  excess  of  iodine  present.  Catgut  so  prepared  is  not  only 
aseptic,  but  also  actively  antiseptic,  and  rarely  causes  trouble  in  the 
tissues  (except,  perhaps,  in  delicate  children).  An  extensive  experi- 
ence of  this  material  for  some  years  has  proved  its  reliability  and 
value.  Various  instrument-makers  provide  sterilized  catgut  in  sealed 
glass  tubes,  which  can  usually  be  trusted. 

7.  The  skin  of  the  patient  is  carefully  prepared  before  operation, 
the  length  of  such  treatment  depending  on  the  cleanliness  or  not  of 
the  part  and  the  urgency  of  the  case.  The  skin  is  first  shaved,  if 
necessary,  and  washed  with  soft  or  ether  soap  and  hot  sublimate 
lotion  (i  in  2,000).  Acetone  may  take  the  place  of  the  ether 
soap.  It  is  then  flushed  with  biniodide  of  mercury  in  spirit 
(i  in  500),  or  with  carbolic  lotion  (i  in  20),  and  afterwards  the 
stronger  antiseptic  is  washed  away  with  a  weaker  solution  either  of 
carbolic  acid  or  sublimate.  The  part  is  finally  wrapped  up  in  an  anti- 
septic compress — i.e.,  of  gauze  or  lint,  soaked  in  i  in  40  carbolic  or 
I  in  2,000  sublimate  solution.  At  the  time  of  operation  the  same 
process  may  be  repeated.  It  must  not  be  forgotten  that  a  very 
vigorous  use  of  carbolic  acid  may  be  followed  by  local  irritation,  as 
well  as  by  its  absorption  into  the  blood-stream,  especially  in  protracted 
operations  and  in  children.  Care  must  also  be  taken  that  the  patient 
does  not  lie  in  a  pool  of  antiseptic  lotion  which  has  run  down  during 
the  washing  and  collected  under  the  sacrum ;  many  a  bad  antiseptic 
burn  has  resulted  therefrom.  Again,  not  only  does  the  quality  of  the 
skin  vary  in  different  individuals  (as  may  be  illustrated  by  contrasting 
that  of  a  coal-heaver,  who  possibly  bathes  once  a  year,  with  that  of  a 
child  or  lady,  which  is  soft,  clean,  and  delicate),  but  it  also  differs  in 
various  regions  of  the  body,  and  hence  the  process  of  purification 
must  be  modified  according  to  the  character  and  thickness  of  the 
integument.  Any  part  where  dirt  may  accumulate  demands  scrupulous 
attention — e.g.,  the  umbilicus,  external  ear,  toes,  or  corona  glandis  in 
persons  with  long  foreskins.  A  word  of  warning  is  also  needed  as 
to  the  too  vigorous  use  of  a  nail-brush  leading  to  a  traumatic  der- 
matitis, or  even  waking  up  into  activity  germs  which  otherwise  would 
have  lain  dormant  in  the  deeper  layers  of  the  uninjured  skin.  It  may 
be  again  mentioned  that  in  cases  of  emergency  it  is  wiser  to  trust  in 
carbolic  lotion  than  in  sublimate,  as  the  former  unites  freely  with  the 
grease  of  the  skin,  and  hence  penetrates  more  deeply. 

Recently  attention  has  been  directed  to  the  penetrating  antiseptic 
properties  of  iodine,  and  Mr.  Waterhouse  (Lancet,  April  16,  1910) 
has  reported  most  favourably  on  it.  He  advises  that  the  part  to  be 
purified  should  be  shaved  and  washed  some  time  before,  so  as  to 
allow  the  skin  to  dry.  Two  hours  before  operation  the  part  should 
be  painted  over  with  a  2  per  cent,  solution  of  iodine  in  rectified,  not 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY         273 

methylated,  spirit ;  this  is  repeated  at  the  time  of  operation.    It  may 
also  be  employed  in  casualty  work. 

8.  The  area  of  operation  is  surrounded  by  mackintoshes,  which 
should  always  be  purified  or  sterilized,  and  these  in  turn  are  covered 
with  dry  sterilized  towels,  fixed  to  the  skin  by  suitable  towel-clips. 
Failing  dry  sterilization,  the  towels  may  be  boiled  or  soaked  in  an 
antiseptic  solution.  During  an  operation  irrigation  or  flushing  is 
unnecessary,  unless  the  proceedings  are  prolonged,  and  then  hot 
sterilized  salt  solution  should  be  employed  for  the  purpose;  but 
a  final  flushing  with  carbolic  lotion  (i  in  40)  or  with  sublimate 
(i  in  2,000)  is  sometimes  useful,  especially  when  operating  under 
conditions  which  are  not  ideal  as  to  surroundings  and  technique. 
The  objection  to  such  flushing  is  that  the  lotion  is  more  or  less  of  an 
irritant,  and  determines  a  certain  amount  of  subsequent  oozing  and 
effusion,  which  will  necessitate  drainage.  More  particularly,  when 
dealing  with  the  peritoneal  cavity  or  interior  of  a  joint,  the  less  one 
employs  antiseptics  the  better  ;  they  lead  to  a  desquamation  of  the 
delicate  endothelial  lining  which  it  is  so  important  to  maintain  intact. 

g.  Before  closing  the  wound  absolute  hssmostasis  should  be 
secured,  and  then  the  wound  may  usually  be  stitched  up  com- 
pletely and  without  drainage.  It  is  important  to  build  up  again  the 
divided  tissues  of  the  part  by  suitable  buried  sutures,  so  as  not  only 
to  secure  more  perfect  apposition,  but  also  to  obliterate  '  dead 
spaces  '  in  which  blood-clot  or  effusion  may  collect.  In  this  way 
wounds  through  fleshy  and  vascular  structures — e.g.,  an  amputation 
through  the  thigh — may  be  completely  closed  up  without  drainage. 
On  the  other  hand,  where  accurate  apposition  of  tissues  and  ob- 
literation of  cavities  cannot  be  obtained,  as  after  clearing  out  the 
axilla,  and  where  some  amount  of  oozing  may  be  expected,  it  is 
advisable  to  insert  a  suitable  drainage-tube,  and  stitch  it  flush  with 
the  surface.  It  is  removed  at  the  end  of  forty-eight  hours  at  most ; 
in  such  cases  the  removal  of  the  discharge  and  the  changing  of  the 
soaked  and  perhaps  stifTened  dressings  add  materially  to  the  comfort 
of  the  patient. 

When  the  operation  has  been  completed,  the  skin  is  cleansed  with 
lotion,  but  only  after  a  piece  of  dressing  has  been  placed  as  a  protection 
over  the  wound.  This  cleansing  should  always  be  accomplished  by 
wiping  peripherally  away  from  the  wound,  and  any  swab  utilized  for 
this  purpose  should  not  again  be  allowed  to  touch  it. 

Wounds  communicating  with  septic  cavities,  such  as  the  mouth  or 
rectum,  should  be  purified  with  a  solution  of  chloride  of  zinc  (40  grains 
to  I  ounce),  and  then  powdered  with  iodoform,  and  either  left  open  or 
lightly  packed.  Infective  manifestations  are  by  this  means  delayed ; 
and  even  when  they  do  occur,  they  may  be  kept  under  control  by 
frequent  dressing  and  irrigation. 

10.  Finally,  a  carefully  arranged  Dressing  is  applied,  and  the  pait 
bandaged  and  placed  at  rest  on  a  splint  or  in  a  sling,  if  such  is 
indicated  by  the  requirements  of  the  case ;  absolute  rest  and  quiet 
are  essential  if  rapid  healing  is  to  be  obtained. 

18 


274 


A  MANUAL  OF  SURGERY 


Lord  Lister  pointed  out  some  years  back  that  the  main  essentials 
of  a  good  dressing  consisted  in  its  containing  some  trustworthy  anti- 
septic ingredient ;  in  this  agent  being  so  stored  up  that  it  cannot  be 
dissipated  before  the  next  dressing  ;  in  its  being  entirely  unirritating; 
and  in  the  capacity  of  the  fabric  readily  to  absorb  blood  or  serum 
that  may  ooze  from  the  wound.  The  original  antiseptic  dressings, 
viz.,  the  carbolic  and  eucalyptus  gauzes,  and  even  the  alembroth 
gauze  and  wool,  failed  to  fulfil  these  requirements ;  but  in  the  double 
cyanide  of  mercury  and  zinc  gauze  we  have  a  material  which  is  to 
all  intents  and  purposes  perfect.  It  should  be  soaked  for  some  hours 
in  carbolic  lotion  (i  in  20),  and  applied  to  the  wound  without  fear 
after  wringing  it  out  of  a  i  in  40  solution ;  or  it  may  be  sterilized 
and  applied  dry.  A  sufficiency  of  this  is  employed  so  as  to  cover  in 
a  wide  margin  of  skin  all  round  the  wound,  and,  finally,  over  all 
a  liberal  covering  of  sterilized  or  antiseptic  wool,  so  as  to  diffuse  the 
pressure,  which  is  applied  by  means  of  careful  bandaging.  The  best 
material  for  bandages  is  butter-cloth,  since  it  is  light  and  adapts 
itself  easily  to  the  outlines  of  the  part.  Other  dressings,  such  as 
boric  lint,  iodoform  gauze,  etc.,  are  occasionally  employed,  but  they 
are  not  so  satisfactory  for  general  use  as  the  cyanide  gauze. 

Many  surgeons  employ  simple  sterilized  gauze  without  any  anti- 
septic ingredients,  and  where  complete  asepsis  has  been  maintained 
and  no  subsequent  discharge  comes  through,  this  will  suffice  ad- 
mirably. An  antiseptic  dressing  is,  however,  an  extra  safeguard 
that  may  be  wisely  adopted,  and  especially  in  cases  where  much 
discharge  is  expected.  Thus  in  a  case  of  excision  of  the  astragalus, 
where  by  an  oversight  the  dressing,  though  badly  soiled,  had  been 
left  untouched  for  a  week,  the  bandage  and  aseptic  wool  soaked 
with  a  blood-stained  discharge  stank  ;  but  on  removing  them  and 
taking  off  the  underlying  cyanide  gauze,  the  fcetor  gradually 
diminished,  and  the  wound  was  found  to  be  uninfected,  and  ran 
an  ordinary  course  to  repair.  The  bacteria,  were  unable  to  penetrate 
the  cyanide  gauze,  which  probably  saved  the  boy  from  losing  his 
foot. 

II.  After-treatment. — If  no  drainage-tube  has  been  employed,  and 
the  dressing  is  not  soaked  through,  it  may  be  left  untouched  for  seven 
or  eight  days,  at  the  conclusion  of  which  period  it  is  removed,  the 
stitches  are  taken  out,  and  in  all  probability  the  wound  will  be 
completely  healed.  When  a  drainage-tube  has  been  inserted,  it  is 
usual  to  take  it  out  at  the  end  of  twenty-four  or  forty-eight  hours  ; 
there  is  no  advantage  in  retaining  it  longer,  since  it  is  only  required 
for  the  removal  of  the  sero-sanguineous  fluid  which  exudes  imme- 
diately after  the  operation.  Should  the  discharge  be  very  abundant 
and  soak  through  the  dressings,  there  is  no  need  to  remove  them 
and  re-dress  during  the  first  twenty-four  hours,  if  cyanide  gauze  has 
been  employed ;  all  that  should  be  done  is  to  damp  the  stained 
external  bandages  with  i  in  20  carbolic  lotion,  and  then  pack  on 
some  more  gauze  or  wool.  This  may  even,  if  necessary,  be  repeated 
a  second  time. 


THE  GENERAL  TECHNIQUE  OF  OPERATIVE  SURGERY        275 

12.  The  after  dressings  of  the  wound  need  to  be  conducted  with  the 
same  precautions  as  to  asepsis  of  hands,  instruments,  etc.,  as  the 
original  operation,  and  not  a  few  instances  of  infection  at  the  first 
dressing  occur.  It  is  essential  that  everything  likely  to  be  required 
should  be  prepared  before  the  dressings  are  removed,  so  that  exposure 
to  the  air  may  last  as  short  a  time  as  possible.  If  the  first  dressing 
is  undertaken  after  twenty-four  or  forty-eight  hours,  and  all  is  going 
on  satisfactorily,  the  tube  is  removed,  and  the  wound  redressed  in 
exactly  the  same  way  as  formerly,  though  probably  much  less 
dressing  will  be  required.  If  the  case  is  left  for  eight  days,  the 
stitches  can  probably  be  taken  out,  and  the  surface  will  then  be 
found  united.  A  small  dressing  of  cyanide  gauze  is  applied,  fitting 
closely  to  the  scar,  and  sealed  down  with  flexile  collodion,  which  will 
not  only  prevent  the  gauze  from  slipping,  but  will  also  by  its  con- 
traction serve  to  steady  the  parts.  This  should  be  covered  with  wool 
and  a  bandage,  so  as  to  support  the  parts,  and  may  be  finally  removed 
at  the  end  of  another  week. 


CHAPTER   XI. 

HEMORRHAGE. 

By  the  term  hemorrhage  is  meant  any  escape  of  blood  from  the 
vessels,  whether  insignificant  and  immediately  arrested  by  natural 
means,  or  more  excessive  and  requiring  treatment  to  prevent  its 
continuance.  Although  most  commonly  due  to  some  injury,  whether 
subcutaneous  or  inflicted  through  the  skin,  it  may  be  predisposed  to 
by  weakness  of  the  vascular  tissues,  especially  if  associated  with 
increased  blood-pressure.  Certain  diseases,  such  as  purpura  and 
scurvy,  are  characterized  by  a  tendency  to  bleeding,  and  there  is  one 
congenital  condition,  haemophilia,  in  which  it  is  difficult  to  stop  the 
flow  of  blood  when  started. 

The  character  of  the  bleeding  differs  according  to  the  vessel  from 
which  the  blood  escapes.  Arterial  Haemorrhage  consists  in  a  flow 
of  bright  red  blood,  which  escapes  at  first  per  saltum,  i.e.,  in  jets 
synchronous  with  the  heart's  beat,  and  may  be  derived,  not  only 
from  the  proximal,  but  also  from  the  distal  end  of  the  divided  vessel, 
if  the  collateral  circulation  is  sufficiently  abundant.  If,  however,  it 
is  derived  from  a  deep  artery,  the  blood  may  well  up  from  the  depths 
of  the  wound  and  not  escape  in  gushes.  In  Venous  Haemorrhage 
the  flow  is  usually  continuous,  and  the  blood  of  a  dark  red  or  almost 
black  colour.  If,  however,  a  large  vein  is  wounded,  such  as  the 
internal  jugular,  the  blood  may  escape  with  a  very  definite  spurt, 
owing  to  respiratory  or  other  influences.  Capillary  Haemorrhage  is 
marked  by  general  oozing  from  a  raw  surface,  the  blood  trickling 
down  into  a  wound,  if  present,  and  filling  it  from  below  upwards.  By 
Extravasation  of  Blood  is  meant  the  pouring  out  of  blood  from  a 
wounded  vessel  or  vessels  into  the  lax  areolar  planes  immediately 
adjacent,  which  become  swollen  and  boggy.  The  usual  constitutional 
signs  may  be  manifested  as  a  result  of  such  extravasation,  and, 
indeed,  fatal  haemorrhage  may  occur  in  this  way  without  any  escape 
upon  the  surface  of  the  body.  Subcutaneous  or  submucous  haemor- 
rhage is  also  met  with  in  the  form  of  small  localized  petechise,  arising 
from  injuries,  or  from  changes  in  the  blood  or  vessel  walls  (as  in 
purpura,  scurvy,  and  septicaemia).  Epistaxis  is  the  term  given  to 
bleeding  from  the  nose.  By  Hasmatemesis  is  meant  the  vomiting 
of  blood ;  it  may  either  have  been  swallowed,  as  in  some  cases  of 

276 


HEMORRHAGE 


277 


fractured  base  of  the  skull,  where  the  pharyngeal  mucous  membrane 
has  been  torn,  or  it  may  have  originated  from  the  upper  part  of  the 
intestinal  tract.  The  blood  is  usually  curdled  and  brownish  in  colour, 
somewhat  resembling  coffee-grounds,  from  the  action  of  the  gastric 
juice  upon  it.  Haemoptysis  is  the  title  given  to  the  escape  of  blood 
from  the  air  passages,  whether  it  results  from  injury  or  disease. 
The  characters  vary  with  the  quantity  lost ;  in  the  milder  cases 
it  is  usually  bright  red  and  frothy  from  admixture  with  air ;  in  gra  ver 
cases,  when  larger  vessels  are  involved,  the  blood  may  escape 
unaltered,  and  be  so  abundant  as  to  asphyxiate  the  patient. 
Hsematuria  {q-v.)  is  a  condition  in  which  blood  is  passed  in  the  urine. 
By  Melsena  is  meant  the  passage  of  dark  tarry  blood  with  the  faeces  ; 
it  is  always  an  evidence  of  disease  or  injury  of  the  intestinal  canal 
sufficiently  far  from  the  anus  to  allow  the  blood  to  become  altered  in 
character  by  the  action  of  the  intestinal  juices.  Blood  derived  from 
the  rectal  mucous  membrane  usually  retains  its  bright  red  colour. 

Constitutional  Effects. — If  the  haemorrhage  is  severe,  as  from 
division  of  a  large  artery,  death  results  from  syncope.  The  surface 
of  the  body  becomes  cold,  clammy,  and  pale  ;  the  lips,  ears,  and 
eyelids  are  livid  ;  the  patient  gasps,  his  respirations  become  quick 
and  sighing,  and  death  ensues  after  perhaps  a  few  convulsive 
twitches  of  the  limbs.  If  consciousness  is  retained  at  all,  patients 
often  complain  of  the  sight  failing,  and  a  sense  of  increasing  dark- 
ness, immediately  preceding  the  fatal  termination.  These  effects 
depend  as  much  on  the  rapidity  of  the  bleeding  as  on  the  total 
amount  of  blood  lost ;  people  can  stand  gradual  loss  of  blood  much 
better  than  when  it  escapes  suddenly. 

If  the  haemorrhage  is  not  so  great  as  to  kill  immediately,  the  patient 
faints,  and  on  recovery  is  in  a  condition  of  severe  collapse  and  weak- 
ness, which  continues  for  some  time ;  he  is  also  liable  to  recurrent 
attacks  of  syncope,  any  one  of  which  may  be  fatal. 

If  the  haemorrhage  is  more  gradual,  but  continuous,  as  from  ulcera- 
tion of  the  stomach  or  duodenum,  or  by  slipping  of  a  ligature  after 
an  abdominal  operation,  the  patient  rapidly  becomes  profoundly 
anaemic,  and  his  face  shrunken  and  drawn  as  a  result  of  the  dehy- 
dration of  the  tissues  of  the  cheeks.  Owing  to  the  insufficient 
amount  of  blood  present,  the  tissues  of  the  body  generally  suffer  from 
want  of  oxygen,  and  hence  the  patient  feels  as  if  he  were  being 
suffocated,  and  is  extremely  restless,  tossing  about  in  bed,  and 
clamouring  for  open  windows  and  more  air  [air -hunger).  Any  sudden 
exertion,  or  even  sometimes  the  attempt  to  sit  up,  is  followed  by  a 
sensation  of  faintness  ;  noises  are  heard  in  the  ears,  the  sight  becomes 
dim,  or  is  even  temporarily  lost  (amblyopia),  and  severe  headache 
may  be  complained  of,  all  arising  from  cerebral  anaemia.  The  pulse 
often  becomes  what  is  known  as  hcBmovvhagic  in  character,  i.e.,  fre- 
quent, and  compressible,  but  collapsing  entirely  between  the  beats, 
and  markedly  dicrotic.  These  peculiar  features  are  due  to  the  sudden 
passage  of  a  small  amount  of  blood  through  a  vessel  which  is  practi- 


278  A  MANUAL  OF  SURGERY 

cally  empty.  From  the  defective  vis  a  terge,  oedema  of  the  extremities 
may  result. 

During  the  continuance  of  haemorrhage  the  blood-pressure  neces- 
sarily falls ;  but  unless  a  volume  equal  to  about  a  third  of  the  total 
bulk  of  blood  in  the  body  is  lost,  it  quickly  rises  again  to  the  normal 
after  the  bleeding  has  ceased.  This  rise  in  blood-pressure  is  partly  due 
to  a  diminution  in  the  size  of  the  vascular  area,  owing  to  vasomotor 
contraction  of  the  peripheral  arterioles  and  of  the  splanchnic  area, 
but  is  also  caused  by  an  increased  flow  of  lymph  into  the  circulation. 
For  the  changes  that  occur  in  the  blood  as  a  result  of  haemorrhage, 
see  p.  49 .  The  haemoglobin  is  gradually  restored,  and  an  increase  of 
I  per  cent,  daily  is  about  the  normal  rate  (Emery). 

Children  and  elderly  people  alike  bear  the  loss  of  blood  badly  ;  but 
whereas  children  rapidly  recover  from  the  immediate  effects,  elderly 
people  do  not. 

General  Treatment. — When  the  loss  of  blood  has  been  severe,  the 
patient  must  be  kept  quiet  with  the  head  low,  whether  syncope  is 
present  or  not.  The  feet  of  the  bed  or  couch  should  be  placed  on 
blocks  or  on  chairs,  so  as  to  assist  in  the  essential  maintenance  of  the 
circulation  to  the  vital  centres  of  the  medulla.  Stimulants  may  be 
necessary  to  maintain  the  heart's  action,  but  should  never  be  given 
until  the  bleeding  has  been  effectively  controlled,  as  otherwise  they  may 
increase  or  re-start  it.  If  death  appears  to  be  imminent,  the  arms 
and  legs  should  be  bandaged,  or  the  abdominal  aorta  compressed, 
in  order  to  confine  the  blood  as  much  as  possible  to  the  head  and 
trunk. 

'  No  patient  should  be  allowed  to  die  of  haemorrhage.'  Such  was 
the  dictum  of  the  late  Mr.  Wooldridge,  of  Guy's  Hospital,  based  on 
a  knowledge  of  the  value  of  transfusion  and  infusion.  By  Transfusion 
is  meant  the  transference  of  blood  from  one  individual  to  another ; 
it  has  now,  however,  been  recognised  that  the  success  of  this  pro- 
ceeding depends  on  the  introduction  of  a  sufficient  quantity  of  fluid 
as  a"  temporary  substitute  for  the  blood  which  has  been  lost,  rather 
than  on  its  quality ;  for  it  has  been  proved  that  the  transfused 
blood  of  another  person  is  rapidly  destroyed  and  eliminated.  Hence 
transfusion  has  '  now  been  replaced  by  what  is  known  as  In- 
fusion, which  consists  in  injecting  some  bland  fluid,  isotonic  with 
blood  -  plasma,  into  the  vessels,  and  by  this  means  greatly  im- 
proved results  have  been  obtained.  The  apparatus  required  is 
a  metal  or  glass  cannula,  the  end  of  which  is  bulbous,  blunt,  and 
bevelled,  which  can  be  inserted  into  a  vein,  and  connected  by 
means  of  a  rubber  tube  with  a  reservoir  containing  the  fluid  (Fig.  85). 
A  vein — e.g.,  the  median  basilic  or  internal  saphena — should  be 
exposed,  tied  below,  and  opened  by  a  longitudinal  or  oblique  incision; 
the  cannula,  filled  with  lotion  so  as  to  exclude  air,  is  then  inserted, 
and  a  ligature  placed  round  the  vessel  just  below  the  bulb,  so  that  on 
withdrawal  it  can  be  tightened.  The  amount  injected  varies  with 
the  circumstances  and  the  effects  produced,  but,  to  be  efficacious, 


HEMORRHAGE 


279 


.-.ome  pints  are  usually  needed ;  4  or  5  pints  have  not  uncommonly 
been  employed  for  the  purpose.  As  a  rule,  one  injection  is  all  that 
is  necessary  in  dealing  with  haemorrhage,  but  where  shock  is  present 
it  may  require  to  be  repeated  two  or  three  times. 

As  to  the  material,  a  warm  saline  solution  is  the  best,  consisting 
of  a  drachm  of  chloride  of  soda  to  a  pint  of  sterilized  water  (or  about 
0-6  per  cent.),  at  a  temperature  of  105°  to  iia°  F.  The  dried  crystals 
of  salt  should  be  dissolved  in  a  small  quantity  of  boiling  water,  so 
as  to  sterilize  it,  and  this  is  then  diluted  to  the  required  bulk.  Of 
course,  the  apparatus  is  carefully  sterilized  by  boiling,  and  no  air 
must  be  admitted.     The  injection  is  made  slowly,  so  that  the  solution 


Fig. 


-Infusion  into  Vein  of  Forearm. 


Above,  a  useful  form  of  metal  cannula  is  represented  ;  below,  the  arrangement  of 
the  ligatures  on  the  vein. 


may  be  mixed  gradually  with  the  blood.  It  has  been  found  by 
experiment  that  after  an  infusion  following  haemorrhage  the  specific 
gravity  of  the  blood  is  only  lowered  for  a  very  short  period,  and 
rapidly  rises  to  a  normal  level,  or  may  even  be  raised  above  the 
normal.  This  suggests  that  the  increased  amount  of  fluid  is  absorbed 
into  the  tissues,  and  explains  why  it  is  sometimes  necessary  to  repeat 
the  injection  more  than  once. 

Another  simple  plan  often  used  with  success  consists  in  the  intro- 
duction of  warm  saline  solution  into  the  rectum  (proctoclysis),  or  through 
an  exploring  needle  connected  with  a  tube  and  funnel  into  the  loose 


28o  A  MANUAL  OF  SURGERY 

connective  tissue  of  the  buttock,  abdomen,  or  submammary  region 
{hypodevniodysis).  In  the  latter  case  the  funnel  must  be  held  at  some 
height  (5  or  6  feet),  in  order  to  gain  sufficient  pressure,  and  by  this 
means  a  pint  or  more  may  be  slowly  injected ;  a  carefully  sterilized 
syringe  and  a  large  needle  may  be  employed  for  the  same  purpose. 
During  the  injection  the  part  should  be  gently  rubbed  so  as  to 
distribute  the  fluid. 

Natural  Arrest  of  Hsemorrliage. 

This  can  best  be  described  under  two  headings,  viz.,  (i)  the 
temporary  arrest,  and  (2)  the  permanent.  The  processes  are  much 
the  same  for  arteries,  veins,  or  capillaries ;  but  since  the  arrest  of 
arterial  hemorrhage  has  been  more  thoroughly  investigated,  and  is 
the  most  important,  we  shall  deal  mainly  with  it. 

The  Temporary  arrest  of  arterial  haemorrhage  is  brought  about  by 
three  principal  factors : 

(i)  The  coagulation  of  the  blood,  which  occurs  in  and  around  the 
vessel,  and  without  which  death  would  ensue  from  the  merest  scratch. 
The  greater  the  loss,  up  to  half  of  the  total  amount  of  blood  in  the 
body,  the  more  coagulable  it  becomes. 

(2)  Diminution  in  the  force  of  the  heart's  action  always  follows 
haemorrhage,  from  anaemia  of  the  cerebral  centres,  a  beneficent 
provision  whereby  coagulation  is  facilitated  and  the  flow  of  blood 
checked.  Until  the  vessel  has  been  efficiently  secured,  stimu- 
lants should  therefore  be  carefully  avoided  for  fear  of  causing  a 
recurrence  of  the  bleeding  by  increasing  the  power  of  the  heart's 
beat, 

(3)  Changes  in  and  around  the  vessel  play  a  most  important  part 
in  completing  the  process.  They  consist  in  the  retraction  of  the 
artery  within  its  sheath  by  reason  of  its  inherent  longitudinal  elas- 
ticity; if,  however,  it  is  only  divided  partially  (or,  as  it  is  called, 
'  button-holed '),  this  condition  cannot  obtain,  and  the  haemorrhage  is 
more  likely  to  continue.  As  a  result  of  this  retraction,  the  rough 
and  uneven  inner  lining  of  the  sheath  is  exposed,  and  upon  this  the 
blood  coagulates  as  it  flows,  thus  gradually  producing  what  is  known 
as  the  external  coagulum.  At  the  same  time  the  transverse  muscular 
and  elastic  fibres  in  the  vessel  wall  cause  contraction  of  the  open 
mouth,  and  thus,  as  the  force  and  calibre  of  the  blood-stream 
diminish,  the  external  coagulum  increases  in  size  by  fresh  deposits 
of  fibrin,  until  at  last  its  resistance  is  too  great  for  the  diminished 
cardiac  impulse  to  overcome,  and  the  sheath  is  filled  with  clot,  which 
extends  to  the  divided  mouth  of  the  vessel.  From  this  an  internal 
coagulum  next  develops,  which  sometimes  extends  upwards  as  far 
as  the  nearest  patent  branch.  Thus  the  haemorrhage  is  arrested  for 
the  time  being,  and  preparation  made  for — 

The  Permanent  closure  of  the  wound  in  the  artery,  which  merely 
consists  in  a  modification  of  the  general  process  of  repair. 


HEMORRHAGE 


281 


After  the  cessation  of  the  haemorrhage,  the  internal  coagulum,  soft 
in  consistence  and  dark  red  in  colour,  extends  from  the  mouth  of  the 
vessel,  or  from  the  site  of  the  ligature,  for  some  distance,  and  perhaps 
to  the  next  collateral  branch  (Fig.  86).  The  vessel  wall  contracts 
upon  this  coagulum,  with  which,  however,  it  does  not  unite,  except 
at  and  near  its  base.  As  a  result  of  the  injury,  a  simple  plastic 
arteritis  is  set  up,  evidenced  by  a  hyperaemic  condition  of  the  vessel 
wall,  due  to  dilatation  of  the  vasa  vasorum,  and  its  infiltration  with 
leucocytes,  which  also  invade  the  coagulum  and  cause  its  base  to 
become  decolourized.  The  leucocytes  break  up  the  clot,  traversing 
the  natural  lines  of  cleavage  which  result  from  its  contraction,  and 
gradually  remove  it,  a  few  giant  cells  occasionally  assisting  in  this 


Fig.  86. — Early  Stage  of  Oblitera- 
tion OF  Artery  after  Ligature. 


Fig.   87. — Later  Stages  of  the 
Same  Process. 


The  thrombus  is  seen  above  and  below 
the  site  of  ligature,  that  on  the  proxi- 
mal (upper)  side  being  the  larger  ; 
commencing  cell  infiltration  of  the 
bases  of  the  clots  is  also  indicated. 


The  clots  are  shrinking,  and  the  lowest 
portions  are  being  replaced  by  granu- 
lation  tissue.      Proliferation   of  the 
tunica  intima  is  also  seen,  reaching 
beyond  the  apices  of  the  clots. 
In   both   these  diagrams  the  arteries  have  been  represented  of  the  same  size 
throughout  for  clearness'  sake ;  in  reality,  the  lumen  would  be  much  con- 
tracted. 


process  (Fig.  89)-  The  tunica  intima  proliferates  concurrently, 
causing  a  secondary  infiltration  with  the  larger  fibroblastic  cells  in 
that  part  of  the  thrombus  which  is  adherent  to  the  vessel  wall 
(Fig.  88) ;  whilst  a  growth  of  cellular  buds  or  granulations,  which 
gradually  increase  in  size  and  encroach  on  the  lumen  of  the  vessel, 
springs  up  in  those  parts  where  the  apex  of  the  clot  lies  free  and 
unadherent  (Fig.  87).  Thus,  the  base  of  the  clot  is  infiltrated  by  a 
cellular  mass  derived  from  proliferation  of  the  tunica  intima,  and  by 
the  development  of  new  vessels  from  the  vasa  vasorum  into  granula- 
tion tissue ;  whilst  the  cellular  buds  which  grow  from  the  walls,  and 
extend  nearly  to  the  next  collateral  branch,  are  also  similarly  changed, 


282 


A  MANUAL  OF  SURGERY 


The  free  conical  extremity  of  the  clot  contracts,  and  is  gradually 
removed,  partly  by  the  activity  of  leucocytes  which  infiltrate  it  from 
the  base,  partly  by  the  erosive  action  of  the  surrounding  granulation 
tissue.  A  similar  set  of  changes  occurs  at  the  distal  side  of  the 
ligature  in  an  artery  tied  in  its  continuity,  although  the  thrombus  is 
smaller  and  less  firm.  The  ligature  itself  may  be  infiltrated  by 
leucocytes,  and  replaced  by  granulation  tissue,  or  may  be  encapsuled. 
A  rod  of  granulation  tissue  is  thus  developed,  blocking  the  vessel,  and 
this,  by  the  usual  process  of  repair,  is  transformed  into  a  firm 
cicatricial  cord  in  the  course  of  a  few  months  (Fig.  89).  It  must  be 
clearly  understood,  however,  that  the  presence  of  a  coagulum  is  by 
no  means  essential  to  the  obliteration  of  an  artery.      Thus,  if  the 


^2:> 


PiQ     88. Diagram    of    Early    Stage    of    Organization   of  Thrombus,  to 

SHOW  THE  Infiltration  of  the  Clot  with  Leucocytes  and  Connective- 
Tissue  Cells  derived  from  the  Endothelium.     (Tillmanns.) 

A,  Tunica  media  ;  B,  tunica  intima,  undergoing  proliferative  changes,  and  there- 
fore thickened  ;  C,  blood-clot  lying  in  lumen  of  vessel,  becoming  infiltrated 
with  leucocytes  (small  dark  cells)  and  larger  fibroblasts  derived  from  the 
endothelium. 

walls  are  merely  brought  into  close  and  accurate  apposition  by  a 
ligature  without  dividing  the  inner  or  middle  coats,  a  proliferative 
endarteritis  without  any  clot  formation  results,  which  is  quite  sufficient 
for  the  occlusion  of  the  vessel. 

The  arrest  of  haemorrhage  from  veins  and  capillaries  is  more  easily 
accomplished,  the  collapse  of  the  walls,  together  with  the  formation 
of  the  external  coagulum,  being  sufficient  for  this  purpose.  The  later 
steps  are  similar  to  those  occurring  in  an  artery,  except  that  there  is 
but  little  internal  coagulum.  In  capillaries,  unless  some  constitutional 
condition  such  as  haemophilia  is  present,  the  mere  falling  together  of 
the  walls  is  sufficient  to  allow  coagulation  to  take  place,  and  thus 
stop  the  bleeding. 


HMMORRHAGE  283 

Surgical  Treatment  of  Haemorrhage. 

Many  different  methods  are  needed,  under  varying  circumstances, 
for  the  effective  arrest  of  haemorrhage.  It  may  be  laid  down  as  a 
prehminary  axiom  that  digital  .pressure  over  the  bleeding-point  will  always 
check  temporarily  the  most  furious  outburst,  whilst  means  for  its  per- 
manent stoppage  are  being  arranged. 

Where  the  bleeding  does  not  come  from  any  one  particular  vessel,  the 
following  measures  can  be  utilized : 

I.  Cold  may  be  employed  in  the  form  of  ice,  cold  water  or  lotion, 
or  simple  exposure  to  the  air,  all  clots,  rags,  pledgets,  etc.,  being 
removed  for  this  purpose ;  it  must,  however,  be  remembered  that  ice 
and   unsterilized  water  may  convey  sepsis      Such  treatment  is  of 


Fig.  89. — Organized  Thrombus  in  Vessel,  showing  the  Newly-Formed  Con- 
nective Tissue  occupying  the  Lumen  of  the  Vessel,  and  Vascularized 
FROM  the  Vasa  Vasorum.     (Tillmanns.) 

Two  giant  cells  are  seen  in  the  centre. 

most   value   for   general   oozing   from   vascular   structures   or-  into 
cavities,  such  as  the  mouth,  vagina,  or  rectum. 

2.  Position. — When  the  bleeding  is  from  one  of  the  extremities, 
especially  the  lower,  elevation  is  a  most  important  factor  in  its  arrest. 
The  veins  are  emptied  by  the  force  of  gravity,  and  this  is  always 
followed  by  a  reflex  contraction  of  the  arteries,  a  proceeding  of  which 
surgeons  avail  themselves  in  order  to  exsanguinate  a  limb  before 
applying  a  tourniquet  in  operations  which  one  desires  to  render  as 
bloodless  as  possible. 

3.  Direct  Pressure. — The  skilful  application  of  an  antiseptic  dress- 
ing, combined  with  pressure,  is  often  effectual  in  arresting  haemorrhage. 
General  oozing  from  cut  surfaces,  which  can  be  brought  into  apposition, 
as  from  an  amputation  wound,  may  be  checked  by  applying  a  firm 
bandage  over  them.     In  cavities  or  hollows,  either  natural  or  made 


284  A  MANUAL  OF  SURGERY 

by  operation,  bleeding  may  be  stopped  by  plugging  with  strips  of 
dressing,  or  by  graduated  layers  of  antiseptic  wool.  Such  dressings 
should  be  retained  firmly  in  position  for  twenty-four  hours,  after  which, 
if  no  further  haemorrhage  has  occurred,  the  bandages  may  be  slackened, 
but  it  is  usually  advisable  to  retain  the  deep  plugs  for  another  day. 

4.  Hot  Water  (130°  to  160°  F.)  is  a  powerful  haemostatic.  A 
certain  proportion  of  carbolic  acid  or  corrosive  sublimate  should  be 
present  to  render  the  water  aseptic,  or  it  should  have  been  previously 
boiled.  It  is  supposed  to  act  by  stimulating  the  involuntary 
muscular  fibres  of  the  vessel  wall ;  but  probably  the  coagulation  of 
the  albumen  of  the  blood  is  an  important  factor,  as  unless  the  water 
is  hot  enough  to  blanch  the  surface  of  the  wound,  the  bleeding  is  not 
stayed,  but  rather  encouraged. 

5.  Chemical  Agents  may  be  used  to  check  oozing  from  spongy 
parts,,  or  bleeding  from  deep  organs  or  cavities.  If  they  are  applied 
locally,  and  act  primarily  by  causing  coagulation  of  the  blood,  they 
are  known  as  Styptics,  or  astringents.  Such  are  the  liquor  ferri 
perchloridi  or  pernitratis,  tannic  or  gallic  acids,  alum,  nitrate  of 
silver,  styptic  colloid,  etc.  If  the  drug  is  administered  internally, 
and  acts  by  increasing  the  coagulability  of  the  blood,  or  by  causing 
constriction  of  the  vessels,  it  is  termed  a  Hsemostatic — e.g.,  supra- 
renal extract  (adrenalin),  ergot,  turpentine,  hamamelis,  acetate  of 
lead,  chloride  or  lactate  of  calcium,  etc.  In  applying  a  styptic,  it  is 
essential  that  the.  surface  of  the  wound  should  first  be  thoroughly 
cleansed,  and  all  coagula  removed.  A  portion  of  the  dressing  dipped 
in  the  solution  is  applied  to  the  surface,  or  the  drug  is  sprinkled  or 
sprayed  upon  it.  The  objection  to  most  of  these  agents  is  that 
healing  is  often  hindered,  whilst  in  the  case  of  perchoride  of  iron 
extensive  sloughing  may  result.  Probably  the  most  powerful  styptic 
is  suprarenal  extract,  which,  however,  loses  its  virtues  when  kept  in 
solution  for  more  than  an  hour  or  two.  One  of  the  dried  tabloids 
(grs.  5)  may  be  dissolved  in  2  drachms  of  a  5  per  cent,  cocaine 
solution,  and  this  is  sprayed  over  the  part,  or  applied  on  a  piece  of 
dressing.  The  effect  is  often  only  temporary,  and  the  haemorrhage 
may  subsequently  recur.  It  is  chiefly  used  in  the  surgery  of  the 
throat  and  nose. 

In  internal  haemorrhage,  as  from  lungs  or  gastro-intestinal  tract, 
opium  is  often  a  valuable  adjuvant  in  treatment,  in  that  it  keeps  the 
patient  and  the  part  quiet,  and  diminishes  the  blood-pressure. 

6.  Cauterization  is  not  very  largely  employed  for  the  arrest  of 
haemorrhage,  except  from  bones  or  from  tissues  thickened  by 
inflammation,  where  retraction  and  contraction  of  the  vessels  are 
difficult.  It  need  in  no  way  interfere  w^ith  primary  union  if  the  skin 
is  not  touched,  for  the  minute  sloughs  formed  are  quite  aseptic,  and 
will  either  be  absorbed  or  cast  off  in  the  discharges.  The  chief 
objection  to  this  method  is  the  risk  of  secondary  haemorrhage  when 
the  sloughs  separate.  The  cautery  is  sometimes  used  for  the  blood- 
less removal  of  vascular  tumours,  either  as  a  galvano-cautery,  a 
Pacquelin's  knife,  or,  in  the  case  of  piles,  as  the  ordinary  clamp  and 


HEMORRHAGE  285 

cautery.  It  must  be  remembered  that,  in  order  to  seal  effectually 
the  mouths  of  the  vessels,  the  cautery  must  be  at  a  dull  red  or  black 
heat ;  a  bright  red-hot  iron  cuts  through  a  vessel  as  cleanly  as  a 
knife,  and  does  not  stop  the  haemorrhage. 

When  the  bleeding  is  more  serious,  and  originates  from  some  definite  vessel 
or  vessels,  more  precise  measures  have  to  be  adopted.  Digital  pressure 
over  or  on  the  cardiac  side  of  the  bleeding  spot  suffices  to  arrest  it 
for  a  time,  whilst  preparations  are  being  made  to  secure  the  wounded 
vessel.  If  possible,  a  ligature  should  be  applied  with  antiseptic  pre- 
cautions, but  other  means  are  used  : 

1.  Acupressure,  as  introduced  by  the  late  Sir  James  Simpson  in 
order  to  obviate  the  use  of  ligatures,  is  now  only  used  in  exceptional 
circumstances.  A  needle  is  passed  either  under  the  vessel  from  the 
skin,  or  over  the  vessel  from  the  surface  of  the  wound,  and,  if  placed 
accurately,  is  quite  sufficient  to  stay  the  bleeding.  With  it,  however, 
is  sometimes  combined  the  pressure  of  a  loop  of  silk  or  wire  passed 
figure-of-8  fashion  around  the  ends  of  the  needle. 

2.  Forcipressure  is  a  plan  of  stopping  haemorrhage  by  crushing  the 
divided  end  of  the  vessel  between  the  strong  and  deeply  serrated 
blades  of  a  pair  of  forceps  with  scissor  handles  provided  with  a  catch ; 
those  known  by  the  name  of  Spencer  Wells  or  Greig-Smith  are  the 
most  convenient.  In  dealing  with  small  vessels,  it  is  quite  sufficient 
to  leave  the  forceps  applied  for  a  few  minutes,  perhaps  twisting  them 
before  removal ;  but  with  the  larger  it  is  advisable  to  apply  a 
ligature,  although  it  is  claimed  for  the  Greig-Smith  pattern  that  the 
artery  is  so  thoroughly  crushed  that  this  is  unnecessary.  In  deep 
wounds,  where  it  is  difficult,  or  almost  impossible,  to  tie  the  vessel, 
the  forceps  may  be  incorporated  in  the  dressings,  and  not  removed 
for  twenty-four  hours  or  longer,  according  to  the  size  of  the  vessel. 

3.  Torsion  was  used  as  a  means  of  sealing  the  ends  of  divided 
vessels  before  aseptic  ligatures  were  introduced.  It  may  be  applied 
in  two  ways — viz.,  (a)  Limited  torsion,  which  is  employed  for  the 
larger  vessels.  The  artery  is  drawn  out  of  its  sheath  for  about  half 
an  inch  with  one  pair  of  forceps,  and  held  close  to  the  tissues  by 
another  pair  applied  transversely,  whilst  the  grasped  end  is  twisted 
sufficiently  to  close  it  thoroughly ;  it  should  not,  however,  be  twisted 
off",  {b)  Free  torsion  is  used  for  the  smaller  vessels,  which  cannot  be 
isolated  completely  from  surrounding  structures  ;  the  vessel  is  laid 
hold  of  with  its  sheath  or  connective-tissue  covering,  and  twisted  as 
much  as  necessary. 

The  effect  of  torsion  is  that  the  inner  and  middle  coats  are  ruptured 
just  above  the  spot  grasped,  and  curl  upwards  into  the  lumen  of  the 
vessel,  whilst  the  outer  coat  is  twisted  up  beyond.  A  coagulum 
forms  upon  the  injured  structures,  and  the  subsequent  processes  to 
secure  permanent  occlusion  are  similar  to  those  described  above. 
Torsion  is  employed  occasionally  in  plastic  work,  and  in  twisting  off 
small  vessels  previously  secured  by  forcipressure  forceps. 

4.  Ligature  is  at  the  present  day  the  method  most  frequently  used 
for  arresting  bleeding  from  a  definite  source. 


286  A  MANUAL  OF  SURGERY 

The  material  should  be  of  sufficient  strength  to  secure  the  vessel, 
of  sufficient  resistance  to  maintain  its  hold  in  spite  of  being  soaked 
in  the  body  fluids,  and  yet  of  such  quality  as  to  be  absorbed,  or  so 
pure  and  unirritating  as  to  become  encapsuled  in  the  tissues.  Catgut 
suitably  prepared  is  frequently  employed,  but  inasmuch  as  com- 
mercial catgut,  even  when  rendered  aseptic  by  immersion  in  carbolic 
acid,  swells  up  in  warm  blood-serum,  and  becomes  a  soft,  pulpy  mass 
in  half  an  hour,  it  is  necessary  to  harden  and  render  it  more  resistant 
by  steeping  it  in  a  mixture  of  chromic  and  sulphurous  acids,  to 
which  corrosive  sublimate  is  added.  The  formulas  and  directions  for 
preparing  this  sulpho-chromic  catgut  have  recently  been  published  by 
Lord  Lister  {British  Medical  Journal,  January  i8,  1908).  The  length 
of  time  that  catgut  remains  unabsorbed  in 
the  tissues  varies  with  the  period  of  its 
immersion  in  chromic  acid,  and  material 
calculated  to  last  ten,  twenty,  thirty,  or 
forty  days  can  be  obtained  in  a  sterilized 
condition  from  instrument  makers.  Inas-  y, 
much  as  catgut  is  prepared  from  sheep's  n\ 
intestines,  by  allowing  them  to  putrefy  in  'i 
water  and  then  scraping  away  the  mucous  Fig.  90.— Reef  Knot. 
and  muscular  coats,  leaving  only  the  sub- 
mucous tissue  with  its  elastic  fibres,  which  is  twisted  up  into  long 
strands,  it  is  obvious  that  very  effective  sterilization  is  necessary  in 
order  to  fit  it  for  surgical  work  (p.  271). 

Sterilized  silk  and  linen  thread  are  also  employed,  whilst  animal 
tissues,  such  as  kangaroo  tendon  and  strips  of  ox  aorta,  have  their 
advocates,  Ballance  and  Edmunds  advise  the  use  of  gold-beaters' 
skin,  prepared  from  the  peritoneum  of  the  ox,  as  a  material  for  tying 
vessels  in  their  continuity,  and  excellent  results  have  followed  its 
employment.  Pagenstecher's  celluloid  ligature  may  also  be  con- 
sidered a  safe  and  harmless  material,  and  can  be  sterilized  by  boiling. 

Ligatures  may  be  applied  either  to  the  divided  end  of  an  artery  in 
an  open  wound  or  to  an  artery  in  its  continuity,  the  effects  and  final 
means  of  occlusion  being  in  both  cases  very  similar. 

When  applied  to  the  open  end  of  a  divided  vessel,  care  should  be 
taken  to  select  a  ligature  the  thickness  of  which  is  proportionate  to 
the  lumen  of  the  vessel  to  be  tied.  The  artery  should  be  cleanly 
picked  up  with  forceps,  so  as  'to  include  as  little  surrounding  tissue  as 
possible,  and  where  a  sheath  exists,  should  be  withdrawn  from  it. 
The  ligature  is  then  passed  round  it  and  tied  in  a  knot  which  will  not 
slip — e.g.,  the  reef  knot  (Fig.  90).  When  the  application  of  a  ligature 
is  difficult,  as  in  very  dense  fibroid  tissue,  it  may  be  advisable  to  pass 
it  under  the  vessel  by  means  of  an  ordinary  curved  needle,  and  then 
to  tie  it. 

For  ligation  in  continuity,  see  p.  328. 

Effects  of  Ligature — i.  On  the  Vessel  Wall. — The  immediate  result, 
if  the  vessel  has  been  tied  in  the  usual  way,  is  to  divide  the  inner 
and  middle  coats,  which  are  separated  from  the  outer  and  curl  up 


i 

--Q     -?*■'■■ 

,\ 

j 

~^''    -j 

HEMORRHAGE  287 

slightly,  whilst  the  outer  coat  is  constricted  and  thrown  into  folds 
within  the  grasp  of  the  ligature  (Fig.  92).  If  an  artery  is  tied  in  its 
continuity,  the  same  effect  is  produced  on  each  side  of  the  ligature. 
The  changes  already  described,  by  means  of  which  the  artery  is 
obliterated  and  transformed  into  a  fibro-cicatricial  cord,  then  manifest 
themselves  in  due  order.  An  exudation  of  plastic  lymph  and  cells 
occurs  into  the  sheath  and  around  the  ligature,  and  if  the  latter  is 

aseptic,  the  whole  is  embedded  in  this- 
plastic  mass,  which  undergoes  the  ordinary 
changes  seen  in  repair.  If  the  ligature, 
however,  is  septic  and  irritating,  it  has  to 
cut  its  way  out  through  the  vessel  wall  by 
an  ulcerative  process  akin  to  the  separa- 
tion of  a  septic  slough,  thus  exposing  the 
patient  to  the  risk  of  secondary  haemor- 
rhage from  the  disintegration  of  the  internal 
coagulum.  The  period  at  which  a  septic 
ligature  is  separated  varies  with  the  size  of 
the  vessel,  from  a  week  or  eight  days  for  an 
artery  the  size  of  the  radial  or  ulnar  to 
twelve  or  fourteen  days  for  the  subclavian 
or  carotid. 

Division  of  the  inner  and  middle  coats  is 
Fig.  9i.-EffectofTying  a  ^ot  an  essential  element  in  gaining  satis- 

LlGATURE    FIRMLY    AROUND     r        ,  i         •  r  ^       £  -^ 

AN  Artery  lactory  occlusion   or    a  vessel,   tor  it    can 

T,,     ,.    ,  .■   ■,    ,         also  be  effectively  accomplished  by  bring- 

The  ligature  was  tied  at  two   •         .  1  1        .       •        ■    j.        1  ■ 

levels,  and  the  artery  then  ^^S  the  vascular  tunics  into  close  apposi- 

laid  open  longitudinally.  tion  with  a  broad  animal  ligature  applied 
by  what  is  known  as  a  '  stay  knot '  (p.  329), 
without  harming  the  tunica  intima.  This  plan  may  be  adopted 
advantageously  (i)  when  the  artery  must  be  tied  at  a  spot  where  it  is 
obviously  diseased ;  or  (2)  in  dealing  with  arteries  of  great  size,  such 
as  the  innominate,  the  first  part  of  the  subclavian,  or  the  common 
iliac.  The  non-observance  of  this  precaution  results  in  aneurismal 
dilatation  at  the  site  of  ligature,  and  this  in  secondary  haemorrhage 
and  death.  On  the  other  hand,  it  is  safer  to  apply  a  ligature  firmly 
on  the  main  trunk  in  an  amputation  stump,  since  the  division  and 
curling  up  of  the  inner  and  middle  coats  must  facilitate  the  deposit  of 
fibrin  and  process  of  repair. 

All  arteries  in  the  body  are  maintained  more  or  less  upon  the 
stretch,  and  hence  retract  within  the  sheath  on  complete  division.  A 
certain  amount  of  longitudinal  tension  must  therefore  always  exist 
upon  any  part  of  an  artery  to  which  a  ligature  has  been  applied  in  its 
continuity,  and  this  may  presumably  predispose  to  secondary  hsemor- 
rhage.  To  obviate  this,  it  has  been  suggested  that  two  ligatures 
should  be  applied,  and  the  vessel  divided  between  them.  This  plan 
may  be  used  with  advantage  in  situations  where  the  artery  is  easily 
accessible,  but  is  scarcely  feasible  in  some  of  the  deeper  operations. 

2.  The  Ligature  itself  undergoes  changes,  which  result  in  its  partial 


288  A  MANUAL  OF  SURGERY 

or  total  absorption,  if  such  be  possible,  or  in  its  becoming  encapsuled 
if  absolutely  unabsorbent.  The  leucocytes  attack  any  soft  material, 
such  as  silk  or  catgut,  insinuating  themselves  amongst  the  fibrillae, 
and  finally  remove  them  by  a  similar  digestive  process  to  that  which . 
leads  to  the  absorption  of  a  small  aseptic  slough.  Multinucleated 
giant  cells  are  often  present,  and  probably  take  some  part  in  the  pro- 
ceeding. Finally,  every  trace  of  the  ligature  disappears,  and  its  place 
is  taken  by  fibrous  tissue,  incorporated  with  that  arising  from  the  end 
of  the  vessel.  Chromicized  gut,  as  already  explained,  lasts  a  variable 
time  according  to  its  method  of  preparation  ;  silk  is  removed,  but 
slowly.  Other  animal  substances  employed  are  dealt  with  in  the 
same  way,  and  even  silver  wire  is  not  unaffected,  its  surface  becoming 
roughened  after  a  time  and  slightly  eroded. 

3.  The  effect  on  the  Circulation  is  the  same  whether  ligature  gi 
any  other  plan  of  occlusion  is  adopted.  The  proximal  end  as  far  as 
the  next  patent  branch  soon  begins  to  contract,  and  is  ultimately 
converted  into  a  fibrous  cord,  which  may  or  may  not  be  pervious  for 
a  short  distance.  Blood  is  conveyed  to  the  vessels  of  the  limb  below 
the  ligature  by  anastomosing  branches,  which  undergo  rapid  dilatation 
and  establish  a  collateral  circulation,  sufficiently  free  as  a  general  rule 
to  maintain  the  vitality  of  the  part.  These  collateral  branches 
become  permanently  enlarged,  lengthened,  and  tortuous,  and  their 
walls  thickened.  If  for  any  reason  the  collateral  circulation  is 
insufficient,  gangrene  is  likely  to  supervene,  starting  in  the  parts 
farthest  away  from  the  centre  of  the  circulation,  or  in  the  structures 
of  least  vitality  {e.g.,  the  fingers,  toes,  or  subcortical  white  substance 
of  the  brain),  and  spreading  backwards  until  a  part  is  reached  which 
receives  enough  blood  to  keep  it  alive. 

Arterial  Hsemorrhage. 

Three  forms  of  arterial  haemorrhage  are  described,  viz.,  primary, 
reactionary,  and  secondary. 

Primary  Arterial  Hsemorrhage  is  met  with  under  two  conditions  ;  (i) 
from  an  open  wound,  or  (2)  where  an  artery  is  ruptured  or  punctured 
subcutaneously,  so  that  extravasation  occurs  into  the  tissues  con- 
stituting either  a  severe  bruise  if  the  artery  is  small,  or  if  the  vessel 
is  large  what  has  been  badly  termed  a  '  diffuse  traumatic  aneurism.' 

A .  Primary  Arterial  Haemorrhage  from  an  Open  Wound.  The  blood 
is  here  poured  forth  upon  the  surface,  and  escapes  freely,  so  that  the 
full  constitutional  effects  are  experienced. 

The  principles  that  guide  us  in  its  Treatment  may  be  enunciated  as 
follows : 

T.  The  vessel  must  be  secured  at  the  bleeding -point,  an  operation  to 
expose  it  being  undertaken  if  necessary.  However  infiltrated  the 
part,  the  rule  of  cutting  down  to  expose  the  wounded  vessel  is  to  be 
adhered  to,  with  one  or  two  exceptions  noted  below,  and  this  for  two 
reasons :  (a)  It  is  often  impossible  to  know  the  exact  source  of  the 
haemorrhage   unless   it   is   laid   bare.      Thus,  the    bleeding  from   a 


HEMORRHAGE  289 

punctured  wound  of  the  front  of  the  leg,  which  was  apparently 
derived  from  the  anterior  tibial  artery,  was  proved  on  incision  and 
careful  dissection  to  come  from  the  peroneal,  the  wound  extending 
backwards  between  the  bones.  In  the  axilla  and  groin  such  uncertainty 
often  exists.  {h)  Proximal  ligature  of  a  vessel  at  some  distance 
above  the  bleeding  spot  is  commonly  insufficient  to  arrest  the 
haemorrhage,  since  the  collateral  circulation  is  quickly  established, 
and  then  reactionary  haemorrhage  is  very  likely  to  ensue. 

2.  Both  ends  of  the  wounded  vessel  must  be  secured  if  it  is  completely 
divided,  whilst  if  it  is  only  punctured,  a  ligature  must  be  placed  on 
each  side  of  the  puncture,  and  the  complete  division  of  the  vessel 
effected.  The  readiness  with  which  a  collateral  circulation  is  estab- 
lished justifies  such  treatment  in  the  case  of  all  arteries  of  large  size. 
Thus,  when  the  facial  artery  is  divided,  jets  of  blood  are  emitted 
from  each  end  quite  freely,  and  with  nearly  as  much  force  from  the 
distal  as  from  the  proximal.  Occasionally  the  distal  end  of  a  bleeding 
vessel  retracts  amongst  the  infiltrated  tissues  to  such  an  extent  as  to 
render  its  isolation  impracticable.  The  surgeon  must  then  trust  to 
plugging  of  the  wound  from  the  bottom,  but  not  until  every  effort 
has  been  made  to  secure  it. 

It  is  only  needful  to  undertake  the  measures  detailed  above  in 
cases  where  primary  haemorrhage  is  actually  proceeding.  If  it  has 
been  once  arrested,  it  is  unnecessary  to  search  for  the  bleeding  spot ; 
the  wound  should  be  dressed  with  the  utmost  care  not  to  dislodge 
clots  or  disturb  the  parts.  If,  however,  the  patient  is  very  faint  and 
collapsed,  and  the  surgeon  has  reason  to  anticipate  that  a  large  trunk 
has  been  injured,  it  may  be  needful  to  seek  for  and  tie  it  at  once ; 
otherwise  recurrent  haemorrhage  is  likely  to  ensue  when  the  heart's 
action  becomes  more  vigorous. 

There  are  a  few  exceptions  to  the  general  rule  of  tying  a  wounded 
vessel  at  the  injured  spot — e.g.,  where  the  depth  of  the  dissection 
might  endanger  important  parts,  as  in  dealing  with  the  deep  palmar 
and  plantar  arches,  or  with  a  punctured  wound  of  the  pterygo-maxillary 
region. 

In  the  actual  treatment  of  any  particular  case,  temporary  arrest  of 
the  bleeding  may  usually  be  effected  by  digital  compression  either  of 
the  bleeding-point  or  of  the  main  trunk  at  a  favourable  spot  nearer 
to  the  heart,  against  some  resisting  structure,  such  as  a  subjacent 
bone.  The  common  carotid  is  controlled  by  grasping  the  neck  from 
behind,  and  compressing  the  artery  by  the  fingers  placed  along  the 
anterior  border  of  the  sterno-mastoid  against  the  transverse  process 
of  the  sixth  cervical  vertebra  (Chassaignac's  tubercle).  Such  pressure 
will  also  control  the  vertebral  and  inferior  thyroid  vessels.  The 
subclavian  is  to  be  compressed  in  the  third  part  of  its  course  against 
the  first  rib  by  the  finger  or  thumb  placed  immediately  behind  the 
clavicle,  in  the  angle  between  it  and  the  sterno-mastoid,  the  pressure 
being  made  downwards  and  inwards.  A  good  deal  of  force  is 
required  in  order  to  maintain  the  pressure,  and  this  may  be  gained 
by  superimposing  the  fingers  or  thumb  of  the  other  hand.     When,  the 

19 


290  A  MANUAL  OF  SURGERY 

pressure  is  to  be  kept  up  for  some  time,  the  padded  handle  of  a 
door-key  may  be  employed  in  the  same  way,  or  an  incision  may  be 
made  and  the  vessel  exposed,  and  controlled  by  direct  digital 
pressure.  The  facial  artery  is  compressed  against  the  lower  jaw  just 
in  front  of  the  masseter  muscle.  Bleeding  from  the  labial  and 
coronary  arteries  is  commanded  by  inserting  the  index-finger  into  the 
corner  of  the  mouth,  and  compressing  the  lip  between  it  and  the 
thumb  outside.  The  temporal  artery  should  be  compressed  against 
the  zygoma  just  in  front  of  the  ear,  the  occipital  at  a  spot  about 
ii  inches  from  the  occipital  protuberance  against  the  superior  curved 
line.  To  control  the  brachial  artery,  the  arm  should  be  grasped  from 
behind,  and  the  fingers  pressed  inwards  along  the  inner  margin  of 
the  biceps  against  the  humerus.  The  radial  and  ulnar  arteries  are 
easily  commanded  above  the  wrist  by  using  both  hands  to  grasp  the 
forearm,  with  a  thumb  on  each  vessel.  The  abdominal  aorta  is  con- 
trolled in  slim  individuals  with  ease  by  pressure  through  the  abdominal 
wall  against  the  body  of  the  third  lumbar  vertebra  a  little  above  and 
to  the  left  of  the  umbilicus,  i.e.,  just  above  its  bifurcation ;  in  stout 
persons  this  is  impossible.  The  common  femoral  artery  is  best  com- 
pressed immediately  below  Poupart's  ligament.  The  surgeon  should 
stand  on  the  same  side  of  the  patient  as  the  artery  to  be  controlled, 
and  use  the  finger-tips  to  press  the  vessel  directly  backwards  against 
the  pubic  ramus.  The  fingers  of  one  hand  placed  over  the  other 
may  sometimes  be  necessary  to  maintain  sufficient  command.  Care 
must  be  taken  not  to  let  the  vessel  roll  aside,  and  so  escape  com- 
pression. When  the  artery  has  to  be  controlled  for  some  time,  as  in 
an  amputation,  the  hands  may  be  used  alternately,  the  one  to  rest  the 
other.  If  it  is  desirable  to  control  the  anterior  and  posterior  tibial 
arteries  close  to  the  ankle  during  operations  upon  the  foot,  the 
assistant  who  steadies  the  limb  accomplishes  this  by  grasping  the 
toes  with  one  hand,  and  with  the  other  compressing  the  vessels,  the 
posterior  tibial  at  a  spot  a  finger's  breadth  behind  the  internal 
malleolus,  the  anterior  midway  between  the  two  malleoli. 

As  digital  compression  cannot,  however,  be  comfortably  main- 
tained for  long,  mechanical  compression  of  a  limb,  as  by  tourniquet  or 
elastic  bandage,  must  be  requisitioned.  Possibly  the  screw  tourni- 
quet will  be  the  best  to  apply,  as  it  can  be  relaxed  and  tightened 
again  as  often  as  is  necessary  during  the  operation. 

The  wound  is  then,  if  need  be,  enlarged  by  incisions,  which,  whilst 
laying  the  parts  freely  open,  should  inflict  the  least  possible  damage 
on  surrounding  structures.  All  coagula  are  removed,  and  a  search 
made  for  the  wounded  vessel.  It  may  be  needful  to  relax  the  tour- 
niquet, and  allow  a  jet  of  blood  to  escape,  in  order  to  ascertain  its 
position.  Both  ends  should  be  sought  for  and  tied,  a  proceeding  often 
easier  said  than  done.  This  especially  applies  to  the  distal  end,  which 
retracts,  and  possibly  does  not  bleed  at  the  time  of  operation,  but  may 
do  so  when  the  collateral  circulation  becomes  established. 

B.  For  Subcutaneous  Rupture  of  an  Artery,  see  p.  298. 


HMMORRHA  GE  291 

Recurrent,  Intermediate,  or  Reactionary  Arterial  Haemorrhage. 

These  terms  are  applied  to  bleeding  which  recurs  within  twenty- 
four  hours  of  an  accident  or  operation.  It  is  an  evidence  of  the 
,  failure  of  the  means  employed  to  arrest  permanently  the  primary 
loss  of  blood,  and  may  result  from  two  chief  causes :  [a]  Defective 
application  of  a  ligature,  which  comes  undone  from  being  badly  tied 
(a  'granny'  knot),  or  slips  off  from  including  within  its  grasp  other 
structures  as  well  as  the  arterial  wall ;  or  {b)  the  coagula  lying  in  the 
mouths  of  divided  vessels  are  not  sufficiently  firm  to  withstand  the 
increasing  blood-pressure  which  supervenes  after  the  shock  has 
passed  away,  or  which  may  be  due  to  excitement  or  the  injudicious 
administration  of  stimulants.  It  is  usually  due  to  the  second  of  these 
causes,  and  is  then  not  very  serious,  inasmuch  as  it  can  only  arise 
from  the  smaller  vessels,  all  the  larger  ones  having  probably  been 
recognised  and  tied  during  the  operation. 

Treatment  .-^Elevation  and  the  pressure  of  a  firm  bandage  are 
often  quite  sufficient  to  arrest  this  form  of  bleeding ;  but  if  unsuc- 
cessful, the  wound  must  be  opened  up,  washed  out  with  hot  or  cold 
lotion,  and  any  bleeding  vessel  tied.  The  actual  cautery  may  even 
be  employed  to  check  oozing  from  cicatricial  surfaces,  and  if  it  is  not 
allowed  to  touch  the  skin,  and  the  wound  kept  aseptic,  no  delay  in  its 
healing  need  be  occasioned.  Should  the  bleeding  persist,  the  wound 
should  be  firmly  packed. 

Secondary  Haemorrhage. 

Under  this  title  are  included  all  forms  of  haemorrhage  from  wounds 
which  occur  after  the  lapse  of  twenty-four  hours.  It  is  usually  due 
to  infection,  and  was  formerly  very  common,  often  leading  to  a  fatal 
termination  ;  since  the  introduction  of  antiseptic  surgery  it  is  but 
seldom  seen.  Where  antisepsis,  however,  cannot  be  efficiently 
carried  out,  as  in  the  mouth,  pharynx,  etc.,  it  is  still  occasionally 
met  with. 

The  Fundamental  Cause  in  the  production  of  secondary  haemor- 
rhage is  without  doubt  a  infected  condition  of  the  wound.  This  may 
act  in  various  ways.  Thus,  in  a  vessel  entirely  divided,  the  cocci 
may  gain  entrance  through  the  open  mouth  to  the  internal  coagulum, 
and  cause  its  disintegration.  This  process  is  assisted  by  an  ulcerative 
form  of  peri-arteritis,  which  leads  to  weakening  of  the  vessel  walls. 
It  is  in  this  latter  way  that  secondary  haemorrhage  is  induced  in 
vessels  ligatured  in  their  continuity,  the  loss  of  support  due  to. the 
opening  up  of  the  wound  being  also  an  element  of  danger.  It  is 
important  to  realize  the  marked  alterations  in  all  the  conditions 
existing  in  an  infected  as  opposed  to  an  aseptic  wound.  In  the 
latter  it  is  not  only  the  clot  in  the  lumen  of  the  vessel  which  is  relied 
on  to  prevent  accidents,  but  the  vital  action  of  all  the  tissues  is 
calculated  to  work  in  the  same  direction,  that  of  insuring  the  patient 
against  haemorrhage.     On  the  other  hand,  when  infection  supervenes, 


292  A  MANUAL  OF  SURGERY 

a  destructive  process  replaces  that  of  repair,  and  the  activity  of  the 
part  is  temporarily  paralyzed  by  the  toxic  influence  of  the  micro- 
organisms and  their  products. 

Various  other  conditions  may  be  mentioned,  however,  as  Con- 
tributory Causes  of  secondary  haemorrhage :  (i.)  The  ligature  may  be 
infected,  or  too  readily  absorbed,  (ii.)  Its  mode  of  application  may 
be  faulty.  Thus,  it  may  have  included  other  structures,  and  so 
become  loose ;  or  the  sheath  may  have  been  opened  too  freely,  and 
thus  the  vitality  of  the  vessel  wall  dependent  on  the  vasa  A^asorum 
is  diminished.  In  large  vessels,  such  as  the  innominate  and  first  part 
of  the  subclavian,  the  mere  division  of  the  inner  and  middle  coats 
weakens  the  wall  to  such  an  extent  as  to  render  it  incapable  of  with- 
standing even  a  normal  blood-pressure,  so  that  aneurismal  dilatation 
and  secondary  haemorrhage  are  almost  certain  to  result,  even  in 
aseptic  cases,  (iii.)  The  ligature  may  have  been  placed  too  near  a 
branch  immediately  concerned  in  the  establishment  of  the  collateral 
circulation  (though  if  asepsis  is  maintained  this  is  comparatively  un- 
important), or  where  there  is  a  considerable  back-flow,  or  the  part 
may  not  have  been  kept  absolutely  at  rest,  (iv.)  The  arterial  wall 
at  the  sight  of  ligature  may  be  the  seat  of  atheroma  or  fatty  degenera- 
tion, a  most  serious  complication  if  the  wound  becomes  infected, 
(v.)  The  state  of  the  blood  may  be  unfavourable  to  the  repair  of 
any  wound,  whether  in  an  artery  or  not  —  e.g.,  in  albuminuria 
or  diabetes.  (vi.)  Increased  blood  -  pressure  after  the  ligature  of 
a  vessel  may  lead  to  secondary  haemorrhage,  as  in  plethora, 
Bright's  disease,  traumatic  fever ;  or  the  heart's  action  may  be  in- 
creased by  injudicious  excitement  or  the  unwise  administration  of 
stimulants. 

The  Phenoraena  are  usually  preceded  by  those  of  septic  contamina- 
tion of  the  wound,  to  w^hich  a  slight  occasional  loss  of  blood  is  added. 
This  continues  with  more  or  less  frequency  and  severity,  until  the 
patient  is  either  worn  out  by  the  constant  repetition  of  small  losses, 
or  destroyed  by  one  or  two  seA^ere  gushes  from  the  larger  vessels. 
The  earlier  the  bleeding  occurs,  the  less  serious  it  is,  as  it  probably 
comes  from  the  smaller  vessels,  and  can  be  easily  dealt  with.  When, 
however,  it  does  not  supervene  till  late,  as  on  the  tenth  or  twelfth 
day,  it  usually  arises  from  the  larger  trunks,  and  is  increasingly 
severe.  When  originating  from  a  vessel  tied  in  its  continuity,  it 
generally  comes  from  the  distal  end,  and  that  for  the  following 
reasons  :  [a)  The  internal  coagulum  is  here  less  firm,  and  forms  later 
than  at  the  proximal  end  ;  (h)  the  pressure  at  the  distal  side  of  the 
ligature,  which  is  at  first  nil,  is  continually  increasing  as  the  collateral 
circulation  is  established,  whilst  proximally  it  diminishes  as  the 
vessel  contracts  and  the  blood-flow  is  deflected  into  other  channels  ; 
and  (c)  the  main  vasa  vasorum,  derived  from  the  sheath,  always  run 
into  and  along  the  vessel  wall  in  the  same  direction  as  the  blood-stream. 
Hence  the  effect  of  isolating  and  tying  the  artery  in  its  sheath  is  to 
diminish  the  vitality  and  power  of  resistance  to  bacterial  activity  of 
the  tunics  just  beyond  the  point  of  ligature. 


HEMORRHAGE  293 

Treatment.— The  case  must  be  watched  night  and  day  until  the 
wound  is  healthy,  as  although  the  bleeding  may  have  ceased  for  a 
while,  it  may  break  out  again  at  any  time.  If  the  wound  is  in  a  limb, 
a  tourniquet  should  be  lightly  adjusted  above  it  as  a  precautionary 
measure,  so  that  at  a  moment's  notice  it  may  be  tightened. 

When  arising  from  an  artery  entirely  divided  across,  as  in  an  amputa- 
tion stump,  elevation  of  the  part  after  re-dressing  and  firmly  ban- 
daging may  be  all  that  is  needed  in  early  cases.  A  recurrence  will 
necessitate  the  opening  up  of  the  wound,  and  the  application  of 
ligatures  to  the  bleeding  vessels,  if  practicable.  The  actual  cautery 
may  be  employed  where  the  tissues  are  too  rotten  to  hold  a  ligature. 
Sloughs  may  be  cut  or  scraped  away,  and  the  wound  packed 
with  gauze  and  firmly  bandaged.  If  this  fails,  the  artery  must  be 
tied  just  above,  or  re-amputation  performed.  When  the  bleeding 
comes  from  the  main  vessel  near  the  trunk,  as  after  amputation  at 
the  shoulder  or  hip,  proximal  ligature  can  alone  be  depended  on, 
should  local  treatment  be  unsuccessful. 

When  coming  from  an  artery  tied  in  its  continuity,  the  wound  is 
opened  up,  and  the  artery  secured  again  above  and  below,  whilst 
every  effort  is  made  to  combat  the  infection.  Failing  this,  proximal 
ligature  may  be  practicable,  but  for  the  large  vessels  of  the  trunk 
pressure  may  be  the  only  resource.  Should  re-ligature  at  a  higher 
spot  fail  or  be  considered  inadvisable,  as  is  often  the  case  in  the 
leg,  amputation  must  be  undertaken  without  delay. 

Venous  Hsemorrliage. 

Bleeding  from  the  smaller  veins  rarely  requires  much  attention,  in 
that  the  walls,  when  once  divided,  rapidly  collapse,  and  this  effectually 
checks  further  loss  of  blood ;  but  if  the  larger  veins  are  involved,  or 
if  the  walls  are  thickened  and  rigid,  as  in  varix,  a  very  considerable 
amount  may  be  lost,  the  blood  welling  up  in  a  dark,  purplish  stream 
from  the  wound,  and  rendering  its  arrest  the  more  difficult  from  the 
fact  that,  except  in  veins  of  the  largest  size,  there  is  no  definite  jet 
or  gush  to  guide  one  to  the  wounded  spot. 

Treatment. — Divided  veins  are  usually  tied  in  the  same  way  as 
arteries,  but  it  is  often  possible  to  secure  a  puncture  or  tear  in  a 
large  vein  without  occluding  its  whole  circumference.  In  amputations 
it  is  usual  to  tie  both  the  main  artery  and  vein.  Where  it  is  difficult 
to  reach  a  vein  in  order  to  tie  it,  the  wound  may  be  packed. 

The  dangers  of  venous  haemorrhage  are  fourfold:  (i)  The  con- 
stitutional symptoms  arising  from  the  actual  loss  of  blood ;  (2)  the 
thrombus  which  forms  may  be  displaced  as  an  embolus ;  (3)  septic 
infection  of  the  thrombus  lying  in  the  mouth  of  the  vessel  may  lead 
to  pyaemia ;  and  (4)  the  entrance  of  air  into  veins,  which,  though 
rarely  met  with,  is  fraught  with  the  most  urgent  danger  to  the 
patient.  The  air  becomes  churned  up  in  the  cavities  of  the  right  side 
of  the  heart,  forming  a  spumous,  frothy  mixture  amongst  the  columnae 
carneae,  which  the  heart  can  eject  only  with  difficulty ;  thus  the  circu-   ' 


294  A  MANUAL  OF  SURGERY 

lation  is  brought  to  a  standstill  in  spite  of  forcible  cardiac  contractions, 
and  the  patient  dies  from  anaemia  of  the  lungs  and  brain. 

The  Cause  of  the  entry  of  air  is  usually  a  wound  of  some  vein  in 
what  is  known  as  the  '  dangerous  region  '  of  the  neck  (lower  portion) 
or  axilla,  or  even  of  such  unlikely  structures  as  the  pelvic  veins  or 
cranial  sinuses.  There  is  but  little  blood-pressure  within  the  veins 
at  any.  time,  but  during  inspiration  the  movements  of  the  thorax 
exercise  an  aspiratory  or  suction  effect  upon  the  blood  in  the  larger 
veins,  a  most  important  element  in  the  maintenance  of  the  venous 
flow.  Any  condition  which  prevents  the  collapsing  of  the  walls  of 
the  veins,  or  brings  about  what  is  termed  their  canalization,  predisposes 
to  this  accident.  Thus  they  may  be  held  open  at  spots  where  they 
pierce  the  deep  fascia  or  the  platysma  ;  if  the  coats  are  thick  and 
rigid  from  inflammation,  or  surrounded  by  indurated  tissue,  or  button- 
holed as  by  excision  of  a  portion  of  the  walls  or  division  of  a  branch 
close  to  the  main  trunk,  or  if  undue  traction  is  exercised  upon  the 
pedicle  of  a  tumour  containing  a  wounded  vein,  then  the  orifice  may 
remain  patent,  and  air  can  be  sucked  in.  If,  however,  the  veins  are  very 
distended,  as  often  in  the  operation  of  tracheotomy,  then  a  wound, 
even  in  the  dangerous  area,  usually  results  in  loss  of  blood  rather 
than  entrance  of  air. 

The  chief  sign  is  a  hissing,  gurgling,  or  sucking  sound,  which  is 
quite  characteristic.  A  few  bubbles  of  air  may  also  be  seen  clinging 
about  the  aperture  in  the  vessel.  If  only  a  small  amount  has  entered, 
or  if  the  entry  is  made  slowly,  no  bad  results  may  follow ;  but  the 
usual  effect  of  the  sudden  introduction  of  even  a  small  quantity  is  to 
produce  severe  faintness,  and  if  the  patient  is  conscious,  a  feeling  of 
dyspnoea  and  distress,  which  is  partly  cardiac  in  origin,  partly  due  to 
obstruction  to  the  flow  of  blood  through  the  lungs.  The  pulse 
becomes  rapid  and  almost  imperceptible,  the  pupils  widely  dilated, 
and  death  usually  follows,  preceded  perhaps  by  convulsions,  although 
the  fatal  issue  may  be  postponed  for  a  few  hours.  If  the  patient 
survives,  no  after-effects  remain. 

Treatment. — This  accident  can  usually  be  avoided  by  dealing 
cautiously  with  all  veins  in  operations  about  the  neck.  Should  -  it 
occur,  any  fresh  entrance  must  be  at  once  checked  by  placing  a 
finger  over  the  bleeding-point  or  pouring  lotion  into  the  wound. 
The  vein  should  be  secured  by  ligature  as  soon  as  possible.  To 
combat  the  general  symptoms,  it  is  essential  to  maintain  a  good  supply 
of  blood  to  the  brain.  The  head  is  lowered,  and,  if  need  be,  the  limbs 
raised  and  bandaged,  or  the  abdominal  aorta  compressed.  Stimulants 
and  artificial  respiration  are  used  in  order  to  maintain  the  heart's 
action  and  to  overcome  the  pulmonary  obstruction.  Warmth  and 
friction  are  also  applied  to  the  extremities. 

Capillary  Hsemorrliage. 

This  is  usually  of  little  significance.  It  is  characterized  by  a 
general  oozing  from  the  wounded  surface,  the  blood  trickling  down 


HEMORRHAGE  295 

to  fill  the  cavity  from  the  bottom.  It  is  often  very  abundant  from 
inflamed  parts,  and  especially  from  fibro-cicatriciai  tissue,  which 
prevents  the  closure  of  the  vessel  mouths.  It  can  usually  be  arrested 
by  pressure,  or  by  the  application  of  cold  or  hot  water,  by  styptics, 
cauterization,  or  plugging. 

Methods  of  Dealing  with  HEemorrhage  from  Special  Sources. 

Carotid  Artery. — Treatment  is  impossible  unless  the  surgeon  is  on  the  spot, 
when  both  ends  should  be  tied. 

Jugular  Vein. — Tie,  or  stitch,  if  possible,  without  occluding  the  whole  lumen. 

Secondary  Branches  of  the  Carotid. — It  may  be  difficult  to  secure  the  divided 
ends  of  these  vessels  either  in  the  neck  or  head,  e.g. ,  in  a  cut  throat  or  a  punctured 
wound  of  the  pterygoid  region.  Under  such  circumstances,  ligature  of  the 
external  carotid  between  the  superior  thyroid  and  lingual  has  been  recommended 
as  more  satisfactory  than  tying  the  common  carotid,  since  the  cerebral  circulation 
is  not  thereby  affected. 

Vertebral  Artery. — The  source  of  such  bleeding  may  be  difficult  to  ascertain, 
as  it  is  scarcely  possible  to  compress  this  vessel  without  also  including  the 
carotid  ;  and  hence  mistakes  in  diagnosis  have  often  arisen.  It  may  be  feasible, 
however,  to  control  the  carotid  alone  by  pinching  it  up  by  the  fingers  placed 
on  either  side  of  the  sterno-mastoid,  without  interfering  with  the  vertebral. 
Treatment  must  follow  the  usual  course  of  cutting  down  and  tying  at  the 
bleeding-point,  if  possible.  To  do  this,  the  incision  must  be  enlarged,  or  a  new 
one  made  along  the  posterior  border  of  the  sterno-mastoid  in  order  to  define  the 
transverse  processes  of  the  vertebrae.  In  the  upper  part  of  its  course  the  vessel 
may  be  secured  by  clipping  away  a  transverse  process  if  necessary,  due  care 
being  taken  of  the  nerve  roots  ;  otherwise  plugging  of  the  vertebral  canal  or  the 
use  of  styptics  must  be  depended  on.  It  is  most  essential  that  the  carotid  should 
not  be  tied  by  mistake  in  these  cases,  as  thereby  more  blood  is  directed  to  the 
vertebral  trunk,  and  the  bleeding  is  correspondingly  increased. 

The  Internal  Mammary  Artery  rarely  calls  for  treatment,  since  an  accidental 
wound  of  this  vessel  is  usually  complicated  with  some  graver  mischief  to  heart, 
liver  or  lungs.  If  recognised,  tie  at  the  bleeding  spot,  possibly  removing  a 
costal  cartilage  to  gain  access.  The  vessel  lies  about  ^  inch  outside  the  border 
of  the  sternum. 

Intercostal  Haemorrhage  usually  results  from  penetrating  wounds  also  involv- 
ing the  rib,  and  is  not  easily  stopped  on  account  of  the  position  of  the  vessels  in 
the  groove.  Treatment. — Incise  the  periosteum  longitudinally  along  the  lower 
border  of  the  rib,  and  detach  it  and  the  vessels  from  the  groove ;  or  remove  a 
portion  of  the  bone,  and  thus  expose  the  bleeding-point ;  or  in  some  cases  a 
suture  passed  round  the  rib  a  little  above  the  injury  has  sufficed;  or  again, 
pressure  may  be  employed  by  pushing  a  piece  of  aseptic  gauze,  like  a  pocket, 
through  the  wound  in  the  pleural  cavity,  and  then  stuffing  it  tightly  with  wool 
or  strips  of  gauze,  so  that  on  pulling  upon  ft  the  vessel  may  be  effectually 
compressed. 

Wounds  of  the  Vessels  of  the  Extremities  need  treatment  according  to  the 
principles  enunciated  above.     Only  one  or  two  require  special  mention. 

Wounds  of  the  Palmar  Arches  were  formerly  much  more  dreaded  than  they 
are  at  present,  when  thorough  antisepsis  and  the  use  of  the  elastic  tourniquet 
allow  us  to  explore  the  depths  of  a  wound  without  much  danger  or  difficulty. 
The  position  of  the  wound  will  usually  indicate  whether  the  bleeding  comes  from 
the  superficial  or  deep  arch,  but  in  case  of  doubt  it  is  well  to  remember  that 
pressure  on  the  ulnar  trunk  mainly  affects  the  superficial  arch,  whilst  pressure 
on  the  radial  will  chiefly  influence  the  deep.  A  wound  of  the  superficial  arch 
presents  little  trouble  in  treatment,  as  it  can  be  readily  secured  by  catch  forceps 
and  ligature  ;  but  the  deep  arch  is  not  so  easily  dealt  with.  It  lies  just  over  the 
bases  of  the  metacarpal  bones  (Fig.  92,  d),  and  to  expose  it  the  wound  must  be 
freely  enlarged  by  a  longitudinal  incision,  and  the  tendons  turned  on  one  side  or 


2q6 


A  MANUAL  OF  SURGERV 


separated.  It  may  be  possible  to  secure,  the  vessel  by  forcipressure  forceps,  and 
these  may  be  left  on  for  twenty-four  hours  if  a  ligature  cannot  be  applied.  Of 
course,  the  strictest  asepsis  is  needful  in  such  cases,  and  passive  movement  of  the 
fingers  must  be  early  undertaken,  in  order  to  prevent  troublesome  adhesions. 
Failing  such  means,  or  in  infected  cases,  the  wound  is  carefully  plugged  with 
gauze,  and  over  this  the  fingers  are  firmly  bandaged.  The  patient  is  kept  in  bed 
for  a  few  days,  and  the  arm  elevated.  Pressure  on  the  main  vessels  above  is 
scarcely  necessary  if  the  compress  is  accurately  applied.  The  bandages  may  be 
relaxed  at  the  end  of  twenty-four  hours,  but  the  deep  dressing  should,  if  possible, 
not  be  touched  for  three  or  four  days.  If,  in  spite  of  this,  bleeding  recurs,  the 
main  vessel  or  vessels  of  the  limb  must  be  tied.     Ligature  of  the  ulnar  and  radial 

at  the  wrist  is  generally  insufficient  to  con- 
trol it,  as  there  is  often  a  communicating 
branch  of  some  size  passing  from  the 
anterior  interosseous  to  the  deep  arch, 
and  hence  it  may  be  needful  to  secure  the 
brachial  artery,  ascertaining  first,  how- 
ever, by  pressure  that  such  would  be 
efficacious ;  for  occasionally  there  is  a 
high  division  of  the  brachial,  or  a  vas 
aberrans  may  exist,  which  would  compel 
the  surgeon  to  tie  the  third  part  of  the 
axillary. 

Bleeding  from  the  Plantar  Arch  must 
be  conducted  on  similar  lines. 

The  Gluteal,  Sciatic,  or  Pudic  arteries 
may  be  wounded  by  stabs  in  the  buttock. 
Treatment.  —  Enlarge  the  wound  in  the 
direction  of  the  fibres  of  the  gluteus 
maximus,  i.e.,  downwards  and  outwards, 
and  secure  the  bleeding  vessel.  The 
gluteal  trunk  emerges  from  the  pelvis 
at  the  junction  of  the  middle  and  inner 
thirds  of  a  line  from  the  posterior 
superior  iliac  spine  to  the  great  tro- 
chanter ;  the  pudic  crosses  the  ischial 
spine  at  the  junction  of  the  middle  and 
lower  thirds  of  a  line  from  the  posterior 
superior  iliac  spine  to  the  tuber  ischii. 
The  sciatic  emerges  from  the  pelvis  just 
above  and  a  little  external  to  the  latter 
sp?t.  The  pudic  may  also  be  divided 
in  the  perineum  by  a  penetrating  wound.  Failing  ligature  of  anj^of  these  arteries 
at  the  seat  of  bleeding,  the  internal  iliac  may  need  to  be  secured. 


Fig.  92. — Hand,  to  show  Position 
OF  Palmar  Arches. 

A,  Radial   artery ;    B,  ulnar    artery  , 
C,  superficial  arch  ;  D,  deep  arch. 


Haemophilia. 

By  haemophilia,  or  the  hagmorrhagic  diathesis,  is  meant  a  disease,  either  con- 
genital and  hereditary,  or  casual  and  accidental,  characterized  by  a  tendency  to 
persistent  and  uncontrollable  bleeding  from  slight  wounds,  whether  open  or  sub- 
cutaneous. This  condition  is  often  associated  with  extravasation  of  blood  into 
the  joints,  and  certain  consecutive  phenomena  (Chapter  XXII.).  The  family 
history  of  the  hereditary  cases  is  interesting,  the  disease  being  usually  transmitted 
through  the  females  of  one  or  more  generations  to  the  males,  whilst  the  former 
may  escape  entirely.  The  cause  of  this  affection  does  not  lie  in  the  vessels,  but 
in  the  blood,  and  is  probably  due  to  an  insufficiency  or  imperfection  of  the  fibrin 
ferment,  or  to  the  presence  of  some  anticoagulable  substance.  Unless  haemor- 
rhage is  actually  occurring,  nothing  abnormal  is  noticed,  but  any  injury  is  sure 
to  be  followed  by  excessive  bleeding  ;  spontaneous  subcutaneous  ecchymoses 
frequently  occur,   as  also  bleeding   from  the   mucous  membranes.     Hence  no 


HEMORRHAGE 


297 


operations  must  be  undertaken  on  such  patients  unless  absolutely  urgent,  even 
such  a  small  matter  as  the  extraction  of  a  tooth  having  proved  fatal 

The  Treatment  of  haemophilia  should  be  directed  more  to  correcting  the 
defect  in  the  blood  than  to  pursuing  the  usual  practice  in  dealing  with  haemor- 
rhage. The  application  or  administration  of  haemostatics,  and  of  substances 
which  tend  to  promote  coagulation  and  the  formation  of  fibrin,  should  be  resorted 
to.  Calcium  lactate,  10  to  20  grs.  in  \  pint  of  water  given  by  the  rectum,  or  5  to 
10  grs.  by  the  mouth,  repeated  two  or  three  times  a  day,  is  decidedly  useful, 
whilst  fibrin  ferment,  suprarenal  extract,  and  cocaine  should  be  employed  locally. 
Position  and  pressure  are  attended  to,  and  in  severe  cases  the  actual  cautery  may 
prove  useful,  or  the  prolonged  application  of  cold.  The  subcutaneous  or  oral 
administration  of  sterilized  horse  or  rabbit  serum  in  doses  of  from  10  to  30  c.c. 
has  been  recently  recommended.  Anti-diphtheritic  serum  may  be  employed 
instead. 


CHAPTER  XII. 

INJURIES    AND    DISEASES    OF    ARTERIES  —  ANEURISM — 
LIGATURE  OF  ARTERIES. 

Injuries  of  Arteries. 

Contusion  of  an  artery  is  the  result  of  violence  applied  directly  to  the 
vessel  wall.  The  effects  vary  with  the  severity  of  the  injury  and 
with  the  condition  of  the  arterial  tunics.  If  atheroma  or  calcification 
exists,  thrombosis  often  follows  slight  injuries,  and  dry  or  senile 
gangrene  may  ensue ;  but  in  healthy  arteries  a  good  deal  of  violence 
is  needed  to  produce  such  an  effect,  as  their  natural  elasticity  enables 
them  to  yield  or  slip  aside,  and  thus  the  consequences  are  usually 
insignificant. 

Rupture  or  Laceration  may  also  follow  blows  or  strains,  being  pre- 
disposed to  by  weakness  or  disease  of  the  arterial  wall.  It  occasion- 
ally results  from  fractures  or  dislocations,  or  from  attempts  to 
reduce  old-standing  dislocations,  or  to  break  down  intra-articular 
adhesions  when  the  vessel  has  become  fixed  in  some  abnormal 
position.  If  the  rupture  is  partial,  the  inner  and  middle  coats  are 
usually  torn  through,  and  by  projecting  into  the  lumen  of  the  vessel 
constitute  a  valve  which  prevents  the  passage  of  blood,  and  leads  to 
subsequent  thrombosis  and  occlusion.  In  cases  where  the  lesion  is 
limited  to  one  side  of  the  vessel,  the  clot  may  become  organized  over 
that  spot,  narrowing  but  not  interfering  with  the  lumen,  and  leaving 
an  area  of  weakness  from  which  an  aneurism  may .  subsequently 
develop.  A  dissecting  aneurism  (p.  310)  may  also  result  under 
special  circumstances  from  such  an  accident.  When  complicated 
with  a  septic  wound,  an  ulcerative  form  of  peri-arteritis  may  ensue, 
giving  rise  later  on  to  secondary  haemorrhage. 

Complete  Rupture  of  an  artery  often  leads  to  but  little  haemorrhage 
in  a  severe  lacerated  wound,  such  as  is  produced  when  a  limb  is 
torn  off :  the  inner  and  middle  coats  give  way  at  a  higher  level  than 
the  adventitia,  and  curl  up  within  it,  whilst  the  outer  coat  and  sheath 
contract  over  them,  and  thus  prevent  bleeding.  If,  however,  the 
artery  is  ruptured  in  a  subcutaneous  injury,  such  as  a  fracture  or 
dislocation,  extensive  extravasation  often  ensues,  constituting  the 
condition  badly  termed  a  Diffuse  Traumatic  Aneurism.    The  objection 


INJURIES  AND  DISEASES  OF  ARTERIES  299 

to  this  name  lies  in  the  fact  that  there  is  no  true  sac  wall  as  in  an 
aneurism,  the  only  boundary  consisting  of  an  ill-defined  mass,  partly 
coagulum,  partly  inflammatory  exudation,  and  in  part  thickened  and 
infiltrated  tissues.  A  similar  condition  may  ensue  from  a  punctured 
wound  dividing  a  vessel,  where  the  track  leading  to  it  is  valvular  or 
becomes  closed  by  clot  or  some  external  application. 

Symptoms. — The  patient  usually  feels  a  snap,  as  though  something 
had  given  way,  accompanied  by  a  sudden  pain,  localized  to  the  injured 
part,  and  often  shooting  down  the  limb  in  the  line  of  the  vessel. 
These  are  succeeded  by  the  following  phenomena:  {a)  Locally,  \he 
formation  of  a  diffuse,  rapidly  increasing  swelling,  the  skin  over 
which  is  at  first  normal,  but  soon  becomes  distended  and  bluish,  and 
finally  bright  red  and  oedematous,  when  the  tumour  is  threatening  to 
give  way.  There  is  no  increased  local  heat  except  in  the  later  stages. 
Distinct  pulsation  is  usually  present,  and  some  amount  of  thrill  and 
bruit,  synchronous  with  the  heart's  action,  although  these  subse- 
quently become  less  obvious,  (h)  Distally,  diminished  sensibility  in 
the  limb  quickly  follows,  together  with  loss  of  pulsation  in  the  vessels 
and  a  fall  of  temperature.  It  lies  more  or  less  useless  and  flaccid, 
and  in  colour  is  either  white  and  blanched,  or  may  be  congested  and 
cedematous  if  the  extravasated  blood  presses  upon  the  venous  trunks. 
{c)  Generally,  the  signs  of  haemorrhage  and  shock  manifest  themselves 
in  varying  degree,  according  to  the  amount  of  blood  lost  and  the 
character  of  the  violence. 

Results. — (i)  The  swelling  may  increase  steadily  in  size  until  the 
skin  becomes  so  distended  as  to  rupture  or  slough,  and  then,  if  help  is 
not  at  hand,  the  patient  dies  of  haemorrhage.  Occasionally  the 
bleeding  continues  into  an  internal  cavity,  or  into  the  tissues  of  a 
limb,  to  such  an  extent  as  to  cause  death  without  any  external  loss 
of  blood.  (2)  Suppuration,  accompanied  by  the  general  signs  of  fever, 
may  result  from  auto-infection,  or  from  the  entrance  of  bacteria 
through  the  small  valve-like  wound.  The  whole  swelling  becomes 
red,  hot,  oedematous,  and  excessively  tender,  looking  like  a  large 
abscess.  Rupture  and  external  haemorrhage  will  probably  conclude 
the  case  if  surgical  assistance  cannot  be  obtained.  (3)  The  pressure 
of  the  extravasated  blood  upon  the  veins  or  on  the  arteries  needed 
for  the  collateral  circulation  may  determine  gangrene  of  the  extremity, 
which  is  almost  always  of  the  moist  type.  (4)  The  process  may 
become  more  or  less  limited  after  a  time  by  coagulation  occurring  in 
the  divided  mouth  of  the  vessel,  which  is  thus  occluded.  Collateral 
circulation  may  be  established,  and  thereby  the  health  and  vitality  of 
the  limb  are  maintained,  whilst  the  blood-clot  is  absorbed  or  organized. 

The  Treatment  is  necessarily  the  same  as  for  a  divided  artery  com- 
municating with  an  open  wound,  viz.,  to  cut  down  and  tie  both  ends. 
The  circulation  is  first  temporarily  arrested  by  an  elastic  tourniquet, 
a  free  incision  made,  and  all  coagula  removed.  The  bleeding-points 
are  then  sought  for  and  tied,  the  tourniquet  being  relaxed  to  allow 
them  to  become  evident.  If  the  distal  end  cannot  be  found,  the 
wound  is  not  closed,  but  should  be  packed  with  gauze,  and  allowed 


300  A  MANUAL  OF  SURGERY 

to  granulate,  a  tourniquet  being  kept  loosely  about  the  limb  ready 
to  be  tightened  at  any  moment,  if  necessary.  When  suppuration  is 
threatening,  the  same  plan  must  be  adopted,  viz.,  free  incision  and 
tying  the  ends  of  the  vessel  if  they  can  be  found ;  but  in  cases  where 
from  the  cedematous  and  unhealthy  state  of  the  surrounding  parts 
this  is  impracticable,  it  will  be  necessary  either  to  tie  the  main  trunk 
on  the  cardiac  side  of  the  rupture,  or  to  trust  to  pressure.  If  gangrene 
is  imminent,  or  if  secondary  haemorrhage  occurs,  amputation  is  the 
only  resource. 

Penetrating  Wounds  of  arteries,  if  completely  dividing  the  vessel, 
are  always  followed  by  haemorrhage,  although  the  blood  may  be 
unable  to  escape  if  the  wound  in  the  skin  is  small  or  valvular,  or  if 
the  opening  is  closed  by  blood-clot  or  dressing ;  under  these  circum- 
stances, the  signs  due  to  subcutaneous  rupture  of  a  vessel  are  pro- 
duced. The  amount  of  bleeding  in  open  wounds  varies  according  to 
the  character,  direction,  and  extent  of  the  lesion,  and  with  the  size  of 
the  vessel.  If  a  large  artery  is  cleanly  cut  across,  the  bleeding  is 
copious,  whilst  from  a  small  vessel  it  soon  ceases,  owing  to  the  con- 
traction and  retraction  of  the  coats.  When  an  artery  is  buttonholed 
— i.e.,  when  a  small  segment  of  the  wall  is  cut  through — the  haemor- 
rhage is  often  continuous  and  prolonged,  since  retraction  cannot  take 
place.  The  treatment  of  this  condition  consists  in  completing  the 
division  of  the  injured  trunk,  if  it  is  a  small  one,  thus  allowing  of 
contraction  and  retraction,  or,  if  the  vessel  is  of  large  size,  in  tying  it 
above  and  below  the  opening,  and  dividing  it  between  the  ligatures. 

If  the  wound  is  in  the  long  axis  of  the  vessel,  it  gapes  but  Httle, 
and  the  loss  of  blood  is  often  slight,  whilst  if  transverse  or  oblique, 
both  contraction  and  retraction  tend  to  increase  the  size  of  the  open- 
ing, rendering  it  more  nearly  circular,  and  therefore  the  haemorrhage 
in  such  cases  is  considerable. 

If  a  small  artery  is  divided  close  to  its  origin  from  a  large  main 
trunk,  the  blood  escapes  with  a  jet,  the  strength  of  which  is  propor- 
tionate to  the  blood-pressure  in  the  main  trunk,  and  not  to  the  size,  of 
the  vessel  divided.  In  such  a  case  the  main  trunk  must  be  tied  above 
and  below  the  wound,  and  divided  between  the  ligatures,  and  the 
distal  end  of  the  divided  branch  also  secured. 

A  good  many  attempts  have  been  made  of  late  to  effect  the  union 
of  wounds  in  the  walls  of  arteries  without  causing  their  obliteration, 
and  with  some  success.  Small  longitudinal  wounds  may  certainly  be 
sutured,  the  stitches  being  of  the  finest  silk  and  applied  so  that  the 
edges  of  the  tunica  intima  are  brought  accurately  into  apposition; 
Heidenhain  reports  a  case  where  a  wound  1-5  centimetres  long  in  the 
axillary  artery  was  successfully  sutured  in  this  way.  End-to-end 
union  of  a  divided  artery  has  also  been  obtained  in  one  or  two  cases,* 
the  upper  end  being  invaginated  into  the  lower ;  such  a  procedure 
can,  however,  only  be  required  under  very  exceptional  circumstances. 

In  punctured  wounds  of  arteries  the  size  of  the  penetrating  body 
is  all-  important.  A  vessel  may  be  traversed  by  a  needle  without 
*  J.  B.  Murphy,  Medical  Record,  January  16,  1897. 


INJURIES  AND  DISEASES  OF  ARTERIES 


301 


haemorrhage  or  any  subsequent  ill  effect,  but  a  larger  puncture  results 
in  extravasation.  If  it  ceases  after  a  time,  the  blood-clot  is  absorbed, 
and  the  wound  in  the  vessel  closed  by  a  cicatrix,  which  may  subse- 
quently yield  to  the  blood-pressure,  and  give  rise  to  a  circumscribed 
aneurism.  This  occurrence  is  not  unf  requent  in  the  neighbourhood  of  the 
wrist  from  glass  wounds,  involving  the  radial  or  ulnar  trunks,  and  hence 
is  not  uncommon  among  window-cleaners  or  mineral-water  bottlers. 

Arterio- Venous  Wounds  are  not  so  frequent  in  the  present  day  as 
formerly,  when  venesection  was  in  vogue.  They  follow  penetrating 
wounds  which  involve  an  artery  and  vein  lying  in  close  contact,  e.g., 
at  the  bend  of  the  elbow  between  the  median  basilic  vein  and  the 
brachial  artery,  in  the  neck  between  the  internal  jugular  and  carotid, 


Fig.  93. — Diagrams  of  A,  Anedrismal  Varix  and  B,  Varicose  Aneurism. 
A,  Artery;  V,  vein;  AN,  aneurism. 

in  the  groin  between  the  femoral  vessels,  and  occasionally  in  the 
orbit.  They  are  also  met  with  in  military  surgery,  owing  to  the  shape 
of  the  modern  bullet  and  the  limited  amount  of  danger  caused  by  it 
in  the  soft  tissues.     Two  conditions  may  result. 

An  Aneurismal  Varix  is  produced  by  a  direct  communication  be- 
tween an  artery  and  a  vein,  no  dilated  passage  intervening  between 
the  vessels  (Fig.  93,^).  The  venous  walls,  unfitted  to  withstand 
arterial  pressure,  are  thereby  dilated  and  rendered  varicose.  A 
pulsating  venous  tumour  results,  the  dilatation  extending  for  a  variable 
distance  above  and  below  the  opening,  and  at  each  beat  of  the  heart, 
a  loud  whizzing  sound  can  be  heard,  likened  by  some  authors  to  that 
caused  by  an  imprisoned  bluebottle  buzzing  in  a  thin  paper  bag.  On  pal- 
pation the  thrill  of  the  blood  as  it  enters  the  vein  can  often  be  detected. 

Treatment. — Nothing  is  usually  required  beyond  the  application  of 
an  elastic  bandage  or  support  to  prevent  further  enlargement.  Should 
pain  or  inconvenience  arise  in  spite  of  this,  the  artery  should  be 
secured  above  and  below  the  abnormal  communication  with  the  vein. 
Occasionally  the  latter  is  so  distended  that  it  has  to  be  removed  before 
the  artery  can  be  reached.     This  operation  should  not  be  undertaken 


302  A   MANUAL  OF  SURGERY 

ill  the  neck  for  the  carotid-jugular  varix  unless  absolutely  essential. 
In  the  orbit  electrolysis  may  be  used  with  advantage. 

A  Varicose  Aneurism  differs  from  the  above  in  that  an  aneurismal 
sac  exists  between  the  artery  and  the  dilated  vein  (Fig.  93,  B),  It 
is  produced  when  the  vessels  are  placed  at  a  short  distance  from  each 
other,  or  when  extravasation  of  blood  has  separated  them.  The 
aneurism  is  of  the  false  type,  its  walls  being  composed  of  newly- 
formed  cicatricial  tissue  ;  it  is  almost  certain  to  become  diffuse.  The 
physical  signs  are  similar  to  those  of  aneurismal  varix,  except  that 
the  aneurism  can  be  sometimes  detected  by  palpation,  whilst  a  soft 
bruit  may  be  heard  over  it,  and  the  distension  of  the  veins  is  not  quite 
so  marked. 

Surgical  Treatment  is  always  required  in  these  cases.  Simple 
ligature  of  the  artery  above  and  below  the  abnormal  communication 
will  sometimes  suffice,  allowing  the  blood  in  the  sac  to  coagulate  ; 
the  veins  will  subsequently  diminish  in  size,  when  the  arterial  blood- 
pressure  is  removed.  Not  unfrequently  the  vein  overlaps  the 
artery,  and  has  to  be  tied  and  removed  before  the  sac  of  the  aneurism 
is  reached ;  it  is  then  better  to  excise  the  sac  and  tie  the  artery  above 
and  below.  In  the  less  urgent  cases  digital  pressure  to  the  artery 
above  the  sac  is  sometimes  successful. 

Inflammation  and  Degeneration  of  Arteries. 

1.  Traumatic  or  Plastic  Arteritis  is  the  result  of  some  injury,  such 
as  total  or  partial  division  of  the  vessel,  laceration,  bruising,  etc. 
The  phenomena  are  merely  those  of  repair,  resulting  in  occlusion  of 
the  vessel,  viz.,  congestion  of  and  exudation  into  the  vessel  walls  from 
the  vasa  vasorum,  together  with  proliferation  of  the  tunica  intima ; 
they  have  been  already  described  at  p.  282. 

2.  Infective  Arteritis  results  from  bacterial  invasion  of  the  arterial 
wall,  and  that  usually  from  without  (peri-arteritis)  and  in  connection 
with  septic  wounds  and  ligatures,  or  spreading  ulceration.  It  is 
characterized  by  hypersemia  and  softening  of  the  vascular  tunics,  the 
fibres  of  which  lose  their  cohesion  with  each  other,  owing  to  the 
peptonizing  action  of  the  toxins.  In  the  smaller  arteries  thrombosis 
usually  occurs  and  seals  the  vessel;  but  in  those  larger  than  the  radial 
there  is  considerable  danger  of  bleeding,  especially  if  the  irritation  is 
confined  to  one  side  of  the  vessel.  Secondary  hsemorrhage  from 
arteries  tied  in  their  continuity  is  generally  due  to  this  cause,  as  also 
bleeding  from  phthisical  cavities,  the  vessels  having  previously  lost  the 
support  of  surrounding  tissues,  and  being  more  or  less  dilated  or 
aneurismal. 

3.  Embolic  Arteritis. — When  a  vessel  is  blocked  by  a  simple 
embolus,  obliteration  as  the  result  of  a  simple  plastic  arteritis  is  the 
usual  consequence.  If  the  embolus  contains  infective  material,  as  in 
a  case  of  infective  endocarditis  or  pyaemia,  an  abscess  may  develop ; 
but  if  the  irritant  is  less  intense,  the  process  may  stop  short  of 
suppuration,  and  yet  an  aneurismal  dilatation  of  the  softened  wall 
takes  place.  The  latter  process  is  the  most  common  cause  of 
spontaneous  aneurism  in  children  and  young  adults. 


INJURIES  AND  DISEASES  OF  ARTERIES 


3'^3 


4.  Acute  Endarteritis  is  usually  associated  with  acute  endocarditis, 
however  produced.  It  is  evidenced  by  the  presence  on  the  inner  aspect 
of  the  vessel  of  more  or  less  raised  patches,  somewhat  pinkish  and 
gelatinous  in  appearance,  soft  and  elastic  in  consistency.  It  is  found 
in  the  aorta  or  in  smaller  vessels,  especially  near  inflamed  wounds. 

5.  Arterio-sclerosis  is  the  term  now  applied  to  a  degenerative  and 
inflammatory  affection  of  the  arteries,  formerly  known  as  chronic 
endarteritis.  It  usually  commences  about  middle  life,  and  is  in  many 
cases  merely  a  physiological  sign  of  the  incidence  of  senility  due 
to  the  wear  and  tear  of  life.  In  younger  patients  and  in  its  more 
severe  forms  it  generally  depends  on  some  form  of  chronic  intoxica- 
tion—^.g'.,  syphilis,  gout,  alcoholism,  lead-poisoning,  or  chronic 
Bright's  disease.  It  is  also  induced  by  excessive  and  particularly 
intermittent  muscular  strain ;  by  cachexia,  the  result  of  malignant 
disease,  tuberculosis,  or  inanition  ;  it  may  follow  as  a  sequela  of 
acute  infections,  such  as  enteric  fever  or  acute  rheumatism  ;  or  may 
arise  from  any  condition  which  leads 
to  persistent  increase  in  the  arterial 
tension. 

The  primary  changes  in  all  cases 
consist  probably  in  a  degenerative 
loss  of  elasticity  in  the  middle  and 
outer  coats,  which  is  followed  by  a 
secondary  hyperplasia  of  the  tunica 
intima.  The  later  changes  vary 
somewhat,  according  to  whether  the 
infection  is  localized  (nodular  variety) 
or  diffuse. 

Nodular  arterio-sclerosis  is  most  com- 
mon in  the  aorta  and  large  vessels, 
and  often  starts  in  the  convexity  of 
the  aortic  arch  at  the  spot  where  the 
impact  of  the  blood -stream  is  felt 
as  it  is  ejected  from  the  ventricles 
(Fig.  94),  or  in  places  where  the 
vessel  passes  over  or  around  some 
bony  projection,  or  at  the  bifurcation 
of  a  main  artery,  or  where  a  large 
branch  is  given  off,  thus  causing  a 
sudden  decrease  in  lumen.  In  the  early  stages  scattered  raised 
patches  are  seen  on  the  inner  lining  of  the  vessel,  translucent  and 
greyish  in  aspect,  and  of  variable  size ;  the  overlying  endothelium  is 
smooth  and  intact.  In  the  later  stages  fibrosis  m.ay  occur  in  the 
patch,  which  becomes  dull  white  in  colour,  and  at  length  calcification 
may  ensue,  giving  rise  to  an  atheromatous  plate.  In  other  cases  the 
process  may  be  followed  by  fatty  degeneration,  the  patches  becoming 
yellowish  in  colour  and  irregular  in  outline ;  they  are  small  at  first, 
but  increase  in  size,  and  coalesce  one  with  another.  The  contents 
are  now  fluid  or  cheesy  in  consistency,   constituting  the  so-called 


Fig.  94. — Atheroma  of  Aorta. 


304 


A  MANUAL  OF  SURGERY 


'  atheromatous  abscess  '  (Gr.  aOiqpr},  '  gruel '  or  '  pap  '),  although  no 
true  pus  exists,  the  pultaceous  material  consisting  of  fatty  granules 
and  debris,  with  oil  globules  and  plates  of  cholesterine  (Fig.  95,/^). 
It  may  be  absorbed  entirely,  leaving  a  weakened  spot  in  the  wall  of 
the  vessel,  from  which  an  aneurism  may  arise  ;  or  the  tunica  intima 
may  give  way  over  it,  allowing  the  contents  to  be  swept  into  the 
general  circulation,  where  it  probably  does  no  harm,  and  the  raw 
surface  left  behind  is  known  as  an  '  atheromatous  ulcer.'  The  outer 
coat  has  by  this  time  become  thickened,  and  hence  no  immediate  ill 
result  follows  the  breach  in  the  inner  coats,  although  subsequently 


Fig. 


g^, — Section  of  Atheromatous  Cerebral  Artery. 

(ZlEGLER,) 


X  50. 


a  Intima  considerably  thickened  ;  h,  bounding  elastic  lamella  of  intima  ;  c,  media  ; 
d,  adventitia  ;  e,  necrosed  denucleated  tissue  with  masses  of  fatty  detritus  ; 
/and /I,  detritus  with  cholesterine  tablets  ;  g,  intima  infiltrated  with  leuco- 
cytes ;  /?,  infiltration  of  adventitia  with  leucocytes. 

dilatation  may  take  place,  even  though  cicatrization  of  the  ulcer  has 
occurred.  Again,  the  blood  may  find  its  way  through  the  opening 
into  the  substance  of  the  wall  and  strip  up  the  inner  from  the  outer 
layers,  constituting  a  '  dissecting  aneurism ' ;  or  a  localized  thrombus 
may  form,  causing  occlusion  of  the  vessel. 

Not  uncommonly  the  cheesy  contents  of  the  abscess  become 
inspissated,  and  later  on  infiltrated  with  lime  salts,  resulting  in  the 
formation  of  calcareous  plates,  which  are  either  covered  with  endo- 
thelium, or  exposed  to  the  blood-stream,  and  hence  may  cause 
thrombosis,  or  become  detached  as  an  embolus,  or  the  blood  may 
get  in  under  the  plate  and  form  a  dissecting  aneurism. 


INJURIES  AND  DISEASES  OF  ARTERIES 


305 


Diffuse  Afterio- sclerosis  occurs  in  elderly  individuals,  commonly  in 
the  smaller  vessels,  and  may  be  associated  with  the  nodular  variety 
in  the  aorta.  The  changes  are  similar  to  those  described  above,  but 
usually  terminate  in  fibrosis  and  contraction  of  the  lumen  of  the 
vessel ;  the  changes  in  the  intima  are  followed  by  thickening  of  all 
the  coats,  but  degenerative  phenomena  are  unusual.  In  the  smaller 
arteries  of  the  brain  this  change  may  progress  to  such  an  extent 
as  to  interfere  seriously  with  the  functions  of  the  part ;  whilst  in  the 
vessels  of  the  limbs  the  condition  may  result  in  the  occurrence  of 
what  is  known  as  Endarteritis  obliterans,  and  may  lead  to  gangrene  of 
the  limb.  In  some  instances  even  the  main  trunks  may  be  involved 
in  this  affection. 

6.  Chronic  Syphilitic  Endarteritis  is  chiefly  met  with  in  the  tertiary 
stage,  and  is  characterized  by  an  overgrowth  of  the  tunica  intima 
(Fig.  g6,  a),  which  is  sub- 
sequently associated  with 
infiltration  of  the  media  {c), 
and  much  more  so  of  the 
adventitia  (i).  The  change 
occurs  in  small  arteries, 
especially  those  of  the 
brain  or  kidneys,  or  in  the 
neighbourhood  of  gummata 
(Fig.  97),  and  but  rarely  in 
the  larger  vessels,  although 
a  considerable  percentage 
of  individuals  affected  with 
internal  aneurism  have  suf- 
fered from  syphilis.  It  dif- 
fers from  simple  atheroma 
(i)  in  attacking  small 
arteries ;  (2)  in  affecting 
the  whole  circumference  of 
the  vessel,  and  not  merely 
patches  ;  (3)  the  newly  - 
formed  tissue  becomes 
vascular,  and  does  not  un- 
dergo fatty  degeneration  ; 
and  (4)  it  leads  to  narrow- 
ing or  occlusion  of  the  vessel 
rather  than  to  weakening 
and  dilatation.  When  in- 
volving the  cerebral  arteries,  various  forms  of  monoplegia,  or  even 
hemiplegia,  may  result. 

7.  Chronic  Tuberculous  Endarteritis  is  met  with  as  a  proliferation 
of  the  tunica  intima,  with  or  without  thickening  of  the  adventitia,  in 
all  places  in  which  tubercle  is  actively  developing ;  in  fact,  tubercles 
are  often  formed  around  arterioles,  and  as  the  mass  grows  the  vessel 
is  slowly  occluded  and  replaced  by  the  typical  anatomical  structure 

20 


Fig.  96. — Syphilitic  Arteritis,      x  150. 

(ZlEGLER.) 

a,  Intima  greatly  thickened  by  newly-formed 
fibro-cellular  tissue  ;  b,  fenestrated  elastic 
lamina  of  Henle  ;  c,  muscle  fibres  of  media, 
infiltrated  towards  the  left ;  d,  adventitia 
thickened  by  cell  infiltration  and  hyper- 
plasia. 


3o6  A  EI  AN  UAL  OF  SURGERY 

of  the  miliary  tubercle.  The  tuberculous  endarteritis  may,  however, 
spread  widely  beyond  the  focus  of  the  mischief,  and  in  almost  any 
portion  of  pulpy  granulation  tissue  this  change  can  be  seen. 

8.  Primary  Calcareous  Degeneration  (Fig.  98)  is  chiefly  met  with 
in  the  smaller  arteries  of  the  extremities.  It  occurs  in  elderly  people 
at  the  same  time  of  life  as  the  calcification  of  cartilages,  etc.,  and 
commences  by  the  deposit  of  lime  salts  in  the  muscular  fibres  of  the 
tunica  media,  constituting  a  series  of  calcareous  rings  which  transform 
the  elastic  expansile  vessels  into  rigid  tubes  like  gas-pipes,  through 
which  alone  can  pass  a  fixed  and  unchangeable  minimal  supply  of 
blood.     It  is  often  associated  with  generalized  arterio-sclerosis. 

The  affected  limb  passes  into  a  condition  of  chronic  anaemia  and 
impaired  nutrition,  resulting  in  coldness  of  the  feet  or  hands,  cramps 
and  spasms  of  muscles,  sensations  of  pins  and  needles,  etc.     The 


Fig.  97.- — Syphilitic  Endarteritis  from  near  a  Gumma.       x  120. 

endothelium  is  not  removed  except  in  the  later  stages,  and  then 
thrombosis  may  be  produced,  or  a  similar  result  may  arise  from  the 
lodgment  of  an  embolus.  Senile  gangrene  is  a  common  termination. 
From  the  general  rigidity  of  the  vessel,  and  the  method  of  deposit  of 
the  lime  salts,  it  follows  that  aneurism  is  not  likely  to  occur. 

g.  Fatty  Degeneration  occurs  independently  of  atheroma,  involving 
merely  the  tunica  intima,  and  manifesting  itself  in  small  patches, 
yellowish  in  colour  and  stellate  in  shape.  As  a  rule,  it  is  of  but  little 
significance  ;  but  occasionally  the  infiltration  is  deeper,  and  the  tunica 
intima  gives  way,  causing  the  so-called  faity  erosion,  and  then  an 
aneurism,  possibly  of  the  dissecting  type,  may  arise.  The  most  usual 
seat  of  this  trouble  is  the  aorta. 

10.  Amyloid  Degeneration  of  the  viscera  commences  in  the  arterial 
walls,  but  is  described  elsewhere  (p.  74). 


INJURIES  AND  DISEASES  OF  ARTERIES 


307 


The  Effects  of  Arterial  Inflammation  and  Degeneration  are  both 
local  and  peripheral.  Locally,  Thrombosis  may  be  produced  whenever 
the  lining  endothelium  is  removed  and  a  raw  surface  exposed,  upon 
which  fibrin  can  collect.  Under  this  fibrinous  coating  repair  is  often 
effected  without  further  complication :  but  if  the  blood-stream  is 
retarded,  or  the  lumen  of  the  tube  narrowed,  complete  thrombosis 
may  follow,  the  clot  extending  some  distance  up  or  down  the  vessel, 
or  even  from  a  branch  into  the  main  trunk,  which  may  be  blocked  by 
this  means.  Aneurism  is  also  a  result  of  any  weakening  of  the 
arterial  tunics.  Obliteration  of  the  artery  is  caused,  either  by  throm- 
bosis, or  by  excessive  proliferation  of  the  tunica  intima  (as  in  syphilitic 


Fig.  q8. 


-Primary  Calcareous  Degeneration  of  Arteries.     (From 
College  of  Surgeons'  Museum.) 


or  tuberculous  disease),  or  by  gradually  increasing  pressure  from 
vv^ithout.     Lastly,  Spontaneous  Rupture  is  occasionally  produced. 

Peripherally,  defective  blood-supply  and  consequent  lowered  vitality 
are  the  most  marked  results  of  arterial  disease,  leading  to  various 
forms  of  ulceration  and  gangrene.  Thus,  senile  gangrene  is  due  to 
calcareous  changes  in  the  arteries,  fatty  degeneration  of  the  heart 
follows  atheroma  of  the  coronary  arteries,  whilst  softening  of  the 
brain  may  ensue  from  various  affections  of  the  cerebral  vessels. 
Similar  results  may  also  arise  from  emboli  detached  from  areas  of 
local  disease. 


3o8  A  MANUAL  OF  SURGERy 

Aneurism. 

An  Aneurism  is  a  tumour  filled  with  blood  communicating  with  the 
interior  of  an  artery,  and  due  to  dilatation  of  part  or  the  whole  of  the 
vessel  walls. 

Causes. — i.  Changes  in  tlie  Vessel  Walls,  by  which  their  resistance 
to  the  intravascular  pressure  is  diminished.  Many  varieties  of 
disease,  e.g.,  atheroma,  predispose  to  aneurismal  dilatation,  especially 
if  occurring  in  syphilitic  or  gouty  men  about  middle  life,  in  whom, 
although  the  arterial  tunics  may  be  weakened,  the  power  of  the  heart 
and  the  resulting  blood-pressure  are  by  no  means  diminished.  The 
difTuse  form  of  arterio-sclerosis  (often  associated  with  calcification)  of 
the  peripheral  arteries  is  antagonistic  to  aneurismal  dilatation.  Any 
injury,  a  contusion,  a  penetrating  wound,  or  a  strain,  may  so  interfere 
with  the  integrity  of  the  vascular  coats  as  to  result  in  aneurism,  and, 
indeed,  a  cicatrix  in  an  arterial  wall  must  always  be  looked  on  as 
a  weak  spot  predisposing  to  dilatation.  The  lodgment  of  an  infected 
embolus  in  the  smaller  arteries  is  stated  to  be  one  of  the  most  common 
causes  of  spontaneous  aneurism  in  young  people. 

2.  Increase  in  the  Blood-Pressure  is  another  factor,  especially  when 
due  to  heavy  stain  or  exertion,  which  leads  to  irregular  excitement 
and  increased  action  of  the  heart.  Steady  laborious  employment, 
such  as  is  seen  amongst  artisans  and  mechanics,  or  regular  exercise, 
does  not  appear  to  predispose  to  this  condition ;  but  irregular  inter- 
mittent efforts,  in  which  for  the  time  being  every  power  is  strained 
to  its  utmost,  are  very  liable  to  determine  its  occurrence.  A  day's 
exertion  in  the  hunting  or  shooting  field  by  an  elderly  man,  accustomed 
to  sedentary  occupations,  is  often  the  cause  of  some  vascular  lesion, 
such  as  aneurism,  apoplexy,  etc.  Hence  aneurisms  are  more  fre- 
quently seen  amongst  men  than  in  women,  in  the  proportion  of  seven 
to  one  ;  whilst  they  are  much  more  common  among  the  dwellers  in 
Northern  climates  than  in  the  more  lethargic  and  ease-loving  inhabi- 
tants of  the  South.  The  energy  and  activity  of  the  Anglo-Saxon 
race  especially  predispose  them  to  this  disease. 

Structure  of  an  Aneurism. — The  sac  consists  more  or  less  evidently 
of  a  distension  of  all  or  part  of  the  original  walls  of  the  vessel  whilst 
it  is  sma.ll ;  but  as  the  aneurisn  increases,  the  original  structure  is 
replaced  by  a  mass  of  newly-formed  fibrous  tissue,  due  to  a  con- 
densation and  matting  together  of  the  surrounding  structures,  with 
or  without  an  internal  lining  of  laminated  fibrin  deposited  on  parts 
where  the  endothelium  has  disappeared.  The  contents  of  the-  sac 
depend  on  the  character,  age  and  size  of  the  aneurism.  Whilst  still 
small  and  with  a  complete  endothelial  lining,  it  contains  fluid  blood  ; 
but  as  the  tumour  grows,  and  especially  if  of  the  sacculated  type, 
fibrin  is  deposited  in  layers  which  gradually  encroach  on  the  cavity, 
and  may  in  time  completely  fill  it,  so  that  in  rare  cases  a  spontaneous 
cure  results.  The  oldest  laminae  are  dry  and  yellowish-white  in 
colour ;  those  more  recently  deposited  are  softer  and  more  reddish, 
whilst  the  last  formed  is  merely  like  ordinary  blood  coagulum.     No 


ANEURISM 


309 


single  lamina  covers  the  whole  area,  but  layer  is  arranged  over 
layer  (Fig.  99)  in  such  a  manner  that  the  oldest  and  necessarily  the 
smallest  laminae  are  nearest  to  the  sac  wall. 

Three  chief  forms  of  aneurism  have  been  described :  the  fusiform, 
sacculated,  and  dissecting. 

I.  The  Fusiform  Aneurism  (Fig.  100,  A)  is  one  in  which  the  whole 
lumen  of  the  vessel  is  more  or  less  equally  expanded,  so  that  the 
swelling  is  tubular  in  character.  It  is  due  rather  to  a  general  increase 
of  blood-pressure,  or  to  a  widely  extended  disease  of  the  arterial  walls, 
than  to  any  localized  lesion  or  injury,  and  hence  is  more  commonly 


Fig.  99. —  Sacculated  Aneurism.     (Museum  of  Royal  College  op 
Surgeons.) 

The  small  mouth  of  the  saccule  is  clearly  seen,  and  the  cavity  is  nearly  filled 
with  laminated  clot. 

met  with  in  the  larger  internal  vessels  than  in  those  of  the  extremities- 
The  tunica  intima  is  usually  represented  throughout  the  whole  extent 
of  the  sac,  but  is  thickened  and  atheromatous  in  patches,  the  margins 
and  surfaces  of  calcareous  plates  being  indicated  by  flocculi  of  fibrin, 
which  are  attached  to  them,  although  no  regular  laminated  deposit 
may  be  present.  The  tunica  media  is  stretched,  atrophied,  and  in 
the  later  stages  practically  non-existent,  whilst  the  adventitia  is  much 
thickened  by  inflamrriatory  new  formation  and  by  incorporation  with 
the  surrounding  tissues.  The  progress  of  fusiform  aneurisms  is 
generally  slow,  so  that  in  some  situations,  e.g.,  the  thorax,  they  may 


3IO  A  MANUAL  OF  SURGERY 

attain  enormous  dimensions,  and  cause  grave  pressure  symptoms. 
A  natural  cure  is  almost  impossible,  and  hence,  if  unchecked  by 
treatment,  a  fatal  termination  is  caused  by  rupture  or  by  implication 
of  important  neighbouring  structures.  Frequently  one  portion  of 
the  aneurismal  wall  yields  more  than  another,  and  thus  a  localized 
sacculation  is  superadded,  which  by  its  rapid  increase  in  size  may 
destroy  life. 

2.  A  Sacculated  Aneurism  (Figs.  99  and  100,  B)  is  due  to  the  yield- 
ing of  some  weak  patch  in  the  vessel  wall  which  does  not  involve  the 
whole  circumference,  or,  as  just  mentioned,  it  may  spring  from  a 
fusiform  aneurism.  It  communicates  with  the  interior  of  the  artery 
by  an  opening  of  variable  size.     All  traumatic  aneurisms,  whether 


A  B  C 

Fig.  ICO. — Diagrams  of  Fusiform,  Sacculated,  and  Dissecting  Aneurisms. 

In  the  fusiform  (A)  the  walls  are  expanded,  but  more  or  less  normal  in  texture ; 

in  the  sacculated  (B),  the  normal  structure  of  the  arterial  wall  ceases  abruptly 

at  the  commencement  of  the  saccule  ;  in  the  dissecting  (C),  the  arterial  wall 

is  split  into  two  lamellae. 
The  interrupted  fine  line  is  supposed  to  represent  the  intima  ;  the  continuous 

dark  line,  the  media  ;  and  the  continuous  fine  line,  the  adventitia. 

due  to  the  yielding  of  a  cicatrix,  or  to  the  partial  division  of  the  coats 
of  the  vessel,  are  of  this  type,  which  is  hence  found  most  commonly 
in  the  extremities.  The  inner  and  middle  coats  can  usually  be  traced 
as  far  as  the  mouth  of  the  saccule,  but  there  they  are  suddenly  lost, 
the  wall  being  constituted  by  a  mass  of  fibro-cicatricial  tissue,  upon 
which  laminated  fibrin  readily  forms,  thus  increasing  its  thickness 
and  power  of  resistance.  Their  progress  is,  however,  much  more 
rapid  than  that  of  the  fusiform,  generally  ending  in  rupture  or 
diffusion,  although  occasionally  a  natural  cure  results. 

3.  A  Dissecting  Aneurism  (Fig.  100,  C)  is  one  in  which  the  blood 
forms  a  cavity  within  the  wall  of  the  vessel  by  stripping  up  the  inner 
from  the  outer  half,  the  line  of  cleavage  being  within  the  middle 
coat,  half  going  with  the  adventitia,  half   with  the  intima.     It  is 


ANEURISM 


311 


usually  the  result  of  extensively  diffused  atheroma.  The  blood  thus 
driven  into  a  cul-de-sac  may  remain  limited  to  this  cavity  for  some 
time,  or  it  may  find  its  way  outwards  and  become  diffused,  or  burst 
back  through  another  atheromatous  spot  into  the  interior  of  the 
vessel.  The  condition  occurs  chiefly  in  the  thoracic  or  abdominal 
aorta,  but  cannot  be  recognised  ante-mortem. 

Symptoms  and  Signs  of  a  Circumscribed  Aneurism.— These  may  be 
divided  into  two  groups  :  the  intrinsic  and  extrinsic. 

Intrinsic  Signs. — -A  tumour,  pulsating  synchronously  with  the  heart's 
beat,  is  present  in  the  course  of  a  vessel.  The  pulsations  are  distensile 
or  expansile  in  character,  i.e.,  the  whole  tumour  increases  in  size  at 
each  systole,  and  that  evenly  in  all  directions,  so  that  if  the  tumour 
is  lightly  grasped  in  any  position  the  fingers  are  separa.ted.  A  definite 
thrill  can  often  be  felt  as  the  blood  enters  the  sac  at  each  heart-beat. 
If  the  supplying  vessel  is  compressed  on  the  proximal  side,  the  pulsa- 
tion ceases,  and  the  tumour  diminishes  in  size  and  becomes  softer ; 
this  is  more  marked  in  fusiform  than  in  sacculated  aneurisms.  The 
application  of  pressure  to  the  sac  itself,  whilst  the  afferent  trunk  is 
compressed  above,  may  still  further  diminish  its  size.  On  removing 
the  pressure,  the  swelling  regains  its  old  dimensions  in  a  certain 
definite  number  of  beats,  usually  not  more  than  two  or  three. 
Pressure  on  the  distal  side  of  the  sac  makes  it  more  tense  and  the 
pulsation  more  marked,  unless  such  compression  is  very  prolonged. 
On  auscultating  the  tumour,  a  bruit  of  variable  character  may  be 
heard ;  usually  it  is  loud,  harsh,  and  systolic,  but  sometimes  quiet 
and  musical.  It  is  occasionally  double  in  some  forms  of  sacculated 
aneurism,  and  in  the  aorta  when  regurgitation  through  the  aortic 
valves  is  also  present.  The  bruit  is  loudest  and  most  rasping  in  the 
fusiform  variety,  and  may  be  absent  in  the  sacculated  form,  v/hen 
the  mouth  is  small  and  the  cavity  nearly  full  of  clot.  Great  disten- 
sion of  the  sac  is  unfavourable  to  the  production  of  a  bruit. 

The  Extrinsic  Signs  of  aneurism  are  those  occurring  in  neigh- 
bouring or  distal  structures  from  its  constantly  increasing  size  and 
pressure,  and  the  interference  produced  by  it  with  the  circulation. 
The  pulse  on  the  distal  side  is  diminished  and  delayed,  its  diminution 
being  caused  partly  by  the  obstruction  experienced,  but  also  in  some 
cases  by  the  pressure  of  the  sac  upon  the  trunk  above  or  below  the 
tumour.  The  delay  is  due  to  the  interference  with  the  transmission 
of  the  heart's  impulse  by  the  intervention  of  the  aneurismal  sac. 
The  smaller  vessels  engaged  in  establishing  collateral  circulation 
may  be  compressed  by  the  sac,  and  thus  the  vitality  of  the  limb 
impaired.  Pressure  on  the  accompanying  vein  or  veins  results  in 
diminution  of  their  calibre,  and  possibly  a  localized  thrombosis, 
together  with  distal  congestion  and  oedema.  Compression  of  nerves 
occasions  neuralgia,  spasm,  or  paralysis.  Muscles  are  displaced, 
expanded,  and  attenuated ;  hones  may  be  eroded,  as  evidenced  by  a 
deep,  constant,  boring  pain,  and  even  spontaneous  fracture  may 
ensue ;  whilst  joints  are  encroached  upon  and  disorganized.  Tubes, 
such  as  the  trachea  or  oesophagus,  are  often  constricted  and  even 


312 


A  MANUAL  OF  SURGERY 


laid  open  by  ulceration.  It  is  interesting  to  note  that  resisting 
tissues,  like  bone,  are  much  more  liable  to  be  eroded  than  elastic, 
yielding  structures,  such  as  cartilage,  and  in  cases  where  the  vertebral 
column  is  encroached  upon  by  an  abdominal  or  thoracic  aneurism, 
the  bones  are  always  destroyed  more  than  the  intervertebral 
discs. 

A  certain  amount  of  compensatory  hypertrophy  of  the  heart  is 
often  present.  Fibrinous  masses  are  occasionally  set  free  as  emboli, 
and  lead  either  to  a  spontaneous  cure,  or  to  gangrene  of  the  parts 
supplied  by  the  vessel,  or  to  death  if  the  brain  is  involved.  Gangrene 
may  result  from  the  diminished  blood-supply  to  peripheral  parts ;  it 
is  usually  of  the  dry  type,  involving  merely  one  or  two  fingers  or 
toes,  unless  the  veins  are  also  compressed,  when  it  may  be  of  the 
moist  variety. 

The  Differential  Diagnosis  of  a  circumscribed  aneurism  is  usually 
not  difficult,  but  the  following  conditions  may  simulate  it  somewhat 
closely  :  I.  A  tumour  or  chronic  abscess  situated  near  an  artery,  and 
deriving  transmitted  pulsation  from  it,  is  recognised  by  the  impulse 
being  merely  heaving  in  character,  and  not  expansile ;  by  the  pulsa- 
tion ceasing  entirely  if  the  tumour  is  lifted  from  the  vessel,  or  allowed 
to  fall  away  from  it  by  assuming  a  suitable  position ;  by  the  size  of 
the  tumour  not  diminishing  if  the  pulsation  is  stopped  by  pressure 
on  the  vessel  above  ;  and  by  the  fact  that  after  stoppage  of  the 
pulsation  the  first  beat  is  equal  to  the  subsequent  ones,  whereas  in 
an  aneurism  it  almost  always  requires  more  than  one  beat  to  re- 
establish the  strength  and  force  of  the  impulse.  Moreover,  the  pulse 
below  is  not  affected  in  the  same  way  or  to  the  same  extent  as  when 
an  aneurism  is  present.  2.  An  artery  is  sometimes  pushed  forwards  by 
an  underlying  growth,  and  its  pulsation  in  a  more  than  usually  super- 
ficial position  may  suggest  an  aneurism.  The  distinguishing  features 
are  the  limitation  of  the  pulsation  to  the  line  of  the  vessel,  and  the 
absence  of  pulsation  in  the  underlying  growth.  3.  K  pulsating  sarcoma 
or  ncBvus  is  known  by  being  rarely  limited  exactly  to  the  line  of  the 
artery,  pulsation  being  present  in  situations  where  an  aneurismal 
dilatation  could  not  be  felt,  and  being  less  forcible  and  regular  in  its 
character.  The  consistency  of  the  swelling  is  more  variable,  and 
pressure  over  the  afferent  trunk  does  not  diminish  its  size  to  any 
marked  extent.  Moreover,  a  sarcoma  is  usually  more  adherent  to 
the  deeper  structures,  and  its  limits  are  not  so  accurately  defined. 
4.  The  pain  caused  by  an  aneurism  may  lead  it  to  be  mistaken  for 
rheumatism  or  neuralgia  {e.g.,  for  sciatica  in  popliteal  aneurism),  and  in 
every  case  of  obstinate  pain  of  this  kind  the  arteries  should  always 
be  carefully  examined. 

Natural  Terminations  and  Results. — i.  Spontaneous  Cure,  though 
very  unusual,  may  occur  in  sacculated  aneurisms,  {a)  It  maybe  due 
to  the  gradual  deposit  within  the  sac  of  fibrin,  which,  in  the  first 
place,  limits  the  expansion  and  extension  of  the  aneurism,  but  may 
finally  increase  to  such  an  extent  as  to  occupy  the  whole  cavity  and 
close  up  its  mouth.     This  condition  can  only  obtain  in  saccules  with 


ANEURISM 


313 


small  mouths,  and  in  vessels  of  the  second  magnitude,  hardly  ever  in 
the  aorta  or  larger  trunks,  the  impetus  of  the  blood-stream  being  too 
great  to  permit  of  the  necessary  deposit  of  fibrin,  [h)  It  may  arise  as 
the  result  of  the  sudden  coagulation  of  all  the  blood  in  the  sac  from 
the  stoppage  of  the  circulation,  owing  to  the  lodgment  of  an  embolus 
either  at  the  mouth  of  the  aneurism  or  in  the  trunk  immediately  below, 
(c)  The  aneurism  may  become  so  large  as  to  compress  the  main  vessel, 
either  going  to  or  coming  from  it,  thus  bringing  about  its  own  cure. 
{d)  Again,  if  the  sac  becomes  inflamed,  consolidation  may  occur  with 
or  without  suppuration,  although  the  latter  process,  as  will  be  seen 
anon,  is  attended  with  serious  danger  to  life  and  limb. 

In  the  non-inflammatory  conditions  the  sac  becomes  more  and  more 
firm,  the  pulsation  less  forcible  and  distinct,  the  bruit  diminishes,  and 
finally  consolidation  is  effected,  a  firm  fibroid  tumour  alone  remain- 
ing, which  gradually  shrinks,  whilst  the  collateral  circulation  is 
opened  up  so  as  to  supply  the  limb  below.  It  is  sometimes  by 
no  means  easy  to  recognise  the  fibroid  mass  resulting  from  the 
spontaneous  consolidation  of  an  aneurism,  and  in  making  a  diagnosis 
the  history  has  mainly  to  be  depended  on.  The  existence  of  a  tumour 
in  the  line  of  an  artery,  the  probable  occlusion  of  the  main  trunk, 
and  the  fact  that  the  circulation  is  carried  on  by  means  of  collateral 
branches,  are  the  chief  points  which  can  be  ascertained  by  a  physical 
examination. 

2.  Diffusion  and  Rupture  result  from  yielding  of  the  walls  of  an 
aneurism,  as  an  outcome  of  .some  mechanical  injury  or  from  simple 
over-distension. 

When  an  internal  aneurism  gives  way,  the  patient  usually  ex- 
periences a  sensation  of  pain  in  the  part,  and  becomes  pale,  cold, 
and  faint,  possibly  dying  within  a  few  minutes  or,  at  most,  hours ; 
or  there  may  be  a  sudden  gush  of  blood  from  the  mouth  if  the 
trachea  or  oesophagus  has  been  opened.  Sometimes  internal 
aneurisms  leak  slowly,  and  the  final  stage  lasts  some  days. 

When  an  external  aneurism  yields,  it  may  do  so  slowly  or  quickly. 
If  the  blood  becomes  effused  slowly  (constituting  what  is  sometimes 
called  a  leaking  anetivisni),  the  tumour  gradually  increases  in  size,  and 
its  outline  is  less  clearly  limited ;  the  pulsation  diminishes  in -force 
and  distinctness,  and  the  signs  of  pressure  upon  the  veins  or  nerves 
become  more  urgent,  until  gangrene  sometimes  supervenes.  If  the 
aneurism  ruptures  suddenly,  the  patient  experiences  severe  pain  in 
the  part  which  becomes  tense,  swollen,  and  brawny  ;  all  pulsation 
ceases,  both  in  the  aneurism  and  below  it,  and  gangrene  of  the  limb 
follows,  or  even  death  from  syncope,  arising  from  the  amount  of 
blood  extravasated,  either  externally  if  the  skin  gives  way,  or  into 
the  tissues  and  under  the  fasciae.  Suppuration  may  also  occui  in 
these  cases. 

3.  Suppuration  is  an  exceedingly  serious,  but  by  no  means  a  usual, 
complication.  It  may  arise  in  the  following  ways  :  {a)  After  ligature 
of  the  main  vessel,  especially  when  the  wound  becomes  septic,  and 
there  is  a  good  deal  of  loose  cellulur  tissue  around  the  sac,  as  in 


314  ^  MANUAL  OF  SURGERY 

the  axilla ;  (b)  after  diffusion,  partial  or  complete,  of  an  aneurism, 
where  there  is  great  tension  upon  surrounding  parts.  Auto-infection 
or  the  presence  of  an  infective  embolus  may  finally  determine  the 
suppurative  process.  The  tumour  shows  signs  of  inflammation, 
becoming  hot,  red,  painful,  and  swollen,  and  the  skin  over  it  may 
pit  on  pressure  ;  whilst  fever  and  general  constitutional  disturbance 
are  also  present.  Sooner  or  later,  if  left  to  itself,  the  tumour  points 
at  one  spot  and  bursts,  giving  exit  to  a  mixture  of  blood-clot,  pus, 
and  a  greater  or  less  amount  of  bright  red  blood.  The  patient  either 
dies  at  once  from  syncope,  or  a  little  later  from  secondary  haemor- 
rhage and  septic  poisoning,  unless  efficient  treatment  is  adopted. 
Occasionally,  but  very  rarely,  the  aff"erent  trunk  becomes  plugged  by 
a  thrombus,  and  spontaneous  cure  may  thereby  be  induced. 


Treatment  of  Aneurisms. 

I.  General  Treatment  is  employed  as  an  accessory  to  surgical 
measures,  or  must  be  depended  on  entirely  in  cases  where  local 
means  are  impracticable  or  contra-indicated,  such  as  an  internal 
aneurisms.  The  general  condition  of  the  patient  must  be  carefully 
investigated,  since  aneurisms  are  associated  either  with  plethora  or 
with  an  enfeebled  and  cachectic  state  of  the  system. 

In  plethoric  individuals,  where  the  disease  often  runs  a  rapid 
course,  absolute  rest,  both  mental  and  physical,  must  be  enjoined, 
with  the  removal  of  all  sources  of  irritation  and  v/orry.  The 
bowels  should  be  kept  gently  open,  and  constipation  and  straining 
avoided.  The  heart's  impulse  may  be  diminished  by  the  use  of 
aconite,  or  even  by  venesection  when  it  is  very  forcible.  Iodide  of 
potassium  is  usually  prescribed,  on  account  of  the  frequent  associa- 
tion of  aneurism  with  syphilis  ;  and  calcium  lactate  (grs.  5,  t.d.s.) 
may  be  useful  in  increasing  the  coagulability  of  the  blood.  The  diet 
must  be  suitably  diminished,  and  only  highly  nutritious  material 
allowed,  and  that  mainly  of  the  nitrogenous  type,  with  as  little  fluid 
as  possible  (not  more  than  about  a  pint  a  day). 

In.  weakly  individuals,  whilst  strictly  enjoining  a  recumbent  posture, 
the  surgeon  should  prescribe  iron  and  a  somewhat  more  liberal  diet, 
in  order  to  improve  the  quality  of  the  blood. 

II.  Surgical  Treatment. — Whichever  of  the  plans  described  below 
is  selected  in  any  particular  case,  the  general  health  must  be 
carefully  attended  to,  and  the  condition  of  internal  organs  fully 
investigated  beforehand,  as  great  harm  may  follow  injudicious 
interference,  if  internal  aneurisms  co-exist. 

A.  The  ideal  treatment  consists  in  dealing  with  the  arterial  wall 
so  as  to  obliterate  the  aneurism,  but  without  occluding  the  original 
lumen  of  the  vessel.  This  is  possible  in  a  few  selected  cases  of 
sacculated  aneurism,  and  a  method  of  Afteriovyhaphy  has  been 
suggested  and  practised  by  Matas*  of  New  Orleans  for  this  purpose, 

*  Annals  of  Surgery,  February,  1903. 


ANEURISM  3i£ 

in  which  the  aneurismal  wall  is  sutured  up  into  pleats.  Further 
experience  is  required  before  any  definite  opinion  can  be  given  as  to 
its  value. 

B.  Complete  Extirpation  of  the  aneurismal  sac  may  be  looked  on 
as  the  best  and  most  satisfactory  method  of  treatment  in  the  majority 
of  cases.  The  sac  is  thus  dealt  with  as  if  it  were  a  tumour,  although, 
owing  to  the  adhesions  always  present,  complete  separation  of  the 
wall  from  surrounding  parts  is  often  difficult.  The  limb  is  ex- 
sanguinated by  elevation,  and  in  suitable  cases  the  aneurism  is 
removed  without  opening  it,  and  the  vessel  secured  by  ligature  above 
and  below,  as  also  any  branches  which  may  arise  from  it.  Some- 
times, however,  it  is  necessary  to  open  it  and  turn  out  its  contents 
before  attempting  its  extirpation.  Not  unfrequently  the  vein  will 
be  encroached  on  in  this  dissection,  and  it  may  have  to  be  removed ; 
bad  results  are  not  likely  to  follow,  since  the  pressure  of  the  sac  has 
already  probably  established  an  efficient  collateral  venous  circula- 
tion. The  results  of  this  operation  which  have  been  recorded  are 
most  encouraging :  primary  union  of  the  wound  is  often  obtained, 
and  hence  the  length  of  treatment  is  curtailed,  whilst  all  chances 
of  local  recurrence  are  removed.  Statistics  also  show  that  there 
is  less  danger  of  gangrene,  and  this  depends,  as  Sir  A.  Pearce  Gould 
has  pointed  out,  on  the  fact  that  only  one  set  of  collateral  circulation 
is  called  upon,  viz.,  that  required  to  bridge  the  gap  made  by  removing 
the  aneurism,  whereas  in  the  Hunterian  operation  a  double  set  is 
needed,  viz.,  at  the  site  of  the  ligature,  and  round  the  consolidated 
aneurism.  It  is  obvious  that  the  nutrition  of  the  limb  is  best  secured 
when  what  Gould  calls  the  '  irreducible  minimum '  of  operative 
treatment,  viz.,  the  occlusion  of  the  vessel  at  the  site  of  the  aneurism 
only,  is  undertaken.  Secondary  haemorrhage  is  also  less  likely  to 
occur. 

C.  The  deposit  within  the  sac  of  fibrin,  which  shall  subsequently 
organize  and  thus  lead  to  the  obliteration  of  both  sac  and  supplying 
vessel,  was  the  ideal  aimed  at  by  the  earlier  surgeons,  and  has  still 
to  be  relied  on  in  many  cases.  It  is  obvious  that  a  slow  and  gradual 
deposit  of  laminated  fibrin  is  likely  to  be  more  satisfactory  than  the 
sudden  distension  of  the  sac  with  soft  red  clot. 

The  various  plans  adopted  with  this  end  in  view  are  as  follows : 
I.  Compression  of  the  main  vessels,  usually  on  the  proximal  side  of 
the  aneurism,  was  much  vaunted  by  the  Dublin  school  of  surgeons 
in  the  last  century,  and  gave  not  a  few  good  results.  It  may  be 
applied  either  continuously  or  at  intervals.  If  intermittent,  the  main 
vessel  leading  to  the  aneurism  is  controlled  by  means  of  fingers 
(digital  compression),  or  by  mechanical  contrivances  (such  as  a 
tourniquet  or  a  conical  bag  filled  with  shot),  for  as  long  a  period  as 
the  patient  can  bear,  which  usually  does  not  exceed  thirty  minutes, 
especially  if  there  is  any  nerve  in  the  immediate  neighbourhood. 
There  seems  to  be  no  necessity  to  arrest  the  flow  of  blood  through 
the  sac  completely,  so  long  as  the  blood-pressure  is  sufficiently 
diminished  to  permit  of  coagulation  within  it.      Continuous  pressure 


3i6  A  MANUAL  OF  SURGERY 

can,  as  a  rule,  only  be  maintained  under  an  anaesthetic,  and  in  such 
cases  the  circulation  through  the  sac  is  entirely  stopped,  so  as  to 
allow  not  only  of  its  contraction,  but  also  in  some  instances  of  the 
rapid  coagulation  of  its  contents.  Such  pressure  may  be  effected  by 
the  fingers  of  relays  of  dressers,  taking  shifts  of  ten  to  fifteen  minutes 
at  a  time ;  but  inasmuch  as  its  effective  maintenance  is  excessively 
tiring  and  difficult,  arrangements  should  be  made  whereby  some 
weight,  such  as  a  conical  shot-bag,  rests  upon  the  thumb  or  finger 
employed,  thereby  relieving  muscular  strain. 

Although  in  suitable  cases  compression  certainly  has  been  successful, 
and  may  be  given  a  trial  before  ligature,  yet  it  is  unwise  to  persevere 
with  it  for  too  long  if  signs  of  improvement  are  not  quickly  observed, 
lest  the  collateral  circulation  be  increased  to  an  undesirable  extent, 
and  the  success  of  the  subsequent  operation  jeopardized.  Especially 
is  this  the  case  in  plethoric  individuals  with  high  arterial  tension.  On 
the  other  hand,  in  feeble,  weakly  patients,  where  gangrene  of  the 
limb  might  be  anticipated,  the  opening  up  of  the  collateral  circulation 
by  compression,  even  if  the  aneurism  is  not  thereby  cured,  is  by  no 
means  a  disadvantage. 

Necessarily,  the  skin  to  which  pressure  is  applied  must  be  protected 
from  local  irritation  by  shaving  and  removal  of  hairs,  by  the  use  of 
dry  aseptic  dusting-powder,  and  by  the  surface  of  any  pad  employed 
being  perfectly  smooth. 

2.  Ligature  of  the  main  vessels  leading  to  or  coming  from  the 
aneurismal  sac  must  next  be  considered.  The  oldest  procedure,  the 
Operation  of  Antyllus,  consisted  in  laying  open  the  sac,  turning  out 
the  clots,  securing  the  vessel  above  and  below,  and  allowing  the 
wound  to  heal  by  granulation  (Fig.  loi.  A).  Performed,  as  it  was 
originally,  without  antiseptics,  it  was  naturally  attended  with  great 
mortality  from  secondary  haemorrhage. 

In  Anel's  Method  (Fig.  loi,  B)  the  artery  was  tied  just  above  the 
sac  on  the  cardiac  side,  with  no  branch  intervening  ;  this  also  proved 
dangerous,  since  secondary  haemorrhage  frequently  resulted,  either 
from  suppuration  within  the  sac,  or  from  injury  to  the  sac  during  the 
operation,  or  from  yielding  of  the  arterial  wall  at  the  site  of  ligature 
from  septic  peri-arteritis.  At  the  present  time  it  is  not  unfrequently 
undertaken  successfully. 

Hunter's  Operation  (Fig.  loi,  C),  which  consists  of  ligature  of  the 
main  vessel  on  the  cardiac  side  at  some  distance  from  the  aneurism, 
was  first  performed  by  him  in  1785.  The  object  to  be  attained  is 
not  to  cut  off  absolutely  the  blood-supply  to  the  sac,  but  to  allow  the 
blood  to  enter  it  with  a  greatly  diminished  impulse,  and  in  small 
amount  at  first,  thus  permitting  of  the  contraction  of  the  sac  wall 
and  of  the  gradual  deposit  of  fibrinous  clot  within  it.  The  sac  thus 
becomes  consolidated,  and  its  place  occupied  by  a  mass  of  firm 
fibroid  tissue.  The  operation  is  most  likely  to  succeed  in  cases 
where  the  aneurism  is  well  defined,  whilst  it  is  desirable,  though 
not  essential,  that  no  branch  of  large  size  should  intervene  between 
the  point  of  ligature  and  the  sac.     The  operation  is  contra-indicated 


ANEURISM 


317 


(i)  in  cas6s  where  serious  cardiac  disease  co-exists,  or  when  an 
internal  aneurism  is  also  present,  rendering  undesirable  any  sudden 
increase  of  the  blood-pressure,  as  by  occlusion  of  a  main  vessel; 
(2)  where  pressure  over  the  vessel  does  not  control  the  circulation 
through  the  sac  ;  (3)  where  the  peripheral  vessels  are  extensively 
calcified  ;  (4)  where  gangrene  of  the  limb  is  threatening  or  present ; 
or  (5)  where  bones  or  joints  have  been  seriously  involved. 

Distal  Ligature  is  only  practised  for  aneurisms  situated  in  positions 
where  it  is  impracticable  to  deal  with  the  artery  on  the  cardiac  side  of 
the  sac,  such  as  the  innominate,  lower  part  of  the  carotid,  or  first 
part  of  the  subclavian.  Brasdor's  Operation  consists  in  tying  the 
main  trunk  beyond  the  sac,  so  as  totally  to  cut  off  the  circulation 
through  it  (Fig.  loi,  D).  In  Wardrop's  Operation  a  ligature  is  placed 
on  one  or  more  of  the  distal  branches  (Fig.  loi,  E).     In  the  former 


Fig.  ioi. — Methods  of  applying  Ligatures  for  Aneurisms. 

A,  Method  of  Antyllus  ;  B,  Anel's  operation  ;  C,  the  Hunterian  operation  ; 
D,  Brasdor's  operation  ;  E,  Wardrop's  method. 


the  sac  gradually  contracts,  and  thus  allows  of  the  deposit  of  fibrin  ; 
in  the  latter  proceeding,  where  the  circulation  is  only  partly  con- 
trolled, the  diminution  of  the  size  of  the  aneurism  goes  on  much 
more  slowly,  and  the  chances  of  the  deposition  of  clot  in  the  sac  are 
correspondingly  lessened. 

It  is  not  unusual,  after  the  application  of  a  ligature  to  a  main  artery 
for  aneurism,  to  observe  a  return  of  pulsation  in  the  sac  after  a  day  or 
two.  In  the  majority  of  cases  this  only  continues  for  a  short  time, 
and  is  by  no  means  an  unfavourable  sign,  indicating  the  re-establish- 
ment of  the  collateral  circulation  ;  but  if  it  commences  a  week  or  ten 
days  after  the  operation,  it  is  more  likely  to  persist.  It  is  most 
frequently  seen  in  cases  where  the  main  vessel  has  been  tied  at  some 
distance  from  the  sac,  as  in  the  superficial  femoral  for  popliteal 
aneurism,  and  where  one  or   more  large   and  important  collateral 


3i8  A  MANUAL  OF  SURGERY 

branches  carry  blood  into  the  artery  below  the  ligature  or  directly 
into  the  sac.  The  early  recurrence  of  pulsation  needs  no  treatment  in 
most  instances ;  but  when  it  comes  on  at  a  later  stage,  it  demands 
serious  attention.  Rest,  elevation  of  the  limb,  and  judicious  pressure 
over  the  trunk  above  the  site  of  ligature,  should  first  be  tried. 
These  failing,  the  following  courses  are  open :  (a)  The  artery  may 
be  again  tied,  either  nearer  the  sac  when  feasible,  or  further  away 
from  it;  (b)  where  the  aneurism  can  be  reached,  it  may  be  cut 
down  on  and  dissected  out,  the  best  course  to  adopt  if  it  be  prac- 
ticable ;  or  (c)  amputation  just  above  the  aneurism  may  be  called  for 
as  a  last  resource. 

3.  Electrolysis  has  been  occasionally  employed  in  dealing  with 
thoracic  aneurisms  when  a  saccule  has  developed  in  an  accessible 
position.  The  clot,  however,  is  soft  and  liable  to  break  up,  and  the 
results  have  not  been  very  satisfactory.  For  details  of  the  methods 
of  employing  electrolysis,  see  p.  355. 

4.  The  Introduction  of  Foreign  Bodies  into  the  Sac  {Moore's  Method) 
has  not  been  followed  by  much  success,  although  a  few  cases  of 
abdominal  aneurism  seemed  to  have  derived  temporary  benefit  from 
it.  Steel  wire  has  been  usually  employed ;  it  is  firmly  wound  round 
a  cotton  reel  to  give  it  a  spiral  coil,  and  inserted  into  the  sac  through 
a  very  fine  cannula.  Varying  lengths  from  10  feet  to  26  yards 
have  been  introduced. 

5.  The  combination  of  the  last  two  methods  (as  originally  suggested 
and  practised  by  an  ItaHan,  Corradi,  in  1879)  has  been  attended  by 
some  very  happy  results,  especially  in  the  hands  of  Stewart  of 
Philadelphia."  He  introduces  a  variable  length  of  gold  or  silver  wire 
(No.  30  gauge),  preferably  the  former,  through  a  small  cannula,  and 
then  performs  electrolysis  through  the  wire  which  is  attached  to  the 
positive  electrode,  whilst  the  negative  electrode  is  placed  on  the  back. 
The  current  is  gradually  increased  up  to  60  or  80  milliampferes,  and  the 
whole  proceeding  lasts  about  thirty  minutes.  Finally,  the  wire  is  cut 
short  and  pushed  back  into  the  sac,  and  the  opening  ligatured. 
Several  most  brilliant  results  have  followed  this  plan  of  treatment, 
including  the  cure  of  an  innominate  aneurism,  the  patient  living  for 
three  and  a  half  years,  and  of  an  aneurism  of  the  abdominal  aorta, 
dealt  with  by  transperitoneal  operation. 

An  ingenious  contrivance  has  been  designed  by  Messrs.  D'Arcy 
Power  and  Colt  for  this  purpose.  It  consists  of  a  fine  wire  wisp  or 
cage,  which  can  be  introduced  closed  up  as  a  cartridge  into  a  special 
trocar,  and  pushed  by  a  ramrod  into  the  sac,  where  it  expands  of 
itself  umbrella- fashion,  thereby  exposing  a  large  surface  of  wire  on 
which  coagulation  can  occur;  it  is  also  arranged  for  electrolysis. 
Satisfactory  results  have  attended  its  employment. 

D.  Quite  distinct  in  principle  from  the  preceding  plans  is  that 
associated  with  the  name  of  Sir  William  Macewen,  who  looks  on 
blood-clot  as  undesirable  material  to  work  with  for  the  cure  of  an 

*  British  Medical  Journal,  August  14,  1897  ;  Philadelphia  Medioal  Journal,  June  25, 
1898. 


ANEURISM  3 '9 

aneurism,  and  directs  his  attention  to  thickening  the  walls  of  the  -sac 
to  such  an  extent  as  to  determine  its  occlusion,  or  to  prevent  its 
subsequent  dilatation.  To  this  end  he  employs  Acupuncture,  intro- 
ducing several  fine  needles  into  the  sac  and  leaving  them  to  be  played 
upon  for  a  time  by  the  blood-stream,  so  as  to  scratch  and  irritate  the 
further  wall  of  the  sac,  and  thus  cause  an  inflammatory  hyperplasia, 
which  shall  subsequently  organize  into  dense  fibro-cicatricial  tissue. 
The  process  must  be  repeated  as  often  as  is  considered  necessary. 
In  his  own  hands  excellent  results  have  been  obtained ;  but  whilst 
admitting  its  value  for  internal  aneurisms,  we  cannot  but  think  that 
for  those  involving  peripheral  vessels  other  methods  would  be  more 
rapid  and  equally  effective. 

E.  Amputation  may  be  required  in  the  treatment  of  aneurisms 
under  a  variety  of  circumstances  :  {a)  When  extensive  gangrene  of 
the  limb  has  occurred  or  is  imminent ;  (&)  for  diffusion  or  suppura- 
tion of  an  aneurism  when  everything  else  has  failed ;  (c)  for 
secondary  hemorrhage  as  a  last  resource  ;  {d)  in  some  cases  of  re- 
current aneurism ;  {e)  when  joints  have  been  opened  or  bones  eroded 
to  such  an  extent  as  to  impair  the  utility  of  the  limb  ;  and,  finally, 
(/)  in  a  few  cases  of  subclavian  aneurism  amputation  at  the  shoulder- 
joint  has  been  practised  in  order  to  diminish  the  amount  of  blood 
flowing  through  the  sac. 

Tlie  Treatment  of  a  Diffuse  Aneurism  varies  somewhat  according 
to  whether  the  diffusion  is  slow  or  rapid.  In  the  leaking  aneurism, 
which  increases  in  size  somewhat  slowly,  the  main  vessel  leading  to 
the  swelling  must  be  tied,  if  this  has  not  already  been  undertaken, 
and  the  influence  of  this  measure,  combined  with  rest,  elevation,  and 
careful  general  treatment,  observed.  Should  the  process  not  be 
stayed,  the  case  is  treated  as  a  diffuse  or  ruptured  aneurism  by  laying 
open  the  sac,  after  exsanguinating  the  limb  by  elevation  and  the 
use  of  an  elastic  band,  and  securing,  if  possible,  the  main  vessel 
above  and  below,  as  also  any  branches  which  may  open  into  the 
sac,  if  they  can  be  found.  If  there  is  any  evidence  of  incipient 
gangrene,  or  if  secondary  haemorrhage  supervenes,  amputation  must 
be  undertaken.  In  such  cases  everything  will  depend  on  the  efficient 
maintenance  of  asepsis. 

Tlie  Treatment  of  an  Inflamed  Aneurism  is  always  a  matter  of 
anxiety  from  the  risk  of  recurrent  and  fatal  haemorrhage.  //  the 
artery  above  the  aneurism  has  not  been  previously  ligatured,  it  would 
certainly  be  correct  practice  to  tie  it,  and  watch  the  effect  produced 
by  that  measure,  together  with  rest,  elevation,  and  the  local  applica- 
tion of  an  ice-bag.  If  the  inflammatory  symptoms  still  continue,  the 
aneurism  should  be  laid  freely  open  after  applying  an  elastic  tour- 
niquet, the  coagula  turned  out,  and  the  main  trunk  secured  above 
and  below.  If  bleeding  still  continues  from  smaller  branches 
opening  into  the  sac,  the  cavity  is  carefully  plugged  with  strips  of 
aseptic  gauze,  but  a  strict  watch  must  be  kept  over  the  case,  for 
fear  of  a  return  of  the  bleeding.  Should  this  happen,  or  should 
gangrene  threaten,  amputation  alone  remains.     //  the  main  vessel  of 


^26  A  MANUAL  OP  SURGERV 

supply  has  been  previously  tied,  the  sac  should  still  be  laid  open  and 
cleared  of  coagula,  all  bleeding-points  secured  if  possible,  and  the 
cavity  packed ;  amputation  is,  however,  likely  to  be  required. 

Special  Aneurisms. 

Aneurism  of  the  Thoracic  Aorta,  though  of  medical  rather  than  of 
surgical  interest,  demands  a  short  notice  here.  Any  part  of  the 
thoracic  aorta  may  be  affected,  and  the  symptoms  arising  therefrom 
are  very  variable.  The  fusiform  type  is  most  commonly  met  with 
in  the  early  stages,  a  limited  sacculation  often  supervening  as  the 
disease  advances,  (i)  In  the  ascending  part  of  the  arch  the  swelling 
rarely  reaches  a  great  size,  especially  if  it  is  intrapericardial,  the  sac 
usually  rupturing  before  marked  pressure  signs  are  evident. 

(2)  When  arising  from  the  transverse  part  of  the  arch,  the  symptoms 
vary  with  the  direction  taken  by  the  enlargement.  If  it  projects 
upivards,  a  pulsating  tumour  may  appear  at  the  episternal.  notch, 
and  cerebral  effects  may  then  ensue  from'  interference  with  the 
circulation  through  the  carotids,  or  from  pressure  on  the  venous 
trunks.  If  it  extends  anteriorly,  it  may  form  a  large  tumour  with 
comparavely  slight  pressure  effects,  except  the  pain  arising  from 
its  erosion  of  the  thoracic  wall ;  it  then  appears  as  a  pulsating 
swelling  to  the  right  of  the  sternum.  .If  the  enlargement  takes 
place  either  posteriorly  or  downwards  within  the  concavity  of  the  arch, 
symptoms  in  the  shape  of  dyspnoea  and  dysphagia  are  early  pro- 
duced from  the  close  contiguity  of  the  trachea,  oesophagus,  and 
pulmonary  vessels.  Dyspnoea  may  also  be  due  to  pressure  upon 
the  left  recurrent  laryngeal  nerve,  causing  paresis  of  the  crico- 
arytenoideus  posticus  muscle  and  difficulty  in  opening  the  glottis  ; 
the  voice,  moreover,  becomes  harsh  and  the  cough  hard,  with  what 
has  "been  described  as  a  'metallic  ring'  about  it,  which  is  extremely 
characteristic.  Laryngeal  or  tracheal  stridor  may  be  noticed  in  these 
cases,  and  a  dragging  of  the  trachea  synchronous  with  the  heart's 
action  (the  so-called  '  tracheal  tug  ').  Radiographic  examination  is  a 
valuable  means  of  diagnosis. 

(3)  Aneurisms  of  the  descending  arch  and  thoracic  aorta  often  attain 
considerable  dimensions,  and  may  project  posteriorly  to  the  left  of 
the  vertebral  column,  causing  a  pulsating  swelling.  The  only  pro- 
minent symptoms  are  pain,  due  to  erosion  of  ribs  or  vertebrae,  and 
interference  with  deglutition,  which  may  be  so  great  as  to  suggest 
the  presence  of  an  oesophageal  constriction  ;  in  fact,  before  a  bougie 
is  passed  in  any  case  of  dysphagia  it  is  always  advisable  to  make 
certain  by  radiography  that  an  aneurism  is  not  present.  Ausculta- 
tion in  the  left  vertebral  groove  may  also  reveal  the  existence  of 
a  systolic  bruit  where  such  a  condition  exists. 

Treatment. — Little  can  be  done  beyond  ordinary  medical  measures, 
such  as  rest,  diet,  and  the  administration  of  iodide  of  potassium. 
When  the  aneurism  has  projected  in  front,  the  introduction  of  coils  of 
iron  wire  or  horsehair  has  been  attempted,  and  in  one  or  two  cases 


ANEURISM 


321 


with  partial  or  temporary  success ;  whilst  Stewart's  method  ot 
electrolysis  and  Mace  wen's  plan  of  acupuncture  have  been  used  with 
some  benefit  for  supposed  cases  of  sacculated  aneurism.  Dyspnoea 
may  be  at  times  severe,  but  tracheotomy  should  never  be  undertaken, 
death  seldom  resulting  from  this  cause. 

Ligature  of  the  right  carotid  and  right  subclavian,  or  of  the  left  carotid 
alone,  has  been  adopted  in  cases  of  aneurism  of  the  ascending  aorta 
or  of  the  arch.  A  certain  amount  of  improvement  followed  some  of 
the  operations,  but  it  is  quite  possible  that  this  was  as  much  due  to 
the  enforced  rest  in  bed  as  to  the  operation.  Of  course,  if  the  lower 
end  of  the  carotid  is  involved  in  the  aneurismal  swelling,  distal 
ligature  may  do  some  good,  as  in  a  case  of  our  own,*  where  the  left 
carotid  and  subclavian  were  tied,-  with  a  short  interval  between  the 
operations.  The  patient's  condition  improved  greatly  for  a  time,  and 
she  was  able  to  return  to  work, 
but  the.  aneurism  finally  burst  into 
the  left  pleura  about  three  years 
after  the  first  operation. 

Innominate  Aneurism  is  usually 
of  the  tubular  variety,  and  fre- 
quently associated  with  a  similar 
enlargement  of  the  aorta.  It  pre- 
sents a  pulsating  tumour  behind 
the  right  sterno-clavicular  articu- 
lation— i.e.,  between  the  heads  of 
origin  of  the  sterno- mastoid — pro- 
jecting either  into  the  episternal 
notch  or  outwards  into  the  sub- 
clavian triangle,  and  perhaps 
pushing  the  clavicle  forwards. 
The  pulse  in  both  the  right 
temporal  and  radial  arteries  is 
diminished ;  oedema  of  a  brawny 
character  of  the  right  side  of  the 
head  and  neck,  and  of  the  right 
arm,  is  caused  by  pressure  on  the  right  innominate  vein,  whilst  less 
commonly  similar  changes  on  the  left  side  may  follow  compression 
of  the  left  vein  or  of  the  superior  vena  cava ;  pain  shooting  into 
the  neck  and  arm  is  often  produced  by  implication  of  the  brachial 
nerves,  whilst  hyperaemia  and  sweating  of  the  right  side  of  the  face 
and  dilatation  of  the  right  pupil  may  result  from  irritation  of  the  sym- 
pathetic trunk.  Dyspnoea  is  induced  by  direct  pressure  on  the  trachea, 
which  may  be  displaced  or  flattened,  or  by  irritation  of  the  right 
recurrent  laryngeal  nerve,  causing  partial  or  complete  paralysis  of 
the  right  vocal  cord.  Dysphagia  occurs  from  pressure  on  the 
cesophagus. 

The  course  of  the  case  is  slowly  progressive,  and. death  most  com- 
monly results  from  asphyxia  or  from  rupture  of  the  sac. 
*  British  Medical  Journal,  December  ■^,  1898. 

21 


Fig,  102.— Application  of  Ligatures 
FOR  Innominate  Aneurism.  (After 
Erichsen.) 

lA,  Innominate  aneurism ;  S,  sub- 
clavian artery  ;  C;  carotid ;  V,  verte- 
bral artery. 


322  A  MANUAL  OF  SURGERY 

Treatment. — Rest  and  the  administration  of  large  doses  of  iodide  of 
potassium  may  cause  improvement,  but  distal  ligature  is  the  most 
hopeful  proceeding.  It  is  obviously  impossible  to  cut  off  all  the 
blood  passing  through  the  sac  to  the  three  main  divisions— viz., 
the  carotid,  subclavian,  and  vertebral— with  safety  to  the  patient 
(Fig.  102).  Ligature  of  any  one  of  these  by  itself  offers  but  little 
prospect  of  improvement,  whilst  tying  both  carotid  and  subclavian, 
with  an  interval  of  more  than  a  week  between  the  two  operations, 
has  practically  the  same  effect  as  a  single  ligature,  for  by  that  time 
the  collateral  circulation  will  have  been  established.  Simultaneous 
ligature  is  doubtless  the  best  plan  of  treatment  to  adopt ;  it  places 
the  sac  in  the  best  possible  condition  for  the  deposit  of  fibrin,  whilst 
the  additional  st-ep  of  tying  the  third  part  of  the  subclavian  does  not 
materially  add  to  the  risk  of  the  operation,  which  is  mainly  due 
to  the  effect  on  the  cerebral  circulation.  Should  these  operative 
measures  seem  undesirable,  recourse  must  be  had  to  Stewart's  or 
Macewen's  methods. 

Aneurism  of  the  Common  Carotid  is  usually  situated  at  the  upper 
part  of  the  trunk  near  the  bifurcation,  and  more  often  on  the  right 
than  on  the  left  side.  The  root  of  the  right  carotid  as  it  springs 
from  the  innominate  is  also  not  unfrequently  dilated,  but  the  intra- 
thoracic portion  of  the  left  carotid  is  rarely  affected,  except  in  con- 
junction with  aneurism  of  the  aorta.  No  other  external  vessel  is  so 
frequently  the  seat  of  aneurism  in  women. 

The  ordinary  intrinsic  signs  of  an  aneurism  are  present,  and  the 
pressure  symptoms  are  mainly  referable  to  interference  with  the 
cerebral  circulation,  to  irritation  of  the  cervical  sympathetic  trunk, 
or  to  pressure  upon  the  larynx,  pharynx,  or  trachea.  The  progress 
of  these  cases  is  usually  slow. 

Diagnosis. — (i)  Froju  similar  disease  at  the  root  of  the  neck  the  distinc- 
tion is  often  made  with  difficulty,  since  either  an  aortic,  innominate, 
or  subclavian  aneurism  may  push  upwards  so  as  to  simulate  it  some- 
what closely.  Percussion  and  auscultation  of  the  upper  part  of  the 
chest,  together  with  a  careful  investigation  into  the  history  of  the 
case,  and  a  digital  examination  of  the  limits  of  the  pulsating  mass, 
may  suffice  to  determine  the  point.  Holmes  suggests  trying  the 
effect  of  carefully  applied  distal  pressure  for  a  few  hours ;  in  a 
carotid  aneurism  the  tension  becomes  distinctly  less  as  the  collateral 
circulation  commences  to  enlarge,  whilst  in  an  aortic  aneurism  no 
difference  is  observed.  The  pressure  effects  must  also  be  carefully 
considered.  '  Pressure  on  the  left  recurrent  laryngeal  nerve  would 
distinguish  an  aortic  aneurism  from  one  on  the  right  vessels ; 
pressure  on  the  right  nerve  in  like  manner  excludes  an  aortic 
aneurism.  Pressure  on  the  left  innominate  vein  indicates  aortic 
aneurism  rather  than  innominate;  compression  of  the  internal 
jugular  or  subclavian  vein  only  points  to  carotid  or  subclavian 
aneurism.  A  "tracheal  tug"  indicates  an  aneurism  of  the  aorta  ' 
(P.  Gould).  The  differences  in  the  peripheral  pulses  may  also  give 
useful  information.     The  two  radial  pulses  should  be  first  examined ; 


ANEURISM 


323 


if  they  are  equally  affected,  an  aneurism  of  the  aorta  on  the  cardiac 
side  of  the  innominate  is  indicated  ;  if  they  are  equal  and  normal,  an 
aneurism  on  the  distal  side  of  the  origin  of  the  left  subclavian.  If  the 
left  radial  pulse  is  alone  aneurismal,  the  root  of  the  left  subclavian 
is  diseased,  whilst  if  the  left  temporal  is  also  affected,  it  suggests  an 
aneurism  of  the  transverse  part  of  the  arch  beyond  the  innominate. 
When  both  radial  and  temporal  vessels  on  the  right  side  show  signs  of 
interference  with  the  pulse,  innominate  aneurism  is  probably  present, 
whilst  an  affection  of  only  one  of  these  branches  indicates  that  the 
corresponding  carotid  or  subclavian  is  dilated.  One  source  of 
fallacy  must  not  be  forgotten,  viz.,  that  any  one  of  these  trunks  may 
be  occluded  or  compressed  by  a  neighbouring  aneurism  without 
being  dilated,  and  hence  the  quality  of  the  pulse  must  be  taken  into 
consideration  rather  than  its  actual  volume,  and  to  this  end  the 
sphygmograph  is  a  useful  adjunct  in  diagnosis.  (2)  From  abscess, 
tumouvs,  or  enlarged  glands  with  a  transmitted  impulse,  a  carotid 
aneurism  is  recognised  by  an  application  of  the  general  principles 
detailed  above  (p.  312).  (3)  Pulsating  or  cystic  goitre  may  be  dis- 
tinguished from  a  carotid  aneurism  by  noting  that  the  goitre  is  not, 
as  a  rule,  limited  to  one  side  of  the  neck,  the  isthmus  being  also 
involved ;  that  the  most  fixed  part  of  the  tumour  is  in  the  median 
line,  and  not  under  the  sterno-mastoid  muscle ;  and  that  the 
swelling  moves  up  and  down  during  deglutition,  an  aneurism 
remaining  fixed.  (4)  An  aneurism  close  to  the  bifurcation  may  be 
simulated  by  an  abnormal  arrangement  of  the  terminal  branches,  the 
external  carotid  crossing  the  internal  from  behind  forwards,  and 
being  pushed  outwards  sufficiently  to  cause  a  pulsating  swelling 
beneath  the  skin.  This  condition  is  usually  symmetrical,  and  can 
be  recognised  by  careful  palpation. 

Treatment. — Ligature  of  the  carotid  above  or  below  the  omohyoid 
is  the  treatment  usually  adopted,  and  generally  with  great  success. 
If  the  aneurism  is  near  the  root  of  the  neck,  proximal  ligature 
becomes  impracticable,  and  the  distal  operation  (Brasdor's)  must  be 
undertaken. 

Aneurism  of  the  External  Carotid  is  seldom  met  with,  except  as 
an  extension  of  one  involving  the  bifurcation.  The  usual  pheno- 
mena are  presented  near  the  angle  of  the  jaw,  and  well  above  the 
thyroid  cartilage.  Pressure  results  are  early  experienced,  e.g., 
paralysis  of  one  side  of  the  tongue  through  implication  of  the  hypo- 
glossal nerve,  aphonia,  or  dysphagia.  In  suitable  cases,  the  sac 
may  be  dissected  out  after  securing  the  branches  arising  from  it,  as 
recommended  by  the  late  Mr.  Walsham.*  Failing  this,  the  common 
trunk  must  be  tied. 

Aneurism  of  the  Internal  Carotid  (extracranial  portion)  presents 
symptoms  which  closely  resemble  those  caused  by  an  aneurism  of 
the  bifurcation  or  of  the  external  carotid,  except  that  the  swelling 
projects  more  into  the  pharynx,  from  which  it  is  separated  merely 
by  the  pharyngeal  wall.     It  appears  as  a  tense  pulsating  tumour, 

*  Trans.  Med.  Chir,  Soc,  February  28,  1899. 


324  A  MANUAL  OF  SURGERY 

placed  immediately  under  the  mucous  membrane,  and  looking 
dangerously  like  an  abscess  of  the  tonsil.  The  Treatment  consists 
in  tying  the  common  carotid. 

Intracranial  Aneurism  occurs  more  commonly  upon  the  internal  - 
carotid  and  its  branches  than  upon  those  arising  from  the  vertebrals, 
although  the  basilar  artery  is  more  often  aflfected  than  any  other 
single  vessel.  The  aneurisms  are  generally  fusiform  in  character, 
and  their  origin  is  often  obscure,  being  attributed  to  a  blow  or  fall ; 
in  children  they  are  stated  to  result  from  the  lodgment  of  septic 
emboli.  They  sometimes  grow  to  a  considerable  size  before  causing 
symptoms  ;  the  patient  may,  in  fact,  have  continued  without  any 
manifestation  of  the  disease,  until  suddenly  seized  with  a  rapidly 
fatal  apoplexy  from  rupture  of  the  sac.  If  there  are  any  symptoms, 
they  are  due  rather  to  compression  of  the  brain  than  to  erosion  of  the 
more  resistant  bony  structures.  Pain  which  is  more  or  less  fixed 
and  continuous  may  be  complained  of,  or  there  may  be  a  feeling  of 
pulsation,  or  of  opening  and  shutting  the  top  of  the  skull.  Sight, 
hearing,  and  other  functions  of  the  brain,  may  also  be  impaired,  but 
physical  changes  in  the  eyes,  such  as  optic  neuritis,  or  atrophy,  are 
not  induced,  unless  there  is  direct  pressure  on  some  part  of  the  optic 
tract.  Occasionally  a  loud  whizzing  bruit  may  be  heard  on  auscultat- 
ing the  skull.  The  only  Treatment  possible,  if  a  diagnosis  can  be 
established,  is  ligature  of  the  internal  carotid  artery,  and  even  this 
will  be  of  little  use  if  the  basilar  is  affected. 

Intra-orbital  Aneurism. — Several  pathological  lesions  may  give  rise 
to  the  condition  of  '  pulsating  exophthalmos,'  which  suggests  this 
diagnosis :  (a)  It  is  rarely  congenital,  and  then  probably  due  to 
a.neurism  by  anastomosis  ;  (b)  it  may  be  traumatic,  and  follow  a 
penetrating  wound  of  the  orbit,  or  result  from  a  fracture  of  the  base 
of  the  skull,  or  from  some  slight  blow;  in  these  cases  probably  an 
aneurismal  varix  between  the  internal  carotid  and  cavernous  sinus 
exists,  or  a.  genuine  traumatic  aneurism  of  the  ophthalmic  artery ; 
(c)  if  idiopathic,  it  is  possibly  a  spontaneous  aneurism  of  the  internal 
carotid  or  ophthalmic  arteries.  The  eyeball  protrudes  (exophthalmos), 
and  definite  pulsation  is  felt  on  palpation  over  the  orbit,  and  perhaps 
seen.  The  patient  complains  of  intra-orbital  pain  and  tension ;  the 
conjunctival  and  retinal  vessels  are  distended,  and  a  marked  bruit 
may  be  present  on  auscultation.  The  movements  of  the  eyeball  are 
limited,  vision  is  impaired,  and  the  cornea  may  become  opaque  from 
exposure ;  finally,  the  whole  globe  may  be  disorganized.  A  marked 
mitigation  of  all  symptoms  usually  follows  compression  of  the 
carotid. 

Diagnosis. — Sarcoma  of  the  orbital  wall  may  exhibit  many  of  the 
characters  of  intra-orbital  aneurism.  Careful  palpation  will,  however, 
generally  demonstrate  the  existence  of  a  more  definite  tumour,  and 
a  less  marked  expansile  pulsation  in  the  sarcoma,  whilst  the  bruit 
is  less  distinct.  The  distortion  of  the  eyeball  and  ocular  axis  is 
often  considerable  in  malignant  tumours,  but  vision  is  not  so  early 
affected. 


ANEURISM  325 

Treatment. — Ligature  of  the  internal  carotid  is  the  only  means 
which  holds  out  any  prospect  of  benefit,  except  in  the  congenital 
cases,  where  electrolysis  has  been  very  successful. 

Subclavian  Aneurism  is  most  frequently  seen  in  men,  and  par- 
ticularly in  soldiers  and  sailors ;  the  right  vessel  is  more  often 
affected  than  the  left.  Any  part  of  the  artery  may  be  involved,  but 
the  greatest  dilatation  naturally  occurs  in  the  third  portion.  A 
pulsating  tumour  develops  in  the  subclavian  triangle,  which  may 
reach  alDove  the  clavicle,  but  chiefly  extends  backwards,  outwards^ 
and  downwards,  causing  pressure  effects  upon  the  veins  and 
nerves  of  the  arm,  and  also  hiccough  by  irritation  of  the  phrenic. 
Occasionally  it  encroaches  on  the  dome  of  the  pleura  and  apex 
of  the  lung,  and  has  been  known  to  burst  into  the  pleural  cavity. 
It  does  not  increase  in  size  very  rapidly,  being  surrounded  by 
dense  unyielding  structures,  and  never  compresses  the  trachea'  or 
oesophagus. 

No  special  difficulty  presents  itself  in  Diagnosis  as  a  rule,  although 
in  the  early  stages  it  may  be  somewhat  simulated  by  a  normal  artery 
pushed  forwards  by  an  exostosis  of  the  first  rib,  or  by  a  super- 
numerary cervical  rib. 

The  Treatment  of  subclavian  aneurism  is  surrounded  with  difficul- 
ties, and  the  results  hitherto  obtained  have  been  most  unsatisfactory 
Extirpation  has  been  undertaken  in  one  case*  with  success  after 
turning  up  the  middle  third  of  the  clavicle,  but  the  aneurism  is 
seldom  sufficiently  limited  to  allow  of  this  proceeding.  Should  any 
undilated  portion  of  the  artery  be  available  outside  the  thorax,  digital 
compression  on  the  cardiac  side  may  be  attempted.  Direct  pressure, 
Stewart's  method  of  electrolysis,  and  needling  the  sac  according  to 
Macewen's  method,  have  been  adopted  with  occasional  success,  but 
cannot  be  relied  on.  Ligature  of  the  innominate  trunk  suggests  itself 
as  the  operation  to  be  adopted  for  cure  by  the  Hunterian  method, 
and  recent  records  would  certainly  encourage  one  to  repeat  it  in  any 
suitable  case.  It  would  appear  that  the  simultaneous  ligature  of  the 
carotid  or  vertebral  trunks  with  the  innominate  is  essential  to  success, 
in  order  to  prevent  the  rapid  backflow  on  the  distal  side  of  the 
ligature  which  otherwise  occurs ;  in  addition,  the  coats  of  the  vessel 
must  be  approximated  by  a  broad  animal  ligature,  e.g.,  of  gold-beater's 
skin,  and  not  divided. 

Ligature  of  the  first  part  of  the  subclavian  has  also  been  attempted, 
but  until  recently  it  vv^as  so  uniformly  fatal  that  it  was  considered 
quite  unjustifiable,  the  first  nineteen  cases  all  dying.  One  or  more 
successful  cases  have,  however,  been  recently  reported. 

As  a  last  resource,  the  plan  suggested  by  the  late  Sir  William 
Fergusson  may  be  followed,  viz.,  amputation  at  the  shoulder -joint  and 
distal  ligature  as  near  the  saC  as  possible.  Distal  ligature  alone  is 
usually  unsuccessful,  owing  to  the  fact  that  the  great  bulk  of  the 
blood  needed  for  the  nutrition  of  the  arm  still  passes  through  the  sac, 

*  Moynihan,  Annals  of  Surgery,  July,  1898. 


326  A  MANUAL  OF  SURGERY 

and  there  is  no  means  of  checking  this  except  by  the  removal  of  the 
limb.  A  few  successful  results  of  such  heroic  treatment  have  been 
reported. 

Axillary  Aneurism  is  usually  the  result  of  falls  on  the  outstretched 
arm,  or  injuries  to  the  shoulder,  such  as  fractures  or  dislocations,  or 
of  attempts  to  reduce  them.  The  Symptoms  are  merely  those  due 
to  the  presence  of  a  pulsating  tumour  and  its  pressure,  which  may 
cause  pain,  local  and  neuralgic,  or  oedema  of  the  arm.  When 
the  upper  part  of  the  vessel  is  affected,  a  pulsating  swelling  is  felt 
immediately  below  the  clavicle,  whilst  if  placed  lower  down  it 
projects  into,  and  may  fill,  the  axilla.  Occasionally  the  clavicle  is 
displaced  upwards,  or  the  aneurism  may  extend  beneath  it  into  the 
neck. 

Treatment. — -Compression  (digital)  or  ligature  of  the  third  part  of 
the  subclavian  artery  is  required,  but  if  the  aneurismal  sac  extends 
under  the  clavicle,  it  may  be  necessary  to  secure  the  second  part  of 
the  artery,  due  care  being  taken  of  the  phrenic  nerve. 

Aneurisms  of  the  brachial  artery,  or  of  any  of  the  vessels  of  the 
forearm,  require  no  special  notice.  They  are  almost  invariably 
traumatic  in  origin,  and  should  be  treated  by  extirpation. 

Abdominal  Aneurism. — The  abdominal  aorta  may  become  the  seat 
of  aneurism,  either  at  the  upper  part  near  the  coeliac  axis,  or  at  the 
bifurcation.  A  pulsating  tumour  is  observed  near  the  middle  line, 
and  either  close  to  the  umbilicus  or  in  the  epigastric  notch  ;  the 
pulsation  is  expansile  in  type,  and  remains  the  same  in  character 
whatever  the  position  of  the  patient.  Pain,  localized  in  the  back 
from  erosion  of  the  vertebrae,  or  neuralgic  from  pressure  on  the  solar 
plexus  or  lumbar  nerves,  is  the  chief  symptom,  whilst  oedema  of  the 
lower  extremities  may  arise  from  compression  of  the  vena  cava. 
There  may  be  some  concurrent  derangement-  of  the  intestinal  func- 
tions. Occasionally  aneurisms  form  independently  on  the  splenic, 
hepatic,  or  mesenteric  vessels. 

Diagnosis. — Many  conditions  give  rise  to  epigastric  pulsation. 
Cardiac  pulsation  may  be  felt  in  the  epigastrium  when  the  heart  is 
dilated,  but  should  be  easily  recognised ;  as  also  an  impulse  trans- 
mitted from  the  aorta  through  a  collection  of  faeces  or  a  cancerous 
growth.  The  examination  of  such  a  case,  if  need  be  under  an 
anaesthetic,  should  be  conducted  not  only  in  the  dorsal  decubitus, 
but  also  in  the  genu-pectoral  position,  so  as  to  remove  the  weight  of 
the  viscera  from  the  aorta,  when  the  pulsation  will  cease  or  be  much 
diminished.  A  large  accumulation  of  abdominal  fat  will  interfere 
seriously  with  any  satisfactory  investigation,  so  that  an  exploratory 
laparotomy  may  be  necessary. 

Treatment. — Failing  medical  treatment  by  rest  and  diet,  compression 
was  formerly  relied  on,  being  applied  either  on  the  distal  or  proximal 
aspect  of  the  sac.  The  method  is,  however,  clumsy  and  liable  to 
bruise  the  abdominal  viscera.  More  recently  treatment  by  needling 
the  sac  has  been  employed,  and  certainly  in  Macewen's  hands  at 
least  one  case  has  been  brilliantly  successful.     There  is  also  one 


ANEURISM  327 

instance  on  record  where  the  introduction  of  wire  into  the  sac,  com- 
bined with  electrolysis,  cured  an  aneurism  as  large  as  an  orange; 
the  abdomen  was  opened,  and  electrolysis  was  maintained  for  thirty- 
seven  minutes. 

Iliac  or  Inguinal  Aneurism  arises  from  either  the  common  or  ex- 
ternal iliac,  or  from  the  common  femoral ;  it  is  frequently  sacculated 
in  type  and  lobulated  in  shape  owing  to  the  pressure  of  fascial  or 
other  structures.  The  symptoms  are  very  typical,  and  diffusion  is 
certain  to  ensue  sooner  or  later.  The  Diagnosis  cannot  be  well 
mistaken  in  the  early  stages,  but  later  on,  and  specially  when  situated 
high  in  the  iliac  fossa,  it  may  be  difficult  to  distinguish  from  a 
pulsating  sarcoma. 

Treatment. — Proximal  compression  of  the  aorta  or  common  iliac, 
where  the  situation  of  the  swelling  and  the  thickness  of  the  abdominal 
parietes  permit,  has  had  a  certain  amount  of  success.  It  is  carried 
out  by  means  of  a  tourniquet,  shot-bag,  or  the  fingers,  and  may  be 
advantageously  combined  with  distal  pressure.  Ligature  of  the 
external  iliac  has  been  frequently  performed  for  inguinal  aneurism, 
and  with  such  success  as  to  warrant  its  being  employed  in  all  suitable 
cases.  Ligature  of  the  common  iliac  is  sometimes  needed  for  aneurisms 
in  the  iliac  fossa,  and  is  now  always  effected  by  the  transperitoneal 
method.  In  ten  instances  ligature  of  the  abdominal  aorta  has  been 
undertaken  for  iliac  or  inguinal  aneurism,  and  in  all  a  fatal  issue 
followed,  seven  of  the  patients  dying  within  forty- eight  hours  ;  one 
survived  as  long  as  the  tenth  day,  and  two  lived  for  forty-eight  and 
thirty-nine  days  respectively.  Of  course,  wherever  practicable,  extiv- 
pation  should  be  resorted  to,  and  at  least  one  successful  case  has 
been  published. 

Aneurisms  of  the  Gluteal  and  Sciatic  Arteries  are  usually  trau- 
matic in  origin,  and  present  as  pulsating  swellings  in  the  buttock, 
the  gluteal  situated  at  the  upper  part  of  the  sciatic  notch,  whilst 
the  sciatic  lies  more  deeply,  and  may  be  partly  intrapelvic.  Pain 
in  the  limb  from  pressure  on  the  sciatic  nerve  is  a  prominent 
symptom,  especially  in  the  sciatic  variety.  The  Diagnosis  is  by  no 
means  easy,  especially  from  a  pulsating  sarcoma.  Treatment. — 
When  the  diagnosis  is  established,  transperitoneal  ligature  of  the 
internal  iliac  artery  should  always  be  adopted.  If  the  sac  is  laid 
open  from  the  buttock  as  a  result  of  a  mistaken  diagnosis,  the  old- 
fashioned  plan  of  treatment  must  be  followed,  viz.,  to  turn  out  the 
clots  and  secure  the  bleeding -points. 

Femoral  Aneurism  is  the  title  given  to  one  forming  in  the  course 
of  the  superficial  femoral  artery.  It  is  not  uncommonly  tubular,  and 
occurs  almost  invariably  in  males.  The  Diagnosis  needs  no  discussion, 
and  the  Treatment  consists  either  in  extirpation,  compression  at  the 
groin,  or  ligature  of  the  common  or  superficial  femoral  trunk. 

Popliteal  Aneurism  (Fig.  io3)occurs  almost  invariably  in  men,  con- 
stituting a  pulsating  tumour  in  the  ham,  rendering  the  knee  painful 
and  stiff,  and  so  much  do  the  symptoms  resemble  those  of  chronic 
rheumatism  that  in  every  such  case  the  popliteal  space    should  be 


328 


A   MANUAL  OF  SURGERY 


examined.  The  limb  is  usually  kept  semiflexed,  and  the  aneurism 
often  increases  rapidly  in  size.  If  the  main  swellmg  is  situated 
to  the  front  of  the  vessel,  there  is  some  likeli- 
hood of  the  knee-joint  becoming  implicated,  and 
neighbouring  bones  carious ;  when  it  extends 
posteriorly,  diffusion  is  not  uncommonly  followed 
by  gangrene,  on  account  of  the  pressure  exercised, 
not  only  upon  the  vein,  but  also  upon  the  articular 
branches  of  the  popliteal  artery,  which  are  most 
important  factors  in  maintaining  the  collateral 
circulation.  The  Diagnosis  has  to  be  made  from 
chronic  enlargement  and  abscess  of  the  popliteal 
glands,  but  in  these  there  is  less  disturbance  of 
the  circulation  in  the  foot ;  from  bursal  tumours, 
by  their  want  of  mobility  and  pulsation  ;  or  from 
solid  tumours,  e.g.,  pulsating  sarcoma  of  the 
femur  or  tibia,  by  attention  to  the  general  prin- 
ciples already  enunciated.  In  a  few  instances 
spontaneous  cure  has  resulted  from  the  pressure 
of  the  sac  upon  the  artery  above. 

Treatment. — Compression  has  been   eminently 
successful  in  many  of  these  cases.     Ligature  of 
Fig  103.-P0PLITEAL  the  femoral  artery  at  the  apex  of  Scarpa's  triangle 
Aneurism.         is,  however,  the  plan  most  commonly  adopted,  and 
with  the  greatest  success.     In  cases  where  either 
of  these  methods  has  failed,  or  where  the  aneurism  has  become  dif- 
fuse or  recurred,  extirpation  of  the  sac  is  the  best  course  to  adopt. 


Ligature  of  Vessels. 

Ligation  in  continuity  is  an  operation  performed  to  arrest  the  flow 
of  blood  to  the  periphery,  in  order  either  to  check  haemorrhage,  or  to 
promote  the  cure  of  an  aneurism,  or  to  diminish  the  rate  of  growth 
of  some  tumour,  or  to  influence  beneficially  some  peripheral  organ 
by  reducing  its  blood-supply,  or  as  a  preliminary  to  removing  some 
vascular  structure,  such  as  the  tongue. 

The  Instruments  needed  are  as  follows :  a  scalpel,  dissecting 
forceps,  director  or  blunt  dissector,  forcipressure  or  artery  forceps, 
blunt  hooks,  retractors  for  deep  wounds,  aneurism  needle,  ligature, 
needles,  and  sutures. 

Operation. — The  artery  is  examined  as  far  as  is  possible,  so  that  a 
healthy  portion  may  be  selected  for  applying  the  ligature.  The  various 
structures  met  with  on  the  way  to  the  artery  are  recognised,  and 
drawn,  if  need  be,  to  one  or  the  other  side,  so  as  to  lay  bare  the 
sheath  of  the  vessel.  It  is  most  important  that  these  anatomical 
landmarks  or  mllying-points  should  each  be  seen  or  felt  in  order, 
so  that  the  operator  may  not  be  led  astray  or  miss  the  vessel. 
Naturally  it  is  easier  to  find  the  artery  in  the  living  subject  than  in 
the  dead,  the  pulsation  being  of  the  greatest  assistance.     The  sheath, 


LIGATURE  OF  VESSELS  329 

having  been  exposed,  must  now  be  opened  over  the  situation  of  the 
artery ;  a  portion  of  the  sheath  should  be  picked  up  between  the 
blades  of  the  forceps,  incised  along  the  longitudinal  axis,  and  stripped 
off  the  vessel.  This  incision  should  be  about  f  inch  in  length,  and 
should  open  not  only  the  general,  but  also  the  special,  sheath  of  the 
artery,  if  such  exist.  The  sheath  is  then  steadied  with  forceps,  whilst 
the  aneurism  needle  is  inserted  unarmed,  and  gently  manipulated  up 
and  down,  so  as  to  free  the  vessel  all  round,  a  matter  of  no  great 
difficulty  if  the  sheath  has  been  correctly  opened  and  the  arterial  wall 
exposed.  The  ligature  may  then  be  passed  through  the  eye  of  the  needle, 
and  carried  round  the  vessel.  It  is  tied  in  a  direction  exactly  at  right 
angles  to  the  longitudinal  axis,  and  in  doing  so  the  artery  must  not 
be  dragged  out  of  its  sheath,  but  the  ligature  should  be  tightened  by 
the  tips  of  the  forefingers  meeting  upon  it.  A  reef  knot  (Fig.  91) 
is  all  that  is  necessary  for  security  in  the  smaller  vessels,  but  in  the 
largest  trunks  it  may  be  advisable  to  employ  what  has  been  termed 


Fig.  104.— Stay  Knot. 

the  stay  knot  (Fig.  I04\  Two  strands  of  ligature  material  are  passed 
round  the  vessel  side  by  side  and  half  knotted  ;  the  two  ends  on  each 
side  are  then  taken  up  together  and  tied  across  in  one  knot.  The 
opening  in  the  sheath  should  be  closed  over  the  ligature  by  a  fine 
buried  stitch,  and  the  various  structures  displaced  in  reaching  the 
vessel  are  similarly  secured  in  good  position. 

The  rule  usually  followed  is  to  pass  the  needle  from  important 
structures,  such  as  the  vein,  but  really  this  is  a  matter  of  little  import- 
ance when  the  above  directions  have  been  carefully  carried  out,  and 
especially  in  superficial  vessels.  Should  the  vein  he  accidentally 
pujictured,  the  needle  must  be  at  once  withdrawn,  and  the  puncture  in 
the  vein  secured  by  ligature,  whilst  the  artery  is  tied  a  little  higher 
or  lower.  In  dealing,  however,  with  the  smaller  vessels,  where  the 
venae  comites  are  in  close  contact  with  the  arteries,  no  harm  will 
attend  their  inclusion  in  the  ligature. 

After-Treatment. — The  patient  must  be  kept  at  rest  for  at  least 
three  weeks  in  order  to  secure  permanent  obliteration  of  the  artery 
and  consolidation  of  the  tissues,  especially  in  dealing  with  the  larger 


330  A  MANUAL  OF  SURGERY 

vessels  and  in  elderly  people.  When  the  main  artery  to  one  of  the 
extremities  has  been  tied,  the  limb  should  be  wrapped  in  aseptic  wool 
and  slightly  raised,  and  if  there  is  any  likelihood  of  gangrene,  it 
should  be  thoroughly  purified. 

There  are  two  great  dangers  liable  to  follow  the  ligation  of  an  artery 
in  its  continuity  : 

1.  Secondary  Hsemorrhage  {vide  p.  291). 

2.  Gangrene  may  arise  from  a  variety  of  causes :  (a)  From  simple 
loss  of  vitality,  owing  to  a  defective  collateral  circulation,  as  when  the 
peripheral  vessels  are  calcareous  and  rigid.  The  tissues  which 
receive  the  smallest  amount  of  blood  die  first,  e.g.,  the  fingers  or  toes, 
or  the  subcortical  white  substance  of  the  brain.  Severe  loss  of  blood 
after  the  operation,  as  from  secondary  hsemorrhage,  may  also  deter- 
mine tissue  necrosis.  Under  such  circumstances  it  almost  always 
takes  on  the  dry  form,  (b)  Interference  with  the  venous  return,  as 
by  injury  to  the  vein  during  operation,  or  the  pressure  of  a  tight 
bandage,  or  thrombosis  induced  subsequently  by  septic  periphlebitis, 
is  very  likely  to  cause  gangrene,  and  then  it  is  of  the  moist  type. 
(c)  Injudicious  after-treatment,  such  as  too  great  elevation  of  the 
limb,  the  application  of  cold  lotions,  an  ice-bag,  or  fomentations 
during  the  period  of  diminished  vitality  immediately  following  the 
operation,  or  even  an  attack  of  erysipelas,  may  also  bring  about  the 
death  of  some  of  the  tissues.  The  Treatment  of  aseptic  gangrene 
following  ligature  is  expectant  in  character,  the  parts  being  allowed 
to  separate  naturally.  But  if  there  is  much  pain,  or  any  tendency  to 
spread,  or  if  septic  mischief  is  present,  giving  rise  to  fever  and  general 
disturbance,  it  is  wiser  to  remove  the  limb  well  above  the  line  of 
demarcation. 

The  Innominate  Artery  has  now  been  tied  with  success  on  at  least  six  occa- 
sions out  of  a  total  of  about  thirty  operations.  An  incision  is  made  along  the 
lower  third  of  the  anterior  border  of  the  sterno-mastoid,  and  is  prolonged  down- 
wards to  sweep  over  the  upper  edge  of  the  episternal  notch.  The  platysma  and  the 
superficial  and  deep  fasciae  are  divided,  and  the  anterior  jugular  vein  secured  if 
necessary  between  two  ligatures  ;  the  sterno-mastoid  is  drawn  outwards,  and 
its  inner  tendinous  fibres  are  divided,  whilst  the  sterno-hyoid  and  -thyroid 
muscles  are  severed  close  to  the  sternum  and  drawn  inwards.  The  carotid 
sheath  is  now  laid  bare  and  opened  at  its  lower  part,  so  as  to  expose  the  carotid 
artery  and  enable  it  to  be  tied,  and  by  following  this  downwards  the  innominate 
trunk  is  reached.  In  some  cases  it  may  expedite  matters  to  remove  portions  of 
the  sternum  and  inner  end  of  the  clavicle.  The  right  internal  jugular  and 
innorhinate  veins  lie  to  the  outer  side  of  the  artery,  but  if  much  engorged  may 
project  over  it,  and  must  then  be  drawn  aside  by  retractors,  whilst  the  inferior 
thyroid  plexus  may  course  directly  downwards  to  reach  the  left  innominate 
vein,  which  crosses  the  vessel.  To  the  outer  or  right  side  and  behind  the 
veins  are  placed  the  vagus  nerve  and  pleural  sac,  and  these  must  be  carefully 
separated  from  the  artery,  whilst  the  needle  is  passed  from  without  inwards,  and 
from  below  upwards.  A  double-curved  aneurism  needle  will  probably  be 
required  to  effect  this.  A  broad  animal  ligature  should  be  used  for  this  vessel, 
and  the  inner  and  middle  coats  must  not  be  divided. 

Collateral  Circulation. — Intracranial :  Vertebrals  and  carotids  in  the  circle  of 
Willis. 

Face  and  Neck  :  Branches  of  the  two  external  carotids  across  middle  line. 

Trunk :  First  aortic  intercostal  with  superior  intercostal  of  subclavian  ;  upper 
aortic  intercostals  with  thoracic  branches  of  axillary  and  intercostals  of  internal 


LIGATURE  OF  VESSELS  331 

mammary ;    deep   epigastric   and   phrenic   with   terminal    divisions   of    internal 
mammary. 

The  Carotid  Artery  may  be  tied  either  above  or  below  the  level  at  which  it  is 
crossed  by  the  anterior  belly  of  the  omo-hyoid.  The  line  of  the  vessel  is  indi- 
cated by  that  drawn  from  the  sterno-clavicular  articulation  to  a  point  midway 
between  the  angle  of  the  jaw  and  the  tip  of  the  mastoid  process,  the  bifurcation 
being  on  a  level  with  the  upper  border  of  the  thyroid  cartilage. 

Ligature  above  the  Omo-hyoid. — This  operation  is  usually  chosen,  if  practicable 
since  the  vessel  is  here  more  superficial,  the  ligature  being  applied  on  a  level 
with  the  cricoid  cartilage.  The  patient  lies  upon  the  back,  with  the  chin  raised 
and  the  head  turned  a  little  towards  the  opposite  side.  A  3-inch  incision  is  made 
in  the  line  of  the  vessel,  the  centre  on  a  level  with  the  cricoid  (Fig.  105,  D).  The 
skin,  platysma,  and  fasciag  are  divided,  and  the  anterior  edge  of  the  sterno- 
mastoid  defined  as  the  first  rallying-point.  The  deep  fascia  is  incised  along  its 
inner  border,  so  that  it  may  be  drawn  aside  by  a  retractor  ;  the  sterno-mastoid 
branch  of  the  superior  thyroid  artery  may  be  divided  at  this  stage,  and  a  vein 
passing  between  the  facial  and  anterior  jugular  may  also  need  to  be  ligatured. 
On  the  inner  side  of  the  wound  the  omo-hyoid  muscle  must  now  be  looked  for, 
trending  forwards  and  upwards  from  under  cover  of  the  sterno-mastoid.  In 
the  angle  formed  by  these  two  structures  the  pulsation  of  the  vessel  should  be 
felt  and  the  sheath  readily  recognised,  with  the  descendens  cervicis  nerve  upon 
it.  It  is  opened  on  the  inner  side,  and  the  artery  well  cleared.  The  needle  is 
passed  from  without  inwards,  and  if  the  sheath  has  been  efficiently  opened,  the 
vagus  nerve  will  run  no  risk  of  being  included. 

Ligature  below  the  Omo-hyoid. — The  incision  is  made  in  a  similar  direction  to 
the  above,  but  lower  in  the  neck,  reaching  from  the  cricoid  cartilage  nearly  to  the 
sterno-clavicular  joint.  The  sterno-mastoid  is  drawn  outwards,  and  perhaps  the 
anterior  fibres  may  need  to  be  divided  ;  the  sterno-hyoid  and  -thyroid  muscles 
are  retracted  inwards  or  divided,  and  the  omo-hyoid  can  usually  be  drawn 
upwards.  The  sheath  is  thus  exposed,  and  opened  on  the  inner  side,  the  needle 
being  passed  as  in  the  previous  operation.  It  must  be  remembered  that  both 
internal  jugular  veins  are  directed  towards  the  right  side  in  the  lower  part  of 
their  course,  and  hence  the  left  vein  is  likely  to  lie  somewhat  in  front  of  the 
artery.  The  inferior  thyroid  veins  may  also  be  seen,  and  need  to  be  drawn 
aside  or  ligatured. 

The  effects  of  ligature  of  the  carotid  upon  the  brain  are  of  great  interest  and 
importance.  Statistics  prove  that  about  25  per  cent,  of  the  patients  develop 
cerebral  symptoms,  either  immediately  in  the  form  of  syncope  from  cerebral 
anasmia,  or  in  the  course  of  a  few  days  from  cerebral  softening,  causing  paralysis 
on  the  opposite  side  of  the  body,  and  even  death.  A  fatal  issue  is  likely  to  result 
in  about  half  the  cases  thus  affected.  Occasionally  a  somewhat  acute  form  of 
congestion  of  the  lungs  follows  ligature  of  the  carotid  within  a  few  hours,  possibly 
due  to  interference  with  the  circulation  in  the  medulla,  or  to  irritation  or  injury 
of  the  vagus  or  sympathetics ;  it  may  run  on  to  subacute  inflammation,  and  is 
best  remedied  by  free  stimulation  or  venesection. 
Collateral  Circulation. — Intracrajiial :  Circle  of  Willis. 

Extracranial :  Communications  across  the  middle  line  of  branches  of  the 
external  carotids  and  vertebrals  ;  inferior  thyroid  with  the  superior  tliyroid  ; 
profunda  cervicis  with  princeps  cervicis  of  occipital ;  superficial  cervical  with 
branches  of  occipital  and  vertebral. 

Ligature  of  the  Internal  Carotid. — An  incision  is  made  along  the  anterior  border 
of  the  sterno-mastoid,  its  centre  being  opposite. the  great  cornu  of  the  hyoid  bone ; 
the  muscle  is  pulled  backwards,  and  the  posterior  belly  of  the  digastric  is  seen 
and  drawn  up.  The  external  carotid  is  displaced  forwards,  and  then  the  internal 
carotid  in  its  sheath  appears.  The  latter  is  opened,  and  the  aneurism  needle 
passed  from  the  jugular  vein. 

The  Collateral  Circulation  to  the  brain  is  maintained  by  the  circle  of  Willis. 
Ligature  of  the  External  Carotid  is  occasionally  required,  the  site  of  election 
being  between  the  superior  thyroid  and  lingual  branches.     An  incision  is  made 
along  the  anterior  border  of  the  sterno-mastoid,  3  inches  in  length,  its  centre' 


332 


A  MANUAL  OF  SURGERY 


corresponding  to  the  great  cornu  of  the  hyoid  bone.  The  edge  of  the  muscle 
is  defined  and  drawn  outwards,  and  the  posterior  belly  of  the  digastric  sought 
for  above,  the  hypoglossal  nerve  lying  just  below  it.  The  sheath  is  now 
opened   below  the  tip  of  the  great  cornu  of  the  hyoid  bone,  and  the  needle 

passed  from  without  inwards.  The 
operation  may  be  rendered  difficult 
by  the  presence  of  enlarged  glcnds 
or  veins,  especially  the  lingual, 
facial,  and  superior  thyroid,  which 
lie  in  front  of  the  vessel.  The 
superior  laryngeal  nerve  is  placed 
immediately  behind  it,  and  must  be 
avoided. 

Collateral  Circulation.  —  Vide  liga- 
ture of  the  common  carotid  (extra- 
cranial portion). 

Ligature  of  the  Lingual  Artery  is 
chiefly  needed  as  a  preliminary  to 
removal  of  the  tongue  for  malignant 
disease.  The  vessel  can  be  secured 
either  close  to  its  origin  from  the 
external  carotid,  or  in  the  sub- 
maxillary triangle  under  cover  of 
the  hyoglossus  muscle. 

Iti  the  Submaxillary  Triangle.  — 
The  patient  lies  on  his  back,  with 
the  shoulders  raised,  and  the  head 
extended  backwards  and  turned 
to  the  opposite  side, 
incision  is  made, 
about  I  inch  below 
to  the  symphysis  menti,  and  skirt- 
ing the  angle  of  the  jaw,  the 
A.,  Flap  incision  used  in  trephining  for  centre  opposite  the  great  cornu 
meningeal  haemorrhage ;  B,  flap  incision  of  the  hyoid  bone  (Fig.  105,  C). 
for  operation  on  roots  of  the  fifth  nerve  ;  The  integument  and  platysma  are 
C.incisionforligatureoflingualartery;  D,  divided,  the  lower  border  of  the 
for  ligature  of  common  carotid ;  E,  for  submaxillary  gland  is  defined,  and 
ligature  of  vertebral  artery;  F,  for  ligature  along  it  the  deep  fascia  is  incised, 
of  the  third  part  of  the  subclavian  ;  G  and  The  gland  is  now  drawn  upwards 
G',  incisions  used  for  tying  first  part  of  and  held  over  the  margin  of  the  jaw 
axillary;  H,  for  ligature  of  internal  with  a  retractor  (Fig.  106, Gs).  On 
mammary  artery.  opening   up  the  wound  thoroughly 

the  two  bellies  of  the  digastric 
muscle  {M  dig)  are  seen  converging  to  the  hyoid  bone,  the  anterior  belly  passing 
superficial  to  the  fibres  of  the  mylo  -  hyoid  muscle  {M  my  ho),  which  course 
nearly  transversely  to  the  mandible,  and  of  which  the  posterior  fibres  may 
be  divided  with  advantage.  The  digastric  tendon  is  drawn  down  with  a  blunt 
hook,  and  in  the  space  thus  cleared  the  hyoglossus  muscle  {M  hyogl)  becomes 
evident  with  its  fibres  passing  vertically  upwards,  and  resting  upon  it  the  hypo- 
glossal nerve  (5)  coursing  forwards  to  get  under  cover  of  the  myio-hyoid,  and 
Either  above  or  below  it  the  ranine  vein.  The  fibres  of  the  hyoglossus  are  now 
divided  transversely  midway  between  the  nerve  and  the  hyoid  bone,  and  in  the 
opening  made  by  their  retraction  is  seen  the  artery  (3),  lying  on  the  middle  con- 
strictor. Should  it  not  be  found  in  this  situation,  the  incision  in  the  hyoglossus 
should  be  extended  backwards,  and  the  vessel  will  then  usually  come  in  sight. 

In  the  Neck  close  to  its  Origin. — An  incision  is  made  along  the  anterior  border 
of  the  sterno-mastoid  similar  to  that  needed  for  ligature  of  the  external  carotid. 
The  muscle  is  drawn  backwards,  and  the  great  cornu  of  the  hyoid  bone  defined. 
The  small  space  is  now  cleared  between  that  bony  process  and  the  posterior 


Fig. 


105. — Incisions  for  Various  Opera- 
tions ON  Head  and  Neck. 


A  crescentic 
commencing 
the   external 


LIGATURE  OF  VESSELS 


333 


belly  of  the  digastric,  in  which  the  artery  can  be  felt  resting  upon  the  middle 
constrictor,  and  secured  just  as  it  rises  from  the  external  carotid. 

The  Facial  Artery  may  be  exposed  and  tied  through  a  horizontal  incision, 
I  inch  in  length,  made  directly  over  the  vessel  as  it  crosses  the  lower  border  of 
the  jaw  immediately  in  front  of  the  masseter.  The  platysma  will  need  division, 
as  well  as  the  skin  and  fascia. 

The  Temporal  Artery  is  reached  in  front  of  the  auditory  meatus,  and  as  it 
crosses  the  zygoma,  through  a  vertical  incision.  It  is  merely  covered  by  skin 
and  fascia,  but  must  be  carefully  isolated  from  the  auriculo-temporal  nerve. 

The  Occipital  Artery  is  tied  through  an  incision  extending  from  the  apex  of 
the  mastoid  process  backwards  for  about  2  inches  towards  the  occipital  pro- 
tuberance. The  posterior  fibres  of  the  sterno-mastoid,  the  splenius,  and  trachelo- 
mastoid,  are  divided  so  as  to  expose  the  artery  as  it  emerges  from  the  groove  on 
the  under  surface  of  the  mastoid  process,  where  it  is  easily  secured. 

The  Subclavian  Artery  has  been  tied  in  each  part  of  its  course,  but  most  fre- 
quently in  the  third.  Ligatures  of  the  first  and  second  parts  are  such  unusual 
proceedings  that  we  must  refer  students  to  larger  textbooks  for  descriptions. 


Fig.  106. — Ligature  of  Lingual  Artery.  (Tillmanns.) 
The  submaxillary  gland  {Gs)  has  been  drawn  over  the  side  of  the  jaw  with  a 
hook;  I,  external  carotid;  2,  internal  jugular  artery  ;  3,  Hngual  artery; 
4,  ranine  branch  of  facial  artery  ;  5,  hypoglossal  nerve ;  M  dig,  digastric  ; 
M  styl,  stylo-hy  Old  ;  _M  my  ho,  mylo-hyoid  ;  M  hyogl,  hyoglossus.  The  place 
where  the  artery  is  tied  is  indicated  by  a  window  in  the  hyoglossus,  through 
which  it  can  be  seen. 


Ligature  of  the  third  part  is  performed  for  axillary  aneurism,  for  haemorrhage, 
as  a  distal  operation  for  aortic  or  innominate  aneurism,  and  sometimes  as  a  pre- 
liminary to  amputation  of  the  upper  extremity.  The  patient  is  placed  on  the  back, 
close  to  the  edge  of  the  table ;  the  arm  is  well  depressed,  and  the  head  turned  to 
the  opposite  side.  The  skin  is  now  drawn  down  by  the  left  hand,  and  an  incision 
3  or  4  inches  long  made  over  the  clavicle  (Fig.  105,  F).  On  releasing  the  skin  it 
retracts  upwards,  so  that  the  wound  comes  to  be  situated  about  J  inch  above  the 
clavicle,  and  thus  the  external  jugular  vein  is  more  efficiently  protected.  The 
incision  should  be  placed  with  its  centre  about  i  inch  to  the  inner  side  of  the 
middle  of  the  clavicle,  and  should  expose  the  space  between  the  sterno-mastoid 
and  trapezius  muscles,  the  fibres  of  which  are  divided  to  a  suitable  extent  if  they 
encroach  abnormally  upon  the  bone.     The  skin,  superficial  fascia,  and  nerves. 


334  A  MANUAL  OF  SURGERY 

with  the  platysma,  are  divided  along  the  whole  length  of  the  incision,  as  also  the 
deep  fascia.  The  external  jugular  and  other  veins  now  come  into  view,  often 
constituting  a  plexus,  which  may  give  the  surgeon  much  trouble  ;  they  are  cither 
drawn  aside  or,  if  necessary,  divided  between  ligatures.  The  cellular  tissue  is 
then  further  incised  in  the  line  of  the  wound,  care  being  taken  to  avoid  the  trans- 
verse cervical  and  suprascapular  arteries,  the  former  of  which  is  above  the  line 
of  operation,  whilst  the  latter  is  hidden  behind  the  clavicle  and  should  not 
appear.  The  posterior  belly  of  the  omo-hyoid,  if  seen  at  all,  is  drawn  upwards. 
Various  layers  of  fascia  must  be  carefully  cut  or  torn  through  until  the  nerves  of 
the  brachial  plexus  appear  ;  the  finger  can  then  readily  define  the  scalene  tubercle 
on  the  first  rib.  The  subclavian  vein  is  situated  in  front  of  the  finger,  but  on  a 
lower  level,  whilst  the  artery  itself  can  be  detected  pulsating  under  the  pulp  of 
the  finger  between  it  and  the  rib.  The  cords  of  the  brachial  plexus  are  placed 
above  and  external  to  it,  the  lower  cord  passing  down  behind.  The  needle  i» 
insinuated  from  above  downwards,  and  must  be  kept  very  close  to  the  artery  to 
prevent  all  possibility  of  including  the  lowest  cord  of  the  plexus.  The  operation 
in  a  thin  patient  may  be  easy,  but  in  a  stout  subject,  with  a  short  thick  neck  and 
high  clavicle,  the  greatest  difficulty  may  be  experienced  in  finding  the  vessel. 
The  chief  dangers  arise  from  wounding  the  aneurismal  sac,  the  pleural  cavity, 
or  the  superficial  veins,  whilst  the  proximity  of  the  cords  of  the  brachial  plexus 
must  not  be  forgotten. 

Collateral  Circulation. — Thoracic  set :  Branches  of  the  aortic  intercostals  and 
internal  mammary  with  thoracic  branches  of  axillary. 

Scapular  set:  Suprascapular  and  posterior  scapular  with  subscapular  and  its 
dorsalis  branch  in  the  venter  or  on  the  dorsum  of  scapula. 

Acromial  set :  Suprascapular  with  acromio-thoracic. 

The  Internal  Mammary  Artery  (Fig.  105,  H)  may  be  exposed  and  tied 
by  dividing  the  intercostal  aponeurosis  and  muscles  for  an  inch  or  more 
from  the  outer  edge  of  the  sternum,  from  which  margin  it  is  distant  about 
\  inch. 

Ligature  of  the  Vertebral  Artery  has  been  undertaken  for  wounds,  for 
secondary  haemorrhage  after  ligature  of  the  innominate,  and  in  the  treatment 
of  epilepsy,  but  without  much  permanent  benefit  in  the  last  case.  An  incision 
is  made  along  the  lower  half  of  the  posterior  border  of  the  sterno-mastoid 
(Fig.  105,  E),  the  platysma  and  deep  fascia  are  divided,  and  the  muscle  drawn 
forwards.  The  scalenus  anticus  is  clearly  defined,  together  with  the  phrenic 
nerve.  The  interval  between  it  and  the  longus  colli  muscle  can  now  be  demon- 
strated, with  the  ascending  cervical  artery  lying  upon  it.  The  anterior  transverse 
process  of  the  sixth  cervical  vertebra  must  be  made  out.  Just  below  this  the 
vertebral  vessels  are  found  entering  the  canal  in  the  transverse  process,  and  the 
vein,  which  is  placed  anteriorly,  is  drawn  outwards  to  allow  the  needle  to  be 
passed  from  without  inwards.  A  few  sympathetic  twigs  are  included  in  the 
ligature,  and  the  resulting  contraction  of  the  pupil  may  (according  to  the  late  Sir 
William  MacCormac)  be  looked  upon  as  satisfactory  evidence  that  the  vertebral 
has  been  in  reality  secured. 

Ligature  of  the  Thyroid  Vessels  is  sometimes  used  as  a  means  of  arresting  the 
growth  of  a  goitre. 

The  superior  thyroid  artery  is  tied  through  an  incision  along  the  anterior  margin 
of  the  sterno-mastoid,  which  has  its  centre  opposite  the  upper  border  of  the 
thyroid  cartilage ;  the  external  carotid  is  defined,  and  the  superior  thyroid 
secured  at  its  origin. 

The  inferior  thyroid  artery  is  reached  through  an  incision  along  the  inner  border 
of  the  sterno-mastoid,  extending  upwards  from  the  clavicle  for  3  inches.  This 
muscle  and  the  subjacent  carotid  sheath  are  drawn  outwards,  the  sterno-hyoid 
and  -thyroid  usually  needing  to  bs  divided.  The  transverse  process  of  the  sixth 
cervical  vertebra  is  sought  for,  and  the  vessel  found  passing  inwards  immediately 
below.  It  is  taken  up  just  behind  the  carotid,  and  as  far  from  the  recurrent 
laryngeal  nerve  as  possible.  _  j.      , 

The  Axillary  Artery  is  tied  for  punctured  wounds  of  the  axilla,  as  a  distal 
operation  for  subclavian  aneurism,  occasionally  for  wounds  of  the  palmar  arch, 


LIGATURE  OF  VESSELS  335 

and  possibly  for  secondary  haemorrhage  from  the  brachial.     Two  classical  opera- 
tions are  described  and  practised  in  classes  on  operative  surgery. 

1.  Ligature  of  the  first  part  of  the  vessel  is  usually  undertaken  through  a  curved 
incision,  with  its  concavity  upwards,  extending  from  the  coracoid  process  to 
within  I  inch  of  the  sterno-clavicular  joint,  and  \  inch  below  the  clavicle 
(Fig.  105,  G').  The  clavicular  origin  of  the  pectoralis  major  is  divided,  and  the 
costo-coracoid  membrane  exposed,  and  divided  along  the  lower  border  of  the 
subclavius  muscle.  Branches  of  the  acromio-thoracic  axis  are  displaced  down- 
wards, and  the  main  trunk  is  exposed  by  a  blunt  dissector  and  forceps.  The 
vein  lies  within  and  below,  and  the  cords  of  the  brachial  plexus  above  and 
to  the  outer  side.  The  needle  is  passed  from  below  upwards.  The  divided 
muscular  fibres  should  be  subsequently  sutured  together. 

An  incision  which  give*  an  unusually  good  approach  and  involves  less  division 
of  muscular  fibres  is  one  which  follows  the  lower  border  of  the  clavicle  from 
its  centre  outwards  to  the  coracoid  process,  and  then  turns  down  to  lie  over  the 
interspace  between  the  pectoralis  major  and  deltoid  muscles  (Fig.  105,  G).  This 
intersection  is  opened  up  and  the  outermost  fibres  of  the  pectoralis  which  arise 
from  the  clavicle  are  divided.  The  costo-coracoid  membrane  is  thus  exposed, 
and  the  cephalic  vein  will  act  as  a  guide  to  the  vessels. 

2.  Ligature  of  the  third  part  of  the  artery  is  performed  from  the  axilla.  The 
arm  is  fully  abducted,  and  the  surgeon  stands  between  it  and  the  body.  An 
incision  is  made  in  the  course  of  the  vessel  at  the  junction  of  the  anterior  and 
middle  thirds  of  the  space  between  the  axillary  folds  (Fig.  107,  A).  The  inner 
border  of  the  coraco-brachialis  muscle  is  clearly  defined,  and  forms  the  first 
rallying-point ;  it  is  drawn  slightly  outwards,  and  the  median  nerve,  together 
with  the  musculo-cutaneous  trunk,  at  once  comes  into  view.  On  drawing  these 
inwards,  the  artery  itself  is  seen,  with  the  vein  to  the  inner  side,  together  with  the 
internal  cutaneous  nerve.     The  needle  is  passed  from  the  vein. 

Collateral  Circulation. — If  above  the  acromio-thoracic,  the  same  as  for  the  third 
part  of  the  subclavian  {q.v,). 

If  above  the  subscapular  and  circumflex  :  Long  thoracic  and  intercostals  with 
thoracic  branches  of  subscapular  ;  suprascapular  and  posterior  scapular  with 
scapular  branches  of  subscapular ;  suprascapular  and  acromio-thoracic  with 
posterior  circumflex  in  the  deltoid. 

If  below  the  circumflex,  same  as  for  ligature  of  brachial  above  the  superior 
profunda — i.e.,  posterior  circumflex  with  superior  profunda  in  the  deltoid. 

The  Brachial  Artery  may  need  to  be  ligatured  for  haemorrhage  from  the 
palmar  arches,  or  from  a  wound  in  the  forearm  or  about  the  elbow,  for  aneurisms, 
or  for  arterio-venous  wounds  at  the  bend  of  the  elbow.  It  may  be  tied  in  one  of 
two  places: 

I.  At  the  Middle  of  the  Arm. — The  arm  is  held  away  from  the  side  at  a  right 
angle,  with  the  hand  supine,  but  with  no  support  beneath  it,  for  fear  of  pushing 
forwards  the  triceps  and  displacing  the  vessel.  Tlie  surgeon  stands  between  the 
arm  and  the  trunk.  An  incision  2  inches  long  is  made  in  the  line  of  the  vessel 
along  the  inner  border  of  the  biceps  muscle  (Fig.  107,6),  and  the  thin  fascial 
investment  of  the  limb  divided.  The  inner  edge  of  the  muscle  is  clearly  exposed, 
and  by  drawing  it  slightly  forwards  the  median  nerve  is  brought  into  view,  and 
perhaps  the  basilic  vein.  The  nerve,  which  is  at  this  spot  crossing  the  artery 
from  without  inwards,  is  drawn  inwards,  and  the  sheath  of  the  vessel  found 
beneath  it.  The  artery  is  separated  from  its  venae  comites,  and  the  ligature 
passed  and  tied. 

The  operation  is  by  no  means  always  easy,  as  there  are  many  traps  into  which 
the  beginner  may  fall.  Thus  the  median  nerve  may  cross  behind  the  vessel  instead 
of  in  front  of  it ;  the  basilic  vein  may  lie  over  its  situation,  and  be  mistaken  for 
it :  or  there  may  be  a  high  division,  and  two  trunks,  usually  lying  close  together, 
must  then  be  sought  for  instead  of  one.  The  most  common  mistake  consists  in 
not  defining  the  biceps  muscle,  and  in  seeking  for  the  artery  behind  its  proper 
situation. 

■2.  At  the  Bend  of  the  Elbow. — An  oblique  incision  is  made,  about  2  inches  long, 
parallel  to  the  inner  border  of  the  biceps  tendon,  its  lower  end  corresponding  to 


336 


A  MANUAL  OF  SURGERY 


f-^S^ 


the  crease  of  the  elbow  (Fig,  107,  C).  The  incision  should  be  placed  at  abou 
an  angle  of  forty-five  degrees  to  the  axis  of  the  limb,  and  to  the  outside 
of,  and  nearly  parallel  to,  the  median  basilic  vein,  which,  if  seen  must  be 
drawn  inwards.     The  bicipital  fascia  is  now  incised,  and  the   artery   with   its 

venas  comites  exposed  in  the  loose  fat,  the 
median  nerve  being  well  away  on  the  inner 
side.  The  needle  is  passed  from  within  out- 
wards. 

Collateral  Circulation. — If  above  the  origin 
of  the  superior  profunda,  posterior  circumflex 
in  deltoid  with  ascending  branches  of  superior 
profunda. 

If  below  the  origin  of  the  inferior  profunda, 
the  anastomoses  around  the  elbow-joint. 

The  Ulnar  Artery  rarely  needs  ligature 
except  for  palmar  haemorrhage  or  direct 
wounds.  In  the  former  case  the  artery  can 
easily  be  secured  just  above  the  wrist,  in  the 
latter  case  by  enlarging  the  original  wound. 
The  following  stereotyped  operations  are  de- 
scribed, but  are  more  often  seen  in  the 
examination-room  or  dead-house  than  in  the 
operating  theatre.  It  should  be  borne  in 
mind  that  the  artery  curves  inwards  from  the 
centre  of  the  bend  of  the  elbow  to  the  radial 
side  of  the  pisiform  bone.  The  lower  two- 
thirds  of  its  course  is  indicated  by  a  line 
drawn  from  the  internal  condyle  of  the 
humerus  to  the  same  spot  below. 

1.  At  the  Wrist. — An  incision  about  i  inch 
in  length  is  made  directly  upwards  from  the 
flexure  of  the  wrist  in  the  line  of  the  vessel 
(Fig.  107,  F).  The  deep  fascia  is  opened,  the 
tendon  of  the  flexor  carpi  ulnaris  drawn  to 
the  inner  side,  and  the  vessels  are  then  seen, 
accompanied  by  the  nerve  which  lies  to  the 
ulnar  side  of  the  artery.  If  possible,  the 
venae  comites  should  be  separated,  and  not 
included  in  the  ligature. 

2.  In  the  Middle  of  the  Foi-eann, — An  incision 
is  made  along  a  line  drawn  from  the  anterior 
edge  of  the  tip  of  the  inner  condyle  to  the  radial 
side  of  the  pisiform  bone  (Fig.  107,  G).  The 
whiteline  indicating  the  intermuscular  septum 
between  the  flexor  carpi  ulnaris  and  flexor  sub- 
limis  digitorum  is  then  sought  for  and  opened 
up  ;  it  is  often  very  slightly  marked,  and  may 
be   difficult   to   distinguish.     If    the   correct 

interspace  has  been  opened,  the  surgeon  is  directed  towards  the  ulna,  and  readily 
finds  the  vessels  under  cover  of  the  flexor  carpi  ulnaris,  with  the  nerve  lying  a 
little  way  to  the  inner  or  ulnar  side.  The  most  common  mistake  consists  in 
getting  too  far  to  the  radial  side,  and  in  separating  various  portions  of  the  flexor 
sublimis,  or  in  passing  between  it  and  the  palmaris  longus.  Occasionally,  even 
when  the  correct  interspace  has  been  entered,  a  beginner  may  pass  beyond  the 
vessels,  and  find  himself  between  the  flexor  carpi  ulnaris  aud  the  flexor  pro- 
fundus. 

3.  The  upper  limit  of  the  ulnar  artery  can  be  reached  through  an  oblique 
incision  along  the  upper  border  of  the  pronator  teres,  thus  opening  up  the  ante- 
cubital  fossa,  and  exposing  the  bifurcation  of  the  brachial. 

Radial  Artery. — The  line  of  the  vessel  extends  from  the  middle  of  the  bend  of 
the  elbow  to  the  interspace  at  the  wrist  between  the  flexor  carpi  radialis  and  the 


Fig.  107 — Incisions  for  Tying 
THE  Arteries  of  the  Arm. 

A,  Third  part  of  the  axillary  ;  B, 
brachial;  C,  brachial  at  the 
bend  of  the  elbow  ;  D,  middle 
third  of  radial ;  G,  middle  third 
of  ulnar  ;  E  and  F,  lower  thirds 
of  radial  and  ulnar. 


LIGATURE  OF  VESSELS  337 

supinator  longus.  It  then  turns  outwards,  and  may  be  felt  beating  in  the  space 
described  by  P'rench  anatomists  as  '  la  tabatiere '  (or  snuff-box),  between  the 
tendons  of  the  extensor  primi  and  extensor  secundi  internodii  muscles. 

1.  At  the  Back  of  the  Wrist  the  vessel  may  be  secured  by  opening  up  the  above- 
mentioned  intertendinous  hollow,  where  the  artery  is  found  coursing  onwards  to 
the  base  of  the  first  interosseous  space.  An  oblique  incision  is  made  between 
the  tendons,  extending  from  the  back  of  the  styloid  process  of  the  radius  to  the 
base  of  the  first  metacarpal  bone.  The  superficial  radial  vein  is  found  beneath 
the  skin,  and  a  few  twigs  of  the  radial  nerve.  A  deeper  layer  of  fascia  is  then 
divided,  passing  between  the  tendons,  and  beneath  it  the  artery  is  exposed, 
crossing  the  incision  obliquely.  The  synovial  sheaths  accompanying  the  tendons 
should  not  be  opened,  or  some  limitation  of  the  movements  of  the  thumb  may 
result. 

2.  Above  the  Wrist  an  incision  is  made  in  the  line  of  the  vessel  (Fig.  107, E), 
which  is  found  after  division  of  the  fascia  between  the  supinator  longus  and 
flexor  carpi  radialis.  The  radial  nerve  has  passed  to  the  dorsum  ere  this,  and  if 
any  nerve  filaments  are  seen  they  are  derived  from  the  external  cutaneous.  A 
small  superficial  vein  usually  lies  over  the  artery. 

3.  In  the  Middle  or  Upper  Third  of  the  Forearm  an  incision  is  made  in  the  line 
of  the  vessel  (Fig.  loy.D),  and  the  inner  border  of  the  supinator  longus  sought 
for  and  retracted.  The  vessels  are  found  under  cover  of  this  structure,  with  the 
radial  nerve  to  the  outer  side,  though  separated  by  an  interval  above. 

Ligature  of  the  Abdominal  Aorta*  has  been  undertaken  in  fourteen  instances 
for  severe  primary  or  secondary  haemorrhage,  or  for  diffuse  inguinal  or  iliac 
aneurism,  when  no  other  method  of  treatment  was  practicable.  All  these  cases 
have  proved  fatal,  though  one  patient  operated  on  by  Monteiro  in  South  America 
survived  till  the  tenth  day,  whilst  Keen's  and  Tillaux's  lived  forty-eight  and 
thirty-nine  days  respectively.  The  fatal  issue  was  in  most  instances  due  to  septic 
contamination  and  secondary  haemorrhage.  The  operation  consists  in  opening 
the  abdomen  through  an  incision  slightly  to  the  left  of  the  middle  line,  having 
the  umbilicus  on  a  level  with  its  centre.  The  intestines  are  retracted,  and  the 
posterior  layer  of  the  serous  membrane  covering  the  aorta  carefully  divided  ; 
there  is  then  no  difficulty  in  passing  a  ligature  around  the  vessel.  Possibly  it 
would  be  well  to  prevent  excessive  backflow  of  blood  by  securing  one  or  both  of 
the  common  iliac  trunks  in  addition ;  such  would  in  no  way  interfere  with  the 
collateral  circulation. 

The  Common  Iliac  Artery  extends  for  a  distance  of  2  inches  from  the  bifurcation 
of  the  aorta  opposite  the  left  side  of  the  body  of  the  fourth  lumbar  vertebra  to 
the  front  of  the  sacro-iliac  synchondrosis.  It  may  be  reached  through  an  incision 
made  in  the  median  line  with  its  centre  a  little  below  the  umbilicus.  The  vessel 
is  sought  for  and  exposed  by  an  incision  through  the  posterior  layer  of  the  parietal 
peritoneum,  and  a  ligature  passed  and  tied.  The  ureter  which  crosses  the  artery 
just  above  its  bifurcation  must  be  carefully  avoided. 

Collateral  Circulation. — Blood  reaches  the  external  iliac  and  its  branches  by 
means  of  the  anastomosis  of  the  lumbar  arteries  ivith  the  circumflex  iliac,  and 
of  the  superior  epigastric,  lumbars,  and  intercostals  with  the  superficial  and 
deep  epigastric.  The  internal  iliac  and  its  branches  are  supplied  by  the  union 
of  (a)  the  lumbar  branches  with  the  ilio-lumbar  ;  (b)  the  middle  sacral  with 
the  lateral  sacral ;  {c)  the  retropubic  anastomosis  of  the  two  obturator  arteries  ; 
and  [d)  the  communications  of  the  pudic,  haemorrhoidal,  and  vesical  trunks  with 
those  of  the  opposite  side. 

Ligature  of  the  Internal  Iliac  Artery  is  occasionally  performed  for  haemorrhage 
from,  or  aneurism  of,  one  of  its  branches,  the  gluteal  being  that  most  commonly 
affected.  The  trunk  is  a  short  one,  at  most  i|  inches  in  length,  and  is  best 
reached  by  opening  the  abdomen  in  the  middle  line  below  the  umbilicus 
(Fig.  108,  C),  pushing  aside  the  intestines,  and  searching  for  the  bifurcation  of  the 
common  iliac.     The  posterior  layer  of  the  peritoneum  is  then  carefully  incised, 

*  See  Tillaux  and  Riche,  Revue  de  Chirurgie,  January,  February,  and  March, 
1901, 

22 


338 


A  MANUAL  OF  SURGERY 


the  ureter  avoided,  and  an  armed  aneurism  needle  passed  without  wounding 
the  vein. 

The  Collateral  Cinulatioji  is  the  same  as  that  given  for  the  internal  iliac 
division  of  the  common  iliac. 

The  Gluteal  Artery  emerges  from  the  pelvis  at  a  spot  indicated  by  the  junction 
of  the  inner  and  middle  thirds  of  a  line  drawn  from  the  posterior  superior  iliac 
spine  to  the  top  of  the  great  trochanter.  To  ligature  it  an  incision  is  made  in  the 
direction  of  this  line — i.e.,  along  the  fibres  of  the  gluteus  maximus,  which  are 
separated  and  held  apart.  The  deep  fascia  beneath  this  muscle  is  then  opened 
up,  and  the  space  between  the  gluteus  medius  and  pyriformis  defined.  Through 
this  the  upper  margin  of  the  sacrosciatic  notch  can  be  detected,  as  also  the 
pulsation  of  the  artery.  The  vessel  must  be  secured  as  deeply  as  possible  on 
account  of  its  early  division.  It  is  always  a  troublesome  dissection,  and  probably 
in  most  cases  it  would  be  wiser  to  deal  with  the  trunk  of  the  internal  iliac. 


Fig.   io8. 


-Incisions  for  Operations  on  Lower  Part  of  Abdomen  and 
Upper  Part  of  Thighs. 


A,  Mott's  incision  for  retro-peritoneal  ligature  of  common  iliac  artery;  B, 
Marcellin  Duval's  incision  for  the  same;  C,  incision  for  transperitoneal 
ligature  of  internal  iliac  artery;  D,  incision  for  excision  of  hip  by  the  anterior 
method  ;  F,  Abernethy's  modified  operation  for  ligature  of  external  iliac  ;  G, 
Astley  Cooper's  incision  for  same  ;  H,  ligature  of  femoral  artery  at  apex  of 
Scarpa's  triangle  ;  K,  ligature  of  femoral  artery  in  Hunter's  canal. 

The  Sciatic  and  Pudic  Arteries  seldom  require  to  be  tied,  but  may  be  reached 
opposite  the  ischial  spine,  at  the  junction  of  the  middle  and  lov/er  thirds  of  a 
line  drawn  from  the  posterior  superior  iliac  spine  to  the  tuber  ischii.  An  incision 
about  4  inches  in  length  is  made  over  this  spot,  corresponding  in  direction  to  the 
fibres  of  the  gluteus  maximus,  which  are  separated.  The  spine  of  the  ischium 
and  lower  border  of  the  pyriformis  should  now  be  defined,  and  the  vessels  and 
nerves  seen  emerging  from  the  foramen.  The  pudic  vessel  lies  to  the  inner  side 
of  the  sciatic  ;  the  ligature  is  passed  as  high  as  possible. 

The  External  Iliac  Artery  is  easily  accessible  in  any  part  of  its  course,  which 
measures  from  3^  to  4  inches  in  length  ;  it  has  but  few  branches,  and  those 
situated  low  down.  Its  position  is  indicated  by  the  lower  two-thirds  of  a  line 
drawn  from  the  bifurcation  of  the  aorta  to  midway  between  the  anterior  superior 
spine  and  the  symphysis  pubis — i.e.,  to  a  point  a  little  internal  to  the  middle  of 
Poupart's  ligament. 


LIGATURE  OF  VESSELS  339 

Many  suggestions  as  to  the  best  means  of  reaching  the  artery  have  been  made 
and  both  trans-  and  extra-peritoneal  methods  have  been  adopted.  It  is  so  readily 
secured,  however,  by  the  latter  that  it  seems  unnecessary  to  open  the  peritoneum. 
There  are  two  chief  forms  of  extraperitoneal  operation. 

Astley  Cooper's  Operation. — An  incision  is  made  parallel  to  the  outer  half  of 
Poupart's  ligament,  commencing  a  little  to  the  inner  side  of  its  centre,  and 
I  inch  above  it,  and  extending  upwards  and  outwards  to  about  i  inch  internal  to 
the  anterior  superior  spine  (Fig.  loS,  G)  The  external  oblique  aponeurosis  is 
divided  along  this  line,  and  the  exposed  lower  margins  of  the  internal  oblique 
and  transversalis  muscles  arching  over  the  inguinal  canal  are  drawn  upwards  by 
retractors.  The  transversalis  fascia  and  loose  subperitoneal  fat  are  now  opened 
with  forceps  and  director,  and  the  vessel  is  felt  pulsating  immediately  under  the 
finger.  The  epigastric  or  circumflex  iliac  arteries  must  not  be  damaged  during 
this  manipulation,  sicce  they  are  important  factors  in  the  collateral  circulation. 
The  needle  is  passed  from  within  outwards,  the  ligature  tied,  and  the  divided 
muscular  and  aponeurotic  structures  united  by  buried  sutures. 

Ahernethy's  Modified  Operation  is  mqre  commonly  utilized.  The  incision,  about 
4  inches  in  length,  extends  from  a  point  i^  inches  within  and  above  the  anterior 
superior  iliac  spine  to  just  external  to,  and  ^  inch  above,  the  middle  of  Poupart's 
ligament  (Fig.  108,  F).  Through  this  the  aponeurosis  of  the  external  oblique  is 
divided  along  the  course  of  its  fibres,  as  also  the  internal  oblique  and  trans- 
versalis. The  transversalis  fascia  is  now  carefully  incised  ;  it  varies  considerably 
in  thickness,  being  sometimes  well  developed,  but  is  occasionally  so  attenuated 
as  to  be  scarcely  recognisable.  The  fingers  are  now  introduced  into  the  wound, 
and  the  peritoneum  and  its  contents  stripped  from  the  iliac  fossa,  and  drawn 
inwards  and  forwards,  where  they  are  kept  out  of  the  way  by  a  broad  spatula. 
In  the  space  thus  opened  up  one  can  see  the  iliacus  muscle  covered  by  its  fascia, 
and  to  its  inner  side  the  rounded  outline  of  the  psoas.  The  vessel  lies  to  the 
inner  border  of  this,  and  can  usually  be  readily  found,  enveloped  in  a  fascial 
sheath,  with  the  genito-crural  nerve  coursing  over  it,  and  perhaps  some  lymphatic 
glands  upon  it.  The  artery  is  separated  from  the  vein  which  lies  to  the  inner 
side,  and  the  needle  passed  from  within  outwards.  If  the  transversalis  fascia  has 
not  been  properly  opened,  it  is  quite  possible  to  strip  it  up  together  with  the 
peritoneum,  and  carry  the  vessels  forwards  with  it,  when  they  may  be  found 
under  cover  of  the  spatula. 

Of  these  two  operations,  the  latter  is  probably  the  better.  By  Cooper's  method 
the  artery  is  tied  very  close  to  important  collateral  branches,  whilst  but  a  small 
portion  of  the  trunk  is  exposed,  so  that  if  this  is  diseased  and  unsuitable  for  the 
application  of  a  ligature,  no  further  choice  is  possible.  In  Abernethy's,  on  the 
other  hand,  the  vessel  is  tied  well  away  from  collateral  branches,  and  if  the 
exposed  portion  of  the  trunk  is  diseased,  the  common  iliac  can  be  reached  and 
secured  without  much  difficulty  by  extending  the  incision  upwards.  The  wound 
also  involves  muscular  tissue,  and  therefore  better  repair  and  less  likelihood  of  a 
subsequent  hernia  are  obtained. 

Collateral  Circulation. — Anterior  set:  Superior  epigastric  of  internal  mammary, 
lumbar,  and  lower  intercostals  with  superficial  and  deep  epigastric  in  sheath  of 
rectus. 

Posterior  set :  Gluteal  and  sciatic  with  internal  and  external  circumflex  and  first 
perforating  of  profunda  at  back  of  great  trochanter  (crucial  anastomosis). 

External  set :  Ilio-lumbar  and  gluteal  with  deep  and  superficial  circumflex  iliac 
and  ascending  branch  of  external  circumflex. 

Internal  set :  Obturator  with  internal  circumflex  ;  and  terminal  divisions  of 
internal  pudic  with  superficial  and  deep  external  pudic. 

The  Common  Femoral  Artery  is  but  rarely  ligatured,  except  as  a  preliminary 
measure  in  amputation  at  the  hip-joint,  since  the  number  of  branches  arising 
from  it  is  likely  to  interfere  with  its  sound  occlusion,  and  the  collateral  circula- 
tion is  better  after  ligature  of  the  external  iliac.  It  may  be  reached  by  a  vertical 
incision  over  the  line  of  the  vessel,  extending  both  a  little  above  and  below  Pou- 
part's ligament.  The  superficial  lymphatics  and  veins  must  be  carefully  avoided, 
the  fascia  lata  divided,  the  sheath  exposed  and  opened,  and  the  ligature  passed 
from  the  inner  side. 


340  A  MANUAL  OF  SURGERY 

Collateral  Circulation. — Internal  set:   Obturator  with   internal  circumflex,   and 
internal  pudic  with  external  pudic. 
External  set :  Circumflex  iliac  with  ascending  branch  of  external  circumflex. 

Posterior  set :  Gluteal  and  sciatic  with  internal  and  external  circumflex,  and  first 
perforating;  comes  nervi  ischiadici  zw^YA  perforating  of  the  profunda  and  muscular 
of  popliteal. 

The  Superficial  Femoral  Artery  is  indicated  by  a  line  drawn  from  mid^^ay 
between  the  anterior  superior  spine  and  the  symphysis  pubis  to  the  tuberosity 
of  the  internal  condyle,  the  limb  being  flexed,  abducted,  and  everted.  It  may 
be  secured  at  'the  site  of  election  ' — i.e.,  at  the  apex  of  Scarpa's  triangle — or  in 
Hunter's  canal. 

Ligature  at  the  Apex  of  Scatpa's  Triangle. — A  4-inch  incision  is  made  in  the 
line  of  the  artery,  the  centre  beinj^  about  4  inches  (or  a  hand's  breadth)  below 
Poupart's  ligament  (Fig.noS,  H).  The  integument  and  fasciae  are  divided,  the 
inner  border  of  the  sartorius  exposed,  and  the  sheath  found  immediately  behind 
It,  the  muscle  being  drawn  slightly  outwards  ;  the  middle  cutaneous  nerve  is 
perhaps  brought  into  view.  A  muscular  branch  to  the  sartorius  may  be  met 
with  at  this  spot,  and  should  be  separately  ligatured.  The  vein  is  placed  behind 
the  artery,  so  that  the  needle  may  be  passed  either  way,  special  care  being  taken 
to  keep  it  close  to  the  vessel. 

Collateral  Circulation. — External  circumflex  with  lower  muscular  of  femoral, 
anastomotica  magna,  and  superior  articular  of  popliteal. 

Profunda  femoris  by  its  perforating  and  terminal  branches  with  the  muscular 
and  articular  branches  oi  femoral  and  popliteal. 

Ligature  in  Hunter's  Canal. — An  incision  4  inches  in  length  is  made  along  the 
line  of  the  artery  in  the  middle  of  the  thigh  (Fig.  108,  K)  The  sartorius  is  exposed 
by  division  of  the  fascia  lata,  its  fibres  running  downwards  and  inwards  ;  its 
outer  border  should  be  defined,  and  the  muscle  retracted  inwards.  The  apo- 
neurotic covering  of  Hnnter's  canal  is  now  in  view,  stretching  between  the 
adductor  longus  and  vastus  internus  ;  it  is  incised,  and  the  sheath  of  the  vessel 
found  below  it,  with  the  nerve  to  the  vastus  internus  lying  to  its  outer  side,  the 
long  saphenous  nerve  crossing  it  from  without  inwards,  and  the  vein  passing 
behind  it,  to  become  external  lower  down.  The  needle  may  be  passed  in  either 
direction,  and  the  ligature  should  not  be  placed  too  low  on  account  of  the 
contiguity  of  the  anastomotica  magna.  A  common  mistake  made  by  students  in 
tying  this  artery  on  the  dead  subject  is  to  burrow  down  along  the  vastus  internus 
on  the  outer  side  of  the  vessels  ;  this  is  to  be  avoided  by  always  keeping  close  to 
the  under  surface  of  the  sartorius  until  the  glistening  transverse  fibres  of 
Hunter's  aponeurosis  are  clearly  visible. 

Collateral  Circulation  is  maintained  through  the  profunda  and  its  branches. 

The  Popliteal  Artery  may  be  tied  either  just  after  it  has  passed  through  the 
adductor  opening,  or  in  the  depths  of  the  popliteal  space,  but  preferably  in  the 
former  situation.     Neither  operation  is  often  required. 

To  tie  the  upper  part,  the  limb  is  fully  abducted  and  everted  sa  as  to  enable 
the  adductor  tubercle  and  tendon  of  the  adductor  magnus  to  be  clearly  defined. 
An  incision,  4  inches  in  length,  is  then  made  from  the  tubercle  upwards 
(Fig.  109,  A),  and  the  tendon  exposed.  The  internal  saphenous  vein  and  nerve 
may  be  seen,  but  are  drawn  backwards  by  means  of  a  broad  retractor,  together 
with  the  sartorius,  gracilis,  and  semi-membranosus.  If  possible,  the  branch  of 
the  anastomotica  magna  which  courses  along  the  tendon  should  be  spared.  The 
fascial  space  behind  is  now  opened  up,  and  the  artery  found  surrounded  by  a 
good  deal  of  loose  connective  tissue.  The  vein  is  usually  seen  on  the  outer  side, 
and  is  here  very  thick  and  dense,  so  that  in  the  dead  subject  it  can  be  readily 
mistaken  for  the  artery. 

The  lower  part  is  tied  through  an  incision  in  the  middle  line  of  the  popliteal 
space,  dividing  the  deep  fascia  and  drawing  out  of  the  way  the  heads  of  the 
gastrocnemius  muscle  and  the  internal  popliteal  nerve.  The  vein  is  superficial 
to  the  artery,  and  is  found  by  following  the  short  saphenous  trunk.  The  needle 
is  passed  from  the  inner  side. 

Collateral  Circulation  is  maintained  by  the  anastomoses  around  the  knee- 
joint. 


LIGATURE  OF  VESSELS 


341 


The  Posterior  Tibial  Artery  but  seldom  requires  to  be  ligatured  except  for 
haemorrhage,  or  on  the  face  of  amputation  stumps ;  hence  the  operations' 
described  below  are  rarely  seen  away  from  the  dead-house.  The  line  of  the 
vessel  is  indicated  by  one  drawn  from  the  centre  of  the  popliteal  space  to  a 
point  a  finger's  breadth  behind  the  internal  malleolus, 

1.  In  the  Middle  of  the  Calf. — The  leg  is  placed  on  its  ©uter  side  and  flexed, 
and  an  incision  4  inches  long  is  made  a  finger's  breadth  behind  the  inner  border 
of  the  tibia  (Fig.  icg,  B),  dividing  the  skin  and  subcutaneous  tissues,  the  long 
saphenous  vein  and  nerve  being  drawn  aside  if  necessary.  The  tibial  origin  of 
the  soleus  is  thus  exposed,  and  incised  directly  towards  the  tibia,  until  the  fibrous 
aponeurosis  on  its  deeper  surface  is  met  with.  This  having  been  cut  through, 
the  muscle  is  drawn  backwards  with  the  retractor,  and  the  vessels,  ensheathed 
in  a  deep  layer  of  fascia,  are  seen  lying  on  the  tibialis  posticus,  and  with  the 


Fig.  109  —Incisions  for  Ligature  of  the  Upper  Part  of  the  Popliteal  (A), 

AND    OF    THE    POSTERIOR    TiBIAL    ArTERIES    (B,  C,  and  D). 

E,  Site  for  Introduction  of  knife  in  Tenotomy  of  Tibialis  Posticus  ; 
F,  Ditto  for  Tendo  Achillis. 


posterior  tibial  nerve  to  the  outer  side.  The  venae  comites  are  separated,  if 
possible,  and  the  ligature  passed  from  the  nerve.  Sometimes  the  above-men- 
tioned aponeurosis  is  in  the  substance  of  the  soleus,  and  a  thin  layer  of  muscular 
fibres  exists  on  its  deeper  aspect. 

2.  In  the  Lower  Third  of  the  Leg. — An  incision  is  made  midway  between- the 
tendo  Achillis  and  inner  border  of  the  tibia  (Fig.  log,  C).     The  skin  and  fasciae, 
including  the  upper  pari  of  the  internal  annular  ligament,  are  divided,  and  the  ' 
vessels  seen  lying  on  the  flexor  longus  digitorum,  with  the  nerve  behind  and  to 
the  outer  side. 

3.  Behind  the  Malleolus. — An  incision  is  made  about  a  finger's  breadth  from 
the  malleolus,  curving  round  its  lower  border  (Fig.  109,  D).  The  deep  fascia  (or, 
as  it  is  here  termed,  the  internal  annular  ligament)  is  divided  over  the  vessels 


342 


A  MANUAL  OF  SURGERY 


between  the  tendons  of  the  flexor  longus  digitorum  and  flexor  proprius  hallucis, 
■and  the  artery  is  then  readily  cleared  and  ligatured.  The  sheaths  of  the  tendons 
should  not  be  opened. 

The  Anterior  Tibial  Artery  is  found  along  a  line  stretching  from  a  point  mid- 
way between  the  outer  tuberosity  of  the  tibia  and  the  head  of  the  fibula  above 
to  the  central  point  between  the  two  malleoli  below.  It  may  be  tied  in  three 
situations. 

I.  In  the  Upper  Third  of  the  Leg. — An  incision  is  made  exactly  in  the  line  of 
the  artery  (Fig.  iio,  A),  and  the  deep  fascia  incised.  The  intermuscular  space 
between  the  tibialis  anticus  and  the  extensor  communis  digitorum  is  opened. 
The  vessel  lies  between  these  muscles  upon  the  interosseous  membrane,  the 
anterior  tibial  nerve  being  to  the  outer  side. 


Fig.  no. — Incisions  for  Liga- 
ture OF  Anterior  Tibial 
(A  AND  B)  AND  Peroneal 
(C)  Arteries.  D,  Site  for 
Introduction  of  Knife  in 
Tenotomy  of  Peronei. 


Fig.  Ill — Incisions  for  Liga- 
ture OF  Lower  Part  of 
Anterior  Tibial  (A)  and 
Dorsalis  Pedis  (B)  Arteries. 
C,  Site  for  performing 
Tenotomy  of  Tibialis 
Anticus. 


2.  In  the  Middle  of  the  Leg  (Fig.  no,  B).-The  same  intermuscular  space  is 
opened,  being  indicated  here  by  a  definite  white  line,  due  to  a  slight  subfascial 
deposit  of  fat.  The  vessels  lie  between  the  tibialis  anticus  and  the  deeply-placed 
extensor  proprius  hallucis,  the  nerve  usually  lying  on  the  artery  and  needing  to 
be  drawn  aside. 

3.  In  the  Lower  Third  ef  the  Leg. — An  incision  "is  made  in  the  line  of  the  artery, 
reaching  upwards  for  2  inches  from  a  point  just  above  the  ankle  (Fig.  iii ,  A). 
The  deep  fascia  and  upper  part  of  the  annular  ligament  are  divided,  and  the 
vessel  is  found  between  the  tendons  of  the  tibialis  anticus  and  of  the  extensor 
proprius  hallucis,  the  nerve  lying  to  the  outer  side. 

The  Dorsalis  Pedis  Artery  extends  from  the  centre  of  the  line  between  the  two 


LIGATURE  OF  VESSELS  343 

malleoli  to  the  interval  between  the  bases  of  the  first  two  metatarsal  bones.  An 
incision  is  made  in  this  direction  (Fig.  iii,  B),  the  deep  fascia  opened,  and  the 
artery  found  lying  between  the  extensor  proprius  hallucis,  which  has  now 
crossed  and  is  internal  to  the  vessel,  and  the.  innermost  slip  of  the  extensor 
brevis  digitorum.  It  is  not  always  easy  to  find,  and  for  practical  purposes  the 
best  plan  would  be  to  divide  the  vessel  by  an  incision  extending  to  the  bones 
and  then  pick  up  and  tie  the  bleeding  ends. 

The  Peroneal  Artery  can  be  reached  through  an  incision  along  the  posterior 
border  of  the  centre  of  the  fibula,  the  leg  being  laid  on  its  inner  side  (Fig.lio.C). 
The  outer  edge  of  the  soleus  is  defined  and  drawn  inwards,  the  lower  fibres  of 
attachment  to  the  fibula  being  divided  if  necessary.  The  flexor  longus  hallucis 
is  thereby  exposed,  and  incised  in  such  a  manner  as  to  allow  the  surgeon  to  reach 
the  postero-internal  border  of  the  fibula  ;  the  artery  is  then  readily  found  lying  in 
an  osseo-aponeurotic  canal. 


CHAPTER  XIII. 
SURGERY  OF  THE  VEINS. 

Venous  111101111)0813. 

By  Thrombosis  is  meant  intravascular  coagulation  in  any  part  of  the 
circulatory  system.  Normally  the  blood  remains  in  a  fluid  condition, 
owino-  to  some  inter-action  between  it  and  the  vessel  walls.  Any 
factor  producing  a  disturbance  of  this  normal  equilibrium  may 
determine  thrombosis,  and  any  part  of  the  vascular  tract  may  be 
affected  by  it,  whether  the  heart,  arteries,  veins,  or  capillaries ;  but 
it  is  in  the  veins  that  it  occurs  most  frequently. 

Causes. — (i)  Changes  in  the  vessel  walls,  as  a  result  of  which  the 
integrity  of  the  endothelium  is  disturbed — e.g.,  injury  (either  division, 
rupture,  puncture,  compression,  or  contusion),  inflammation  or 
degeneration  (as  in  varicose  veins). 

(2)  Changes  in  the  constitution  of  the  blood  whereby  its  coagulability 
is  increased.  In  clinical  work  this  is  brought  about  most  frequently 
by  infective  conditions,  which  lead  to  an  excess  of  toxins  in  the  blood. 
Hsemorrhage  up  to  half  of  the  whole  amount  in  the  body  also 
increases  its  coagulability,  but  excess  of  leucocytes,  as  in  leukaemia, 
has  the  opposite  effect.  The  percentage  of  calcium  salts  in  the 
blood  is  also  an  important  factor;  and  the  rate  of  coagulation 
may  be  definitely  influenced  by  administering  calcium  chloride  or 

lactate. 

(3)  Diminished  rate  of  the  bloodstream  predisposes  to  thrombosis  if 
some  other  condition  is  present  to  determine  it.  Lister  showed  years 
ago  that  blood  can  remain  fluid  for  a  long  time  if  confined  in  a  tube 
formed  of  a  suitable  length  of  the  vein  wall ;  but  when  either  of 
the  preceding  factors  is  present,  a  retardation  of  the  blood-stream 
materially  assists  in  causing  coagulation.  Thus,  when  a  vein  is 
pressed  upon  by  a  tumour,  the  obstruction  to  the  blood-flow  produces 
a  clot  at  the  spot  where  the  nutrition  of  the  wall  is  interfered  with. 
After  fevers,  such  as  typhoid,  where  the  character  of  the  blood  is 
somewhat  altered  and  the  action  of  the  heart  weakened  by  changes 
in  the  muscular  fibres,  the  defective  vis-a-tergo  causes  a  retardation 
of  the  flow  in  the  veins,  as  a  result  of  which  the  intravenous  pressure 
is  diminished,  and  the  valves  are  only  partially  pushed  back,  spaces 
being  left  behind  them  in  which  the  blood  stagnates.     Coagulation  is 

344 


SURGERY  OF  THE  VEINS 


345 


probably  determined  by  some  slight  injury  or  pressure  which  is  not 
noticed  by  the  patient,  or  by  some  lessened  vitality  of  the  wall  of  the 
vein,  or  by  disintegration  of  the  leucocytes  and  setting  free  of  fibrin 
ferment  owing  to  the  defective  circulation.  The  clots  thus  formed 
behind  the  valves  gradually  increase  in  size  until  the  whole  lumen  of 
the  ',"essel  is  obstructed. 

The  Character  of  the  clot  varies  according  to  whether  it  is  deposited 
slowly  or  is  due  to  a  rapid  coagulation  of  the  blood.  In  the  former 
case  the  so  called  White  Thrombus  is  met  with,  which  is  formed  upon, 
and  adheres  to,  the  vessel  wall,  and  gradually  increases  by  fresh 
deposits  of  fibrin  until  it  entirely  blocks  the  channel.  If  the  process 
is  more  rapid,  a  certain  number  of  red  corpuscles  are  entangled  in 
the  meshes  of  the  clot,  which  is  termed  a  Mixed  Thrombus.  Should 
the  blood  coagulate  en  masse  in  a  vein,  as  after  its  total  division 
or  ligature,  an  ordinary  Red  Thrombus  is  produced,  which  at  first  is 
not  adherent  to  the  wall,  but  becomes  so  later  on,  especially  at  its 
base.  A  similar  type  of  clot  is  usually  found  post  mortem  capping  any 
white  clot  which  has  formed  previously. 

The  Effects  of  thrombosis  may  be  considered  under  the  following 
headings  :  local,  distal,  and  proximal. 

Locally  :  {a)  The  clot  may  be  organized  into  connective  tissue,  a 
fibrous  cord  replacing  the  vessel  in  the  same  way  as  was  described 
for  arterial  thrombosis  (p.  281).  {b)  The  lumen  of  the  vein  may  be 
re-established  by  cleavage  and  shrinking  of  the  thrombus  to  one  side 
of  the  vein  wall,  or  by  canalization  of  the  clot  or  of  the  fibrous 
cicatrix  replacing  it,  owing  to  the  dilatation  of  the  vessels  contained 
within,  (c)  The  clot  may  soften,  disintegrate,  and  be  washed  away 
in  minute  particles  into  the  circulation.  If  this  is  not  due  to  bacterial 
invasion,  no  harm  need  follow ;  but  if  infective  in  origin,  local  abscesses, 
or  even  diffuse  suppuration,  may  occur  along  the  vein,  together  with 
general  pyaemia,  [d)  The  clot  may  shrink  or  become  loosened  in  an 
ampulla  of  a  varicose  vein,  forming  a  fibrinous  mass  which  is  subse- 
quently infiltrated  with  calcareous  particles,  constituting  a  vein  stone 
or  Phlebolith. 

Distally,  congestion  of  the  terminal  veins  results,  and  if  a  main 
trunk  is  affected,  oedema  of  the  limb  follows,  and  possibly  ulcera- 
tion or  gangrene.  If,  however,  the  condition  affects  the  femoral 
vein  of  a  person  in  the  recumbent  position,  there  may  be  little  or 
no  cedema  as  long  as  the  limb  is  elevated.  The  diagnosis  is  then 
made  by  the  pain  along  the  course  of  the  vein,  which  can  be  felt  as 
a  hard  cord.  In  favourable  cases  collateral  circulation  is  soon  estab- 
lished by  the  opening  up  and  dilatation  of  other  venous  channels, 
which  after  a  time  may  become  varicose  and,  if  situated  superficially, 
are  very  often  obvious.  Thus,  if  the  common  femoral  or  external 
iliac  vein  is  occluded  above  Poupart's  ligament,  the  internal  saphenous 
and  superficial  epigastric  veins  become  distended  and  varicose,  and 
the  latter  may  be  seen  coursing  up  the  abdominal  wall  towards  the 
umbilicus,  and  uniting  with  the  same  branch  on  the  opposite  side  to 
find  its  way  to  the  saphena  vein  of  that  limb.     If  the  inferior  vena 


346 


A  MANUAL  OF  SURGERY 


cava  is  obstructed,"  the  mammary  and  epigastric  veins  become  dilated 
and  tortuous,  standing  out  prominently  on  the  anterior  abdominal 
wall. 

Proximally,  the  process  may  gradually  extend  upwards,  and 
finally  involve  larger  and  rhore  important  trunks  than  that  in  which 
it  originated.  Moreover,  a  portion  of  a  thrombus  may  be  detached 
as  an  Embolus  (Fig.  112,  B),  If  the  clot  is  undergoing  molecular 
disintegration  and  only  minute  portions  are  set  free,  they  are  filtered 
off  by  the  lungs  or  kidneys,  and  no  symptoms  need  be  caused.  If, 
however,  a  large  portion  is  detached,  urgent  dyspnoea  and  even  death 

occur  from  obstruction  to  the  pulmonary 
vessels  and  subsequent  arrest  of  the  circu- 
lation. If  the  clot  becomes  infected  and 
fragments  conveying  organisms  are  carried 
into  the  circulation,  pyaemia  is  the  result, 
preceded,  however,  in  the  portal  area  by 
pylephlebitis — i.e.,  suppurative  phlebitis  of 
the  portal  trunks  in  the  liver. 

Venous  thrombosis  is  of  most  interest 
to  the  surgeon  when  it  involves  the  main 
femoral  or  iliac  vein,  and  is  then  most 
frequently  seen  on  the  left  side  of  the 
body,  possibly  spreading  to  the  vena  cava, 
and  developing  at  a  later  date  in  the  other 
limb.  It  is  not  an  uncommon  complica- 
tion of  parturition,  and  is  then  due  to  ex- 
tension of  the  clotting  from  the  pelvic 
veins  (phlegmasia  alba  dolens).  From  a 
similar  cause  it  may  follow  operations  on 
the  pelvic  viscera — e.g.,  hysterectomy.  It 
may  arise  as  a  complication  of  appendicitis, 
and  may  spread  from  veins  divided  in  the 
parietal  incision,  or  on  the  right  side  from 
direct  involvement  of  the  iliac  vein  in  the 
inflammatory  trouble ;  it  may  develop  in 
the  course  of  typhoid  fever ;  or,  finally, 
any  condition  or  operation  which  depresses  the  patient's  vitality  and 
keeps  him  bedridden  with  the  legs  quiet  may  lead  to  this  trouble. 
Thus,  one  of  the  worst  cases  we  have  seen  occurred  after  a  severe 
operation  for  glands  in  the  neck,  which  healed  by  first  intention. 
The  Clinical  Signs  and  Treatment  are  as  for  Phlebitis  (p.  348). 


Fig.  112.  —  Thrombus  and 
Embolus.  (Keen  and 
White.) 

A,  Thrombus  in  situ;  B,  em- 
bolus detached  from  the 
same. 


Embolism. 

An  Embolus  is  the  term  applied  to  any  foreign  body  which  travels  for  a  greater 
or  less  distance  in  the  bloodvessels  until  it  becomes  lodged  within  them  and 
causes  obstruction.  ■  There  are  four  main  varieties  of  embolus  :  {a)  Simple 
Emboli — e.g.,  blood-clot,  gi^anulations  or  fibrinous  vegetations  from  the  cardiac 
valves  after  acute  endocarditis,  atheromatous  plates,  air-bubbles,  fat  globules,  etc. 
{b)  Infective  Emboli  consist  of  either  zoogloea  masses  of  bacteria  or  disintegrated 


SURGERY  OF  THE  VEINS  347 

portions  of  blood -clot  carrying  micro-organisms  and  originating  a  pysemic 
abscess  wherever  they  lodge,  (c)  Malignant  Emboli  are  formed  by  portions  of 
some  malignant  growth,  from  which  the  various  secondary  deposits  originate  ; 
such  are  met  with  more  frequently  in  the  sarcomata  than  in  the  carcinomata. 
(d)  Parasitic  Emboli  also  occur,  such  as  the  ova  and  scolices  of  the  Tttnia  echino- 
coccus  and  the  Filaria  sanguinis  homiitis. 

Emboli  may  be  detached  from  the  heart,  veins,  or  arteries,  although  necessarily 
they  are  never  arrested  in  a  systemic  vein,  but  only  in  the  arteries  or  portal  vein. 
They  are  of  all  sizes,  and  the  character  of  the  resulting  symptoms  depends  much 
on  this.  A  large  embolus  started  in  a  peripheral  vein  lodges  in  one  of  the 
branches  of  the  pulmonary  artery,  and  may  cause  instant  death  ;  a  smaller  one 
is  arrested  in  one  of  the  smaller  arteries  of  the  lung  and  may  do  but  little  harm, 
whilst  minute  ones  may  possibly  pass  through  the  pulmonary  capillaries  to  the 
left  side  of  the  heart,  and  subsequently  become  impacted  in  the  systemic  vessels. 

Effects  of  an  Embolus.— The  Local  effects  of  the  lodgment  of  a  simple  embolus 
consist,  firstly,  in  the  deposit  of  fibrin  upon  it,  renderingthe  obstruction  complete  ; 
organization  of  the  thrombus  usually  follows,  although  occasionally  it  may  dis- 
integrate and  disappear.  Under  these  circumstances  a  weak  spot  may  be  left  in 
the  arterial  wall,  from  which  an  aneurism  is  subsequently  developed.  The  local 
effects  of  infective,  malignant,  and  parasitic  emboli  are  dealt  with  elsewhere. 

The  Distal  effects  of  embolic  obstruction  depend  entirely  on  the  relation  of  the 
vessel  blocked  to  the  surrounding  circulation. 

(i)  Should  the  embolus  be  lodged  in  an  artery  which  gives  off  anastomotic 
branches  below  the  point  of  obstruction,  or  if  the  capillary  anastomosis  is 
abundant,  a  transient  anaemia  is  all  that  occurs  in  most  cases.  If  the  artery  is 
small,  or  goes  to  unimportant  structures,  no  symptoms  need  arise  from  this  ;  but 
if  the  vessel  is  large,  or  supplies  delicate  and  important  tissues,  serious  results  may 
follow  even  a  temporary  arrest  of  the  circulation  ;  thus,  embolus  of  the  central 
artery  of  the  retina  always  causes  permanent  blindness,  although  the  retina  still 
lives. 

(2)  Should  the  embolus  block  what  Cohnheim  called  a  '  terminal  artery '  {i.e., 
one  with  no  anastomosis  between  the  embolus  and  the  terminal  capillaries),  or  a 
vessel  with  insufficient  collateral  circulation^the  obstruction  will  lead  to  death  of, 
at  any  rate,  a  portion  of  the  anaemic  region — e.g.,  gangrene  in  a  limb,  or  white 
or  yellow  softening  in  the  brain.  In  an  organ  such  as  the  kidney  or  spleen,  the 
result  of  embolic  obstruction  to  one  of  the  terminal  arteries  is  the  development 
of  what  is  known  as  an  infarct — i.e.,  a  wedge-shaped  area  of  tissue  with  the 
blocked  artery  at  its  apex  becomes  devitalized,  and  in  consequence  looks  white 
and  feels  firmer  than  the  surrounding  parts.  The  tissues  cannot  be  properly 
stained  for  microscopic  purposes.  Sometimes  the  anasmic  area  becomes  engorged 
with  blood  to  such  an  extent  as  to  lead  to  extravasation,  and  a  firm,  solid  patch  of 
a  dark-red  colour  results,  known  as  a  haemorrhagic  infarct.  Whatever  its  appear- 
ance, the  infarct  is  subsequently  invaded  by  granulation  tissue  developed  from 
the  surrounding  healthy  parts,  and  this  finally  results  in  the  formation  of  a 
depressed  cicatrix  containing,  perhaps,  a  few  haematoidin  crystals.  The  con- 
ditions necessary  for  the  production  of  an  infarct  are  met  with  in  the  lungs, 
spleen,  kidney,  and  brain;  in  the  liver  the  anastomosis  is  generally  too  free  to 
allow  of  its  formation,  although  it  has  been  known  to  occur. 

Effects  of  the  Lodgment  of  Emboli  in  Various  Organs. — In  the  Brain,  the  middle 
cerebral  artery  is  most  commonly  blocked,  resulting  in  immediate  hemiplegia, 
which  may  be  almost  entirely  recovered  from,  but  commonly  leaves  some  im- 
pairment of  function.  In  children  the  symptoms  are  less  m.irked,  but  aneurism 
of  the  affected  vessel  occasionally  follows.  In  the  Central  Artery  of  the  Retina. 
sudden,  total,  and  irremediable  blindness  is  produced  ;  the  branches  of  the  vessel 
are  seen  to  be  almost  empty,  the  retina  becomes  oedematous,  the  macula  alone 
retaining  its  normal  colour,  appearing  as  a  cherry-red  spot,  contrasting  markedly 
with  the  pallid  oedematous  tissues  around.  In  the  Lung,  fatal  results  supervene 
from  obstruction  to  the  main  pulmonary  artery;  attempts  have  been  made  to 
save  life  by  opening  the  chest,  incising  the  pulmonary  artery,  and  scraping 
or  pulling  out  the  clot,  and  subsequently  suturing  the  vessel.  It  is  obvious  that 
such  a  proceeding  is  not  likely  to  be  feasible  frequently.     If  one  of  the  smaller 


348  A  MANUAL  OF  SURGERY 

branches  is  blocked,  a  certain  amount  of  pain  and  dyspnoea  is  produced,  followed 
by  the  formation  of  an  infarct,  as  indicated  by  blood-stained  sputum,  dulness, 
bronchial  breathing,  and  bronchophony.  In  the  Liver,  an  embolus  of  the  hepatic 
artery  causes  sudden  hypochondriac  pain,  and  perhaps  a  temporary  glycosuria. 
The  portal  vein  and  its  branches  are  not  unfrequently  obstructed  by  emboli, 
which,  being  usually  of  an  infected  nature,  give  rise  to  pyasmic  symptoms  (pyle- 
phlebitis). In  the  Spleen,  a  sudden  pain  in  the  left  hypochondrium  is  ex- 
perienced, the  organ  becomes  enlarged,  and  a  considerable  rise  of  temperature 
may  follow.  In  the  Kidney,  sudden  pain  in  the  loin  and  a  temporary  haematuria 
constitute  the  main  symptoms.  In  the  Intestine,  localized  ulceration  or  extensive 
gangrene  is  likely  to  follow,  according  to  the  size  of  the  vessel  obstructed. 
In  the  Limbs,  the  emboli  usually  lodge  at  the  bifurcations  of  main  vessels, 
often  saddling  across  the  fork,  and  blocking  both  branches.  Sudden  pain  is  felt 
at  the  spot,  shooting  downwards,  and  either  recovery  or  gangrene  ensues  (p.  104). 
Here,  also,  it  has  been  attempted  to  remove  or  tunnel  the  clot  by  open  operation, 
but  the  results  have  not  been  satisfactory.  Massage  to  break  it  up  and  drive 
it  on  may  also  be  tried. 

Phlebitis. 

Phlebitis,  or  inflammation  of  the  vein  wall,  arises  from  a  variety 
of  causes,- and  is  not  uncommon  in  surgical  practice.  The  following 
forms  may  be  described  : 

1.  Simple  Phlebitis,  in  which  a  more  or  less  localized  inflammation 
of  the  wall  of  a  vein  is  attended  by  thrombosis,  which  extends  for 
a  variable  distance  up  and  down  the  vessel,  (a)  It  may  arise  from 
injury,  either  subcutaneous  or  open,  or  from  the  continued  pressure 
and  irritation  of  a  tumour  or  aneurism ;  (h)  it  may  be  idiopathic  in 
nature,  attacking  the  larger  veins  of  the  lower  extremity,  or  vessels 
which  have  been  long  subject  to  varix,  especially  in  gouty  individuals, 
(c)  It  may  follow  primary  thrombosis,  either  in  the  main  trunk  or  in 
a  varicose  peripheral  vein  ;  or  (d)  it  may  be  induced  by  inflammation 
of  the  tissues  around  the  vein  {periphlebitis),  usually  of  bacterial  origin. 
In  the  last  case  the  bacteria  gradually  spread  through  the  vein  wall, 
and  finally  invade  the  clot. 

2.  Infective  Phlebitis  is  a  much  more  serious  condition,  inasmuch 
as  the  thrombus  resulting  therefrom  is  always  invaded  by  micro- 
organisms, and  the  disease  is  often  of  the  spreading  type.  It  arises 
(a)  in  traumatic  cases  where  asepsis  has  not  been  maintained,  the 
organisms  invading  the  clot  which  lies  in  the  open  mouth  of  the  vein  ; 
or  (b)  as  a  result  of  infective  periphlebitis  in  wounds,  or  in  infective 
inflammation  of  bones,  such  as  when  a  suppurative  mastoiditis  leads 
to  disease  of  the  lateral  sinus ;  and  (c)  by  auto-infection  of  the  clot 
present  in  simple  phlebitis,  as  e.g.,  in  varicose  veins. 

The  Morbid  Anatomy  of  phlebitis  shows  the  walls  of  the  vein  to 
be  congested  and  thickened,  and  the  endothelial  lining  hypertrophied ; 
the  thrombus  contained  in  the  vessel  varies  in  its  characters.  If 
aseptic,  it  early  becomes  adherent  to  the  vein  wall  and  organized,  or 
is  absorbed.  If  infected,  it  becomes  soft  and  pultaceous,  resembling 
dirty-looking  pus  ;  a  localized  abscess  may  form  within  the  vein,  or  the 
suppuration  may  extend  for  some  distance  along  and  around  the  vein. 
In  the  more  favourable  cases  the  spread  of  the  infection  is  limited  by 
the  terminal  portions  of  the  clot  remaining  firm  and  unaffected. 


SURGERY  OF  THE   VEINS  349 

The  Symptoms  of  inflammation  of  a  superficial  vein  are  sufficiently 
obvious.  The  vessel  becomes  swollen,  hard  and  painful,  with  localized 
enlargements  or  knobs  corresponding  to  the  valves  or  to  the  pouches 
in  varicose  veins.  The  skin  over  them  is  dusky  and  congested,  and 
there  may  be  some  oedema  of  the  region  from  which  the  blood  flowing 
in  the  vein  is  gathered  ;  this,  however,  rarely  amounts  to  much,  since 
the  collateral  circulation  is  always  abundant.  The  temperature  is 
usually  raised,  and  the  patient  feels  ill.  If  suppuration  occurs,  the 
signs  of  a  localized  abscess  are  noted. 

When  the  deeper  veins  are  involved,  it  may  be  impossible  to  detect 
them  on  palpation,  although  a  blocked  common  femoral  is  easily  felt ; 
but  acute  deeply-seated  pain  over  the  vein  and  well-marked  fever  are 
characteristic  evidences  of  what  has  occurred.  CEdema  of  a  more 
or  less  solid  character  develops,  although  if  the  limb  is  maintained  in 
the  horizontal  position  throughout  the  attack  this  need  not  occur. 
Obliteration  of  the  vessel,  and  any  of  the  local,  distal,  or  general 
processes  detailed  under  thrombosis  (p.  345),  may  result. 

The  onset  of  Septic  Spreading  Phlebitis  is  marked  by  fever  and 
perhaps  rigors,  whilst  the  local  signs  are  due"  to  the  rapid  extension 
of  a  suppurative  inflammation  along  the  vein  and  its  branches,  so 
that  a  large  tract  of  tissue  is  very  quickly  invaded,  and  diffuse  sup- 
puration follows.  The  development  of  pyaemia  would  be  indicated 
by  a  repetition  of  the  rigors. 

Treatment  of  Simple  Phlebitis. — The  limb  must  be  kept  absolutely 
at  rest  to  limit  the  inflammation  and  prevent  the  detachment  of 
emboli,  and  also  elevated  to  assist  venous  return.  Locally,  bella- 
donna fomentations  may  be  applied,  or  the  parts  may  be  painted 
with  glycerine  and  extract  of  belladonna,  swathed  in  a  thick  layer  of 
cotton-wool,  and  lightly  bandaged.  The  patient  should  be  kept  on 
an  unstimulating  though  nutritious  diet,  and  the  general  health 
attended  to.  When  every  sign  of  inflammation  has  subsided,  and 
sufficient  time  has  been  allowed  for  the  absorption  or  organization  of 
the  clot  (six  to  eight  weeks),  massage  may  be  commenced,  to  assist 
in  the  removal  of  oedema  and  local  thickening,  and  an  elastic  bandage 
is  usually  serviceable  in  restoring  the  circulation.  Operation  is 
sometimes  undertaken  in  cases  of  phlebitis  associated  with  varix, 
but  not  when  the  deeper  veins  are  involved.  If  abscesses  form,  they 
must  be  opened  antiseptically. 

Spreading  Infective  Phlebitis  is  treated  by  following  up  the  sup- 
purative process  with  the  knife,  laying  open  the  tissues  around  the 
involved  veins.  The  wounds  thus  made  should  be  treated  with 
peroxide  of  hydrogen  and  lightly  packed  ;  at  the  same  time,  the  limb 
is  raised  and  kept  absolutely  quiet.  Should  pyaemic  phenomena 
develop,  it  may  be  possible  to  place  a  ligature  between  the  disinte- 
grating clot  and  the  heart,  and  to  scrape  or  wash  away  the  septic 
mass ;  thus  in  septic  thrombosis  of  the  lateral  sinus,  following 
suppuration  in  the  middle  ear,  the  internal  jugular  vein  should  be 
ligatured,  the  lateral  sinus  opened,  and  the  clot  removed.  Of  course, 
such  treatment  is  only  feasible  in  cases  where  a  single  trunk  is 


350 


A  MANUAL  OF  SURGERY 


affected.  When  the  process  involves  the  veins  of  a  limb,  and  cannot 
be  stopped  by  either  of  these  plans  of  treatment,  the  question  of 
amputation  may  have  to  be  raised. 

Varicose  Veins,  or  Varix. 

A  vein  is  said  to  be  in  a  condition  of  varix  when  it  has  become 
permanently  lengthened,  dilated,  and  more  or  less  tortuous.  The 
superficial  veins  of  the  leg,  especially  the  internal  and  external 
saphena,  are  those  most  commonly  affected ;  the  spermatic  veins  are 
often  in  a  similar  condition,  constituting  what  is  known  as  a  varico- 
cele, whilst  piles  are  primarily  due  to  varicosity  of  the  haemorrhoidal 
plexus.  We  shall  here  only  deal  with  the  first  of  these  three  mani- 
festations. 

Causes. — Varix  is  due,  in  the  first  place,  to  some  inherited  weakness 
of  the  venous  wall,  or  irregularity  in  the  arrangement  of  the  valves, 
though  possibly  this  produces  no  effect  until  some  exciting  cause 
comes  into  action  and  throws  a  strain  on  the  circulation.  The  facts 
that  varix  sometimes  appears  quite  early  in  life  and  without  adequate 
cause,  and  often  involves  the  same  vein  in  different  members  of  a 
family,  confirm  this  hypothesis. 

Any  condition  which  leads  to  frequently  repeated  or  more  or  less 
permanent  distension  of  a  vein  may  result  in  varix — e.g.,  prolonged 
standing,  as  in  those  serving  behind  counters  ;  the  pressure  of  tight 
garters,  especially  if  worn  below  the  kriee  ;  prolonged  or  forcible 
exertion  of  the  limb ;  the  pressure  of  a  pregnant  or  displaced  uterus, 
or  of  a  pelvic  tumour.  Severe  exertion — such  as  occurs  in  football- 
playing,  hard  training,  weight-lifting,  etc. — will  throw  a  heavy  strain 
on  the  vein  walls,  and  sometimes  lead  to  the  giving  way  of  the  valves, 
usually  from  above  downwards  in  the  legs.  This  valvular  incom- 
petence results  in  increasing  pressure  on  the  venous  walls,  which 
gradually  pass  into  a  condition  of  varix. 

Obstruction  to  and  occlusion  of  the  deeper  veins  is  another  well- 
recognised  cause  of  varix,  and  we  have  already  drawn  attention  to 
the  effects  produced  by  blocking  of  the  common  femoral  vein  and 
inferior  vena  cava.  A  less  known  instance  is  the  varix  of  the  internal 
saphena  or  some  of  its  branches  below  the  knee  which  follows  throm- 
bosis of  the  venae  comites  of  the  posterior  tibial,  due  to  strains  of  the 
leg  and  similar  injuries.  If  the  thrombus  is  absorbed,  the  dilatation 
disappears ;  but  if  the  block  is  permanent,  the  superficial  veins 
become  varicose,  usually  extending  to  just  below  the  knee.  Any 
abnormal  communication  between  an  artery  and  a  vein  also  causes 
varicosity,  from  the  inability  of  the  latter  to  withstand  arterial 
blood-pressure  {vide  Aneurismal  Varix,  p.  301).  The  tendency  to 
varix  increases  with  age  till  the  middle  period  of  life  is  reached, 
and  is  favoured  by  the  relaxation  of  the  system  resulting  from . 
sedentary  habits.  When  once  a  vein  has  become  varicose  and  its  walls 
thin  and  expanded,  the  valves  become  incompetent,  and  the  weight 
of  the  superincumbent  blood  still  further  increases  the  mischief. 


SURGERY  OF  THE  VEINS 


3S» 


Morbid  Anp.tomy. — To  the  naked  eye  a  varicose  vein  in  an  early 
stage  appears  thickened,  distended,  and  tortuous;  the  walls  are  so 
thick  that  the  vein  when  cut  across  does  not  collapse,  but  presents  a 
gaping  mouth,  like  an  artery  ;  the  valves  atrophy,  and  are  functionally 
useless.  After  a  time  the  walls  become  further  stretched  and  irregu- 
larly expanded,  forming  here  and  there  cyst-like  dilatations,  which 
are  very  obvious  under  the  attenuated  skin,  to  which  they  are  often 
adherent  (Fig.  113).  Microscopically,  the  change  consists  in  a  trans- 
formation of  the  normal  structures  of  the  vein  wall  into  fibro- cica- 
tricial tissue.      The  tunica  media  is  mainly  affected,  most  of  the 


Fig. 


113. — Varix  of  Internal 
Saphena.  (From  a 
Photograph.) 


Fig 


114. — Varix  of  Left  Internal 
Saphena,  showing  an. 
Ampulla  above. 


muscular  fibres  disappearing,  whilst  the  tunica  intima  is  but  little 
changed,  and  the  adventitia  thickened.  In  the  pouches  the  middle 
coat  is  atrophied,  and,  indeed,  is  often  completely  absent. 

Clinical  History. — The  enlarged  veins  are  seen  ramifying  under  the 
skin  with  a  more  or  less  tortuous  and  serpentine  course  (Fig.  113), 
and  they  often  feel  thickened.  One  or  more  veins  may  be  affected, 
and  the  tortuosity  may  be  at  parts  so  marked  as  to  constitute  large 
clusters  of  dilated  vessels,  which  look  bluish  under  the  thin  and 
stretched  integument.  In  other  cases  a  single  vein  is  enlarged,  and 
stands  out  prominently  under  the  skin  ;  or  perhaps  one  or  more  cyst- 
like pouches  develop  in  connection   with  these  (Fig.  114).     Should 


352  A   MANUAL  OF  SURGERY 

the  upper  end  of  the  internal  saphena  be  involved,  it  is  almost 
always  dilated  so  as  to  form  a  large  pouch,  in  which  a  marked  thrill 
is  felt  when  the  patient  coughs,  thereby  simulating  a  femoral  hernia. 

The  Effects  of  this  condition  are  very  varied.  The  limb  often  feels 
heavy  and  tired  ;  forcible  exertion  may  cause  a  sensation  of  tension, 
and  after  standing  or  exercise  there  is  usually  some  oedema  of  the 
ankle.  The  capillaries  in  the  papillae  often  become  dilated,  appear- 
ing as  minute  reddish  puncta,  which  subsequently  run  together  and 
form  brownish  patches  of  pigmentation.  Eczema  is  induced  by  the 
irritation  of  rough  and  coarse  trousers  or  dirt,  often  terminating  in 
actual  ulceration.  Any  lesion,  such  as  a  scratch  or  abrasion,  instead 
of  healing  readily  under  a  scab,  tends  to  spread  and  form  an  ulcer. 
Injury  to  the  vein  may  lead  to  thrombosis  and  spontaneous  cure,  but 
coagulation  sometimes  occurs  idiopathically  in  cysts  or  acute  kinks, 
especially  in  gouty  subjects.  The  clot  may  subsequently  shrink  and 
form  a  small  fibrinous  or  calcareous  mass,  known  as  a  'phlebolith,'  but 
sometimes  the  thrombosis  spreads  into  deeper  or  larger  veins,  and  then 
fragments  of  clot  may  be  detached  as  emboli.  Occasionally  the 
dilated  pouch  of  a  varicose  vein  gives  way,  and  an  alarming  gush 
of  blood  results ;  the  same  may  follow  the  extension  of  ulceration 
through  the  vein  wall.  The  blood  under  these  circumstances  is 
derived,  not  only  from  the  lower,  but  also  from  the  upper  end, 
inasmuch  as  the  valves  have  become  incompetent ;  a  column  of  blood 
extending  from  the  right  auricle  is  thus  tapped  near  its  lower  end, 
and,  unless  prompt  precautions  are  taken,  the  patient's  life  may  be  lost. 

The  Treatment  of  varicose  veins  may  be  described  as  palliative 
and  radical. 

Palliative  Treatment  consists  in  removing  any  source  of  obstruction 
in  the  shape  of  tight  garters,  in  limiting  the  amount  of  standing,  in 
moderate  massage,  together  with  the  application  of  either  an  elastic 
stocking  or  an  indiarubber  bandage.  The  bowels  should  be  regu- 
lated, and  the  general  health  attended  to.  Eczema  may  be  treated 
by  the  application  of  soothing  and  drying  ointments,  e.g.,  ung.  zinci 
benzoaitis;  or  if  the  skin  is  chronically  infiltrated  and  thickened, 
by  the  use  of  weak  tarry  applications,  e.g.,  ol.  Rusci  (i  part  to  4  of 
vaseline),  or  of  ichthyol  (5  or  10  per  cent,  in  vaseline).  Varicose 
ulcers  are  suitably  treated  (p.  94),  but  repair  is  often  delayed  till  the 
veins  have  been  dealt  with  by  operation. 

Eadical  Treatment  consists  in  the  excision  of  the  distended  veins. 
Before  operating  it  is  important  to  investigate  the  history  and  ascer- 
tain if  the  condition  is  due  to  thrombosis  of  the  deep  trunks,  as 
interference  might  then  do  more  harm  than  good.  Operation  is 
specially  indicated  when  thin,  dilated  pouches  exist ;  when  elastic 
stockings  cannot  be  comfortably  worn,  as  in  the  tropics ;  when 
ulcers  exist  which  refuse  to  heal ;  when  the  condition  is  very  exten- 
sive and  painful,  and  especially  if  large  bunches  of  dilated  veins 
are  seen  ;  or  when  there  is  a  distinct  impulse  or  thrill  on  coughing, 
indicating  that  the  valves  which  protect  the  veins  of  the  leg  are 
defective. 


SURGERY  OF  THE  VEINS  353 

Various  methods  of  operating  have  been  adopted :  (a)  Small 
portions  may  be  removed  at  several  different  situations.  The  skin  is 
pinched  up  over  the  vein,  and  incised  by  transfixion  ;  the  vessel  is 
usually  bared  by  this  means,  but  may  need  a  little  clearing.  An 
aneurism  needle  is  passed  beneath  it,  and  the  vein  isolated  sufficiently 
to  allow  of  its  being  grasped  by  two  pairs  of  forceps,  and  divided 
between.  Each  end  is  now  freed,  and  drawn  out  of  the  wound  as  far 
as  possible ;  it  is  then  ligatured  and  removed.  Probably  2^  inches 
of  vein  may  be  taken  away  through  a  i-inch  incision.  The  wound  is 
sutured  without  drainage  and  dressed,  (b)  Long  incisions  are  made, 
perhaps  6  inches  or  more,  through  which  larger  clusters  of  veins  may 
be  dealt  with.  The  wound  should  not  lie  over  the  most  dilated  parts 
of  the  vessel,  as  there  the  skin  is  often  thin  and  unhealthy,  but  should 
be  curved  so  as  to  include  as  much  sound  skin  as  possible,  whilst 
crossing  the  vessels  once  or  twice.  All  collateral  branches,  especially 
the  deep  ones,  must  be  secured,  and  this,  in  fact,  constitutes  the  great 
advantage  of  the  operation,  viz.,  that  so  many  anastomosing  channels 
are  obliterated.  In  very  bad  cases  most  extensive  operations  are 
sometimes  required,  the  incisions  involving  nearly  the  whole  length 
of  the  limb.  (c)  A  simpler  procedure  has  been  advocated  by 
Trendelenburg,  viz.,  the  removal  of  a  portion  of  the  internal  saphena 
close  to  the  saphenous  opening,  so  as  to  break  the  weight  of  the 
superjacent  column  of  blood.  In  many  cases,  but  especially  where 
there  is  an  impulse  on  coughing,  and  the  vein  fills  from  above,  this  is 
essential,  though  it  is  also  desirable  that  the  enlarged  veins  lower  down 
should  be  excised. 

After  an  operation  for  varix  the  patient  should  remain  in  the 
recumbent  posture  for  three  weeks,  to  allow  clots  to  become  firm  and 
to  permit  the  circulation  to  accommodate  itself  to  the  new  arrange- 
ments. On  first  rising  from  bed,  it  is  well  to  support  the  limb  for  a 
time  by  a  '  Crepe  Velpeau '  bandage. 

Inflamed  Varicose  Veins  are  not  unfrequent,  and  may  result  in  a 
natural  cure  of  the  condition.  The  symptoms  are  those  of  a  superficial 
phlebitis,  and  the  treatment  indicated  for  that  condition  should  be 
followed.  In  cases  where  there  is  much  pain  it  may  be  justifiable  to 
excise  the  thrombosed  vessels,  taking  the  precaution  first  to  secure 
by  ligatiire  the  vein  above  the  clot,  so  as  to  prevent  any  risk  of 
embolic  detachment.  Operation  of  a  similar  type  is  also  required 
when  thrombosis  is  gradually  spreading  upwards,  and  threatening  to 
affect  the  deep  trunks,  e.g.,  in  the  neighbourhood  of  the  saphenous 
opening ;  or  when  portions  of  clot  are  being  detached  as  emboli, 
giving  rise  to  pulmonary  symptoms. 

Haemorrliage  from  a  Ruptured  Vein  needs  prompt  and  decisive 
treatment.  The  bleeding  spot  should  be  commanded  by  digital  com- 
pression, and  the  patient  laid  on  the  back  with  the  limb  elevated,  until 
either  a  pad  of  antiseptic  dressing  can  be  applied  to  the  wound,  or  a 
handkerchief  or  bandage  secured  over  it. 

23 


354  A  MANUAL  OF  SURGERY 

Nsevus. 

A  naevus  is  a  vascular  tumour  developing  in  the  skin  or  mucous 
membrane  and  in  the  underlying  tissues,  and  consists  of  a  congeries 
of  vessels  held  together  by  connective  tissue.  Nsevi  are  of  congenital 
origin,  or  develop  soon  after  birth.  Left  to  themselves,  they  may 
shrink  and  disappear,  but  more  often  they  increase  in  size  more  or 
less  rapidly,  whilst  sometimes  they  remain  quiescent  and  persist 
unchanged  through  life.     Two  chief  varieties  are  described  : 

The  Capillary  Naevus  (or  mother's  mark)  occurs  in  the  form  of  a 
slightly  raised  flattened  mass,  bright  red  or  purple  in  colour,  according 
to  the  relative  amount  of  arterial  or  venous  blood  present,  and  with 
occasionally  a  somewhat  irregular  or  nodulated  surface,  in  which 
larger  vessels  may  be  seen  ramifying.  It  consists  merely  of  a  mass 
of  capillaries  lined  with  endothelium  communicating  with  a  few 
arterioles  and  venules,  and  held  together  by  loose  connective  tissue. 
Several  such  growths  may  be  present  in  the  same  individual,  and 
they  are  usually  quite  small,  not  exceeding  an  inch  or  two  in  diameter, 
though  sometimes  they  extend  widely  over  the  face  and  neck,  and 
are  then  very  superficial  in  character,  and  somewhat  dusky  in  colour, 
constituting  the  '  port-wine  stain.'  If  cut  into,  they  bleed  freely,  but 
the  haemorrhage  is  easily  stopped  by  pressure. 

Occasionally  a  nsevoid  development  may  be  observed  involving 
half  the  body,  and  limited  almost  exactly  by  the  middle  line ;  this 
condition  is  known  as  navus  unius  lateris.  It  may  consist  of  a  purely 
vascular  manifestation,  or  the  skin  may  be  hypertrophied  and  covered 
with  small  soft  papillary  excrescences. 

Treatment  is  usually  simple  in  the  extreme.  Small  superficial 
nsevi  can  be  completely  cured  by  some  form  of  cauterization,  the 
best  results  being  obtained  by  the  use  of  solid  carbonic  acid. 
Appliances  for  the  supply  of  this  agent  are  obtainable  at  instrument 
makers.  In  exposed  situations  electrolysis  {vide  infra)  may  be  the 
best  plan  to  adopt,  but  excision  will  often  give  an  equally  good 
result. 

The  Cavernous  or  Venous  Nsevus  (Fig.  56)  most  commonly  involves 
both  skin  or  mucous  membrane  and  the  underlying  tissues,  but  is 
sometimes  purely  submucous  or  subcutaneous.  It  consists  of  a  more 
or  less  prominent  swelling,  soft  to  the  touch  and  easily  compressible, 
but  refilling  when  the  pressure  is  removed.  There  is  no  pulsation  or 
bruit,  and  the  mass  may  be  lobulated.  If  subcutaneous,  the  skin 
over  it  is  somewhat  bluish  in  colour,  but  the  mixed  forms  are  dusky 
red.  Occasionally  it  may  undergo  spontaneous  cure  from  inflam- 
mation and  thrombosis,  and  cysts  are  sometimes  found  in  the  centre 
of  a  naevoid  mass,  indicating  that  a  partial  attempt  at  this  process  has 
occurred.      For  their  structure,  see  p.  206. 

The  Treatment  is  by  no  means  as  simple  as  in  the  former  variety. 
The  following  plans  may  be  mentioned  : 

I.  Excision  of  the  growth  should  always  be  adopted  where  prac- 


SURGERY  OF  THE   VEINS  355 

ticable.  Cases  which  formerly  were  dealt  with  by  strangulation  are 
now  treated  by  this  method.  The  bleeding  is  never  great,  even  if  the 
nsevoid  tissue  is  encroached  upon  by  the  knife,  and  only  a  few  vessels 
will  need  to  be  tied.  Circular  growths  should  be  removed  by 
crescentic  incisions,  and  a  little  undercutting  will  usually  enable  the 
edges  to  be  approximated  easily.  In  exposed  situations  Halstead's 
subcuticular  suture  should  be  utilized. 

2.  Where  excision  is  impossible.  Electrolysis  should  be  employed. 
It  consists  in  the  passage  of  an  electric  current  through  the  mass, 
producing  chemical  and  physical  changes  in  the  contained  blood. 
Both  needles  may  be  inserted  into  the  nsevus,  but  it  is  sometimes 
wiser  only  to  introduce  one  or  more  needles  connected  with  the 
positive  pole,  whilst  the  negative  pole  is  attached  to  a  large  electrode 
moistened  and  placed  on  some  indifferent  part  of  the  body,  such  as 
the  arm,  back,  or  thigh.  The  needle  is  often  with  advantage  made 
of  iron  or  steel,  since  it  is  usually  corroded,  and  the  chloride  of  iron 
thus  formed  acts  beneficially  in  determining  coagulation  of  the 
blood ;  it  must  be  carefully  and  thoroughly  insulated  when  deep 
naevi  are  treated,  so  as  to  protect  the  skin  and  prevent  the  current 
passing  through  it.  The  use  of  the  negative  pole  is  more  likely  to 
produce  scarring,  since  a  caustic  sodium  compound  is  formed  around 
it,  and  this  may  lead  to  sloughing  of  the  tissues ;  the  clot,  moreover, 
is  loose  and  spongy,  whilst  a  much  firmer  coagulum  occurs  around 
the  positive  pole.  If  the  positive  pole  alone  is  introduced,  a  current 
equal  to  about  200  milliampferes,  as  measured  by  a  galvanometer, 
may  be  passed  for  ten  or  fifteen  minutes  ;  if  both  poles  are  used, 
a  current  half  this  strength  is  sufficient.  An  anaesthetic  is  needed, 
and  the  immediate  effect  should  be  to  make  the  mass  feel  hard  and 
firm  by  the  coagulation  of  the  blood ;  organization  of  the  thrombus 
leads  to  obliteration  of  the  vascular  spaces  and  disappearance  of  the 
tumour.  The  operation  may  require  to  be  repeated  several  times, 
and  the  needles  should  be  freely  worked  about  through  the  mass. 
For  the  treatment  of  superficial  naevi,  there  is  no  necessity  to  have 
the  needle  coated  ;  it  is  introduced  into  the  mass  in  a  number  of 
places,  especially  where  any  definite  vessels  are  seen,  and  of  course 
does  not  penetrate  deeply.  A  very  short  application  of  the  current 
usually  suffices  at  each  puncture  ;  the  naevoid  tissue  turns  white, 
and  there  is  a  little  bubbling  of  gas  around  the  needle.  It  is  best  to 
deal  first  with  the  periphery  of  a  nasvus,  and  then  when  its  extension 
is  arrested,  the  central  parts  can  be  treated.  Of  course,  some 
scarring  cannot  be  avoided,  and  hence  it  is  wise  not  to  do  too  much 
at  one  sitting,  and  to  make  the  intervals  sufficiently  long  to  allow 
cicatrization  to  take  place. 

A  Nsevo-Lipoma  is  the  name  given  to  a  somewhat  rare  tumour,  in 
which  a  fatty  element  is  blended  with  naevoid  tissue.  It  is  usually 
of  congenital  origin,  or,  at  any  rate,  appears  early  in  life,  and  is 
probably  due  to  the  undifferentiated  formative  cells  of  the  embryo 
developing  in  a  twofold  direction,  so  as  to  produce  not  only  fatty 
connective    tissue,  but  also  vessels.     It  gives   rise   to   a   swelling, 


356 


A  MANUAL  OF  SURGERY 


lobulated  and  doughy,  like  a  fatty  tumour,  although  it  is  usually  a 
little  denser  in  texture  than  the  ordinary  lipoma.  It  may  be  possible 
to  reduce  its  size  by  compression,  but  no  thrill  or  pulsation  can  be 
detected;  a  few  dilated  veins  or  capillaries  are  often  seen  on  the 
surface.     The  only  treatment  is  excision. 


Venesection. 

Venesection  or  phlebotomy  is  a  means  of  treatment  which  has 
largely  fallen  into  disuse  of  late  years,  but  is  still  occasionally 
employed  with  benefit.  When  a  patient  is  becoming  cyanosed,  and 
asphyxia  is  threatening  either  (a)  as  a  result  of  pulmonary  engorge- 
ment from  mitral  incompetency,  owing  to  the  heart  being  unable  to 
drive  the  blood  into  the  systemic  circulation ;  or  (b)  as  a  consequence 
of  some  accident  involving  the  chest-wall  and  lungs,  whereby  the 
blood-aerating  surface  is  so  diminished  that  it  cannot  deal  with  the 
blood  reaching  it  through  the  right  side  of  the  heart,  which  hence 


Fig.  115. — Venesection. 


becomes  enormously  distended,  and  threatens  to  stop  in  a  condition 
of  diastole  :  or  (c)  where  inflammation  of  the  brain  is  pending,  and 
the  pulse  is  hard  and  full ;  or  (d)  in  many  inflammatory  states  in 
strong,  full-blooded  individuals  where  the  pulse-tension  is  high — in 
any  of  these  conditions  venesection  may  be  used  with  advantage. 

The  median  basilic  vein  at  the  bend  of  the  elbow  is  that  usually 
opened,  since  it  is  larger  than  the  median  cephalic,  though  placed 
more  directly  over  the  brachial  artery,  from  which  it  is  only  separated 
by  the  bicipital  fascia. 

Requisites. — A  strip  of  bandage  about  4  feet  long;  a  lancet;  a 
graduated  bleeding-bowl ;  and  finally  something,  such  as  a  stick  or 
bandage,  to  be  grasped  by  the  hand,  so  as  to  cause  contraction  of 
the  muscles,  thus  pressing  the  blood  from  the  deep  into  the  superficial 
veins  along  the  communicating  branch  which  enters  the  median  just 
below  its  bifurcation. 

Operation. — The  patient  should  be  seated  in  a  chair  or  in  bed ; 
standing  would  produce  syncope  too  rapidly,  whilst  the  recumbent 
posture  would  allow  too  great  an  abstraction  of  blood  before  Nature's 
danger-signal  {i.e.,  syncope)  is  evident.  The  skin  in  front  of  the 
elbow  having  been  purified,  as  also  the  hands  of  the  surgeon  and 
the  lancet,  the  bandage  is  tied  round  the  arm  with  sufficient  tight- 


SURGERY  OF  THE  VEINS  357 

ness  to  arrest  the  venous  circulation  whilst  the  arterial  supply  is 
unimpeded.  Grasping  the  stick  firmly  causes  the  veins  to  become 
prominent.  The  median  basilic  is  now  steadied  by  the  left  thumb, 
and  an  incision  made  into  it  (Fig.  115,  A).  Blood  will  flow  from  it  in 
a  full  stream,  and  is  collected  in  the  bowl.  When  sufficient  has  been 
withdrawn,  the  stick  is  removed  from  the  patient's  hand,  a  sterilized 
swab  is  pressed  over  the  bleeding  spot,  the  bandage  above  is  relaxed, 
and  a  pad  of  antiseptic  dressing  placed  over  the  wound  and  firmly 
bandaged  in  position ;  the  arm  is  kept  at  rest  for  a  few  days  to  allow 
the  small  incision  to  heal.  Occasionally  neuralgic  pain  is  caused  by 
the  implication  of  some  of  the  fibres  of  the  internal  cutaneous  nerve 
in  the  cicatrix ;  whilst,  if  the  lancet  is  plunged  too  deeply,  an  arterio- 
venous wound  may  be  produced. 


CHAPTER  XIV. 

DISEASES  OF  THE  LYMPHATICS. 

Rupture  or  Division  of  the  Thoracic  Duct  may  occur  as  a  result  of 
a  penetrating  or  bullet  wound  of  the  neck,  or  during  operations  in  the 
supra-clavicular  fossa.  The  main  trunk  has  also  been  torn  in  a 
fracture  of  the  spine,  and  the  lymph  has  escaped  into  the  pleural 
cavity.  Wounds  near  the  outflow  into  the  junction  of  the  jugular 
and  subclavian  veins  usually  involve  one  or  more  of  the  several 
branches  into  which  the  main  trunk  divides  before  opening  into  the 
venous  system  ;  lymph  or  chyle  escapes,  but  if  the  divided  vessel  is 
tied,  no  further  trouble  arises  as  a  rule.  Failing  ligature,  the  wound 
should  be  packed  with  gauze,  and  the  flow  generally  ceases  after  a 
while.  Should  this  not  occur,  an  attempt  must  be  made  to  anasto- 
mose the  divided  end  of  the  duct  with  one  of  the  deep  veins,  for  a 
persistent  and  excessive  loss  of  lymph  means  the  exhaustion  of  the 
patient. 

In  a  few  cases  the  opening  of  the  thoracic  duct  has  been  obstructed 
or  compressed,  leading  to  such  backward  tension  that  the  receptaculum 
chyli  has  ruptured  and  the  peritoneal  and  pleural  cavities  have  been 
filled  with  a  serous  or  chylous  exudation.  Virchow  described  one 
case  where  the  opening  was  congenitally  absent  (in  a  calf)  and  the 
lymphatics  throughout  the  body  were  enormously  distended,  especially 
those  of  the  small  intestine. 

Acute  Lymphangitis,  or  Inflammation  of  the  Lymphatic  Vessels, 
ensues  almost  invariably  from  the  absorption  and  passage  along  the 
lymphatics  leading  from  an  impure  wound  of  bacteria  and  toxins, 
which  give  rise  to  inflammation  of  the  lymphatic  vessels  involved 
and  of  the  tissues  around  them,  and  this  may  even  run  on  to  suppura- 
tion. The  walls  of  the  lymphatics  become  hyperaemic  and  infiltrated, 
and  the  tissues  around  are  inflamed.  The  lymph  is  said  to  coagu- 
late in  the  vessels,  forming  a  pinkish  clot.  The  process  is  usually 
limited  by  the  nearest  lymphatic  glands,  which  arrest  and  filter  off 
the  toxic  products,  with  or  without  the  occurrence  of  suppuration ; 
but,  in  spite  of  this,  a  general  infection  of  the  system  occasionally 
results. 

Clinical  Signs. — The  causative  wound  may  be  obviously  infected,  or 
is  possibly  very  slight  and  covered  by  a  dry  scab.  The  characteristic 
appearance  is  that  of  fine  red  lines  or  streaks  following  the  course  of 

358 


DISEASES  OF  THE  LYMPHATICS  359 

the  lymphatics,  perhaps  up  to  the  nearest  glands ;  the  parts  thus 
inflamed  are  tender  and  oedematous.  If  the  mischief  is  limited  to 
the  main  trunks  {ttihular  lymphangitis),  they  may  be  felt  hard  and 
cord-like,  and  the  red  lines  remain  isolated  from  each  other ;  but  if 
all  the  smaller  lymphatic  channels  of  a  part  are  affected  (vetiform 
lymphangitis),  the  redness  merges  into  a  generalized  blush,  and  the 
condition  is  practically  identical  with  cellulitis.  Localized  foci  of 
suppuration  in  the  course  of  the  lymphatics  often  follow,  the  redness 
increasing  and  the  parts  becoming  dusky  and  brawny,  until  finally 
the  centres  soften  and  fluctuate.  These  phenomena  are  associated 
with  fever  and  malaise,  the  temperature  rising  to  102°  or  103°, 
possibly  attended  by  rigors,  vomiting,  and  diarrhoea. 

Under  suitable  treatment  resolution  rapidly  follows,  but  suppura- 
tion may  occur  either  in  the  glands  or  in  some  loose  mass  of  cellular 
tissue  traversed  by  the  lymphatic  trunks,  or  as  a  chain  of  abscesses 
in  the  course  of  the  vessels.  Occasionally  the  lymphatic  vessels 
become  permanently  occluded,  and  a  form  of  solid  or  lymphatic 
cedema  results.  Recurrent  attacks  of  this  type  are  not  uncommon 
in  connection  with  chronic  eczema  or  ulcers  of  the  leg,  and  may  lead 
to  elephantiasis.  In  a  few  cases  the  patient  dies  from  general 
septicaemia,  or  from  exhaustion  following  diffuse  suppuration. 

Treatment  is  first  of  all  directed  to  the  causative  focus,  which  must 
be  opened  up  and  purified,  so  as  to  cut  off  the  supply  of  bacteria  and 
toxins  to  the  lymphatics.  The  limb  itself  is  kept  at  rest  in  a  slightly 
elevated  position,  and  fomented,  or  soaked  in  a  hot  bath.  Abscesses 
are  opened  as  soon  as  they  develop.  Any  subsequent  oedema  of  the 
limb  is  remedied  by  massage  and  firm  bandaging,  provided  no  venous 
complications  are  present. 

Constitutional  treatment  consists  in  the  administration  of  a  purge, 
followed  by  a  light  and  nutritious  diet,  quinine  and  tonics,  care  being 
taken  that  constipation  is  not  thereby  produced. 

Chronic  Lymphangitis  either  results  as  a  sequela  of  an  acute  attack, 
or  is  met  with  as  a  separate  condition.  It  is  most  frequently  seen  in 
connection  with  venereal  disease,  the  dorsal  lymphatics  of  the  penis 
becoming  enlarged,  hard,  and  cord-like,  especially  in  cases  of  primary 
syphilis.  This  is  usually  accompanied  by  a  solid  oedematous  condition 
of  the  prepuce  and  enlargement  of  the  inguinal  glands.  Under 
appropriate  antisyphilitic  treatment,  the  swelling  quickly  subsides. 

A  tuberadous  type  of  chronic  lymphangitis  also  exists  in  which  a 
primary  focus,  say,  on  a  finger  is  associated  with  secondary  deposits 
along  the  lymphatics  up  the  arm.  Each  nodule  is  at  first  of  firm 
consistency,  but  gradually  softens  and  breaks  down.  Naturally,  such 
a  case  is  liable  to  be  followed  by  general  dissemination.  The  treatment 
consists  in  the  excision,  if  possible,  of  each  focus. 

The  cheeks  and  nose  are  occasionally  the  seat  of  a  chronic 
relapsing  lymphangitis,  due  to  the  absorption  of  sepsis  from  sores  or 
ulcers  within  the  nostril.  It  is  characterized  by  patches  of  hyper- 
aemia  and  some  amount  of  tissue  infiltration,  and  for  its  cure  the 
causative  sores  must  be  treated.     The  thick  lips  of  a  tuberculous 


36o  A  MANUAL  OF  SURGERY 

child  are  of  a  similar  nature,  and  due  to  the  constant  irritation  of 
cracks  along  the  lip  margin. 

Lymphatics,  like  bloodvessels,  are  liable  to  distension  and  dilata- 
tion, which  may  be  either  congenital  or  acquired,  and  are  known  as  - 
Lymphangioma  or  Lymphangiectasis.  It  is  impossible  to  draw  an 
absolute  line  of  distinction  between  the  two  conditions,  but  the  latter 
term  is  applied  mainly  to  cases  where  normal  lymphatics  are  dilated 
and  their  continuity  with  the  normal  lymphatic  circulation  persists, 
whilst  a  lymphangioma  is  the  result  of  a  new  formation.  Not 
unfrequently  the  two  conditions  develop  side  by  side. 

Lymphangiomata  *  are  growths  composed  of  newly-formed  lym- 
phatics, together  with  a  variable  amount  of  connective  tissue,  which 
is  sometimes  of  a  fatty  nature.  They  may  be  congenital  or  acquired, 
but  even  in  the  latter  case  there  is  probably  an  underlying  congenital 
element,  which  was  only  awaiting  some  irritation  or  localized  injury 
to  determine  its  development.  Two  varieties  may  be  described,  the 
capillary  and  cavernous. 

(a)  The  Capillary  Lymphangioma  is  usually  congenital  in  origin, 
but  often  increases  considerably  as  the  child  grows,  and  may  attain 
large  proportions.  When  developing  in  the  skin,  it  may  be  termed 
a  lymphatic  nsevus,  and  in  origin  and  development  it  well  merits  the 
title.  The  patch  is  usually  of  a  dull  yellowish-brown  colour,  but  this 
varies  with  the  amount  of  blood  present ;  it  may  be  smooth-topped 
like  a  wheal,  or  warty  in  appearance,  but  on  examination  with  a 
lens  each  projecting  point  contains  a  vesicle.  This  type  of  growth 
is  sometimes  very  extensive,  and  may  be  associated  with  tumours  of 
the  underlying  connective  tissues.  We  recently  removed  a  large 
fatty  mass  from  the  anterior  thoracic  wall  of  a  child,  the  greater  ' 
portion  of  the  projecting  surface  of  which  was  covered  with  a  capillary 
lymphangioma.  The  only  treatment  for  this  condition  is  excision  or 
cauterization. 

In  the  subcutaneous  tissues  the  capillary  variety  is  often  associated 
with  large  cysts  of  the  cavernous  type.  It  constitutes  a  soft  swelling 
which  when  cut  into  has  a  spongy  texture  and  exudes  a  large  amount 
of  lymph,  with  some  blood.  This  form  is  rarely  well  defined,  and 
may  burrow  widely,  invading  and  infiltrating  the  tissues,  and,  indeed, 
in  some  cases  may  almost  be  looked  on  as  of  a  malignant  nature. 
Free  excision  is  the  only  cure. 

(b)  Cavernous  Lymphangioma. — The  lymphatics  here  lose  their 
tubular  condition  and  give  rise  to  cyst-like  swellings  which  vary 
much  in  size. 

In  the  skin  they  are  rarely  larger  than  a  split  pea,  and  may  co-exist 
with  the  capillary  variety.  Any  part  of  the  body  may  be  affected, 
and  the  lesion  manifests  itself  as  a  series  of  small  vesicles,  which 
persist  and  are  unaccompanied  by  any  inflammatory  redness,  thus 
serving  to  distinguish  it  from  herpes.     They  contain  lymph,  and,  if 

*  See  Carless,  '  Some  Cases  of  Lymphangioma,'  Brit.  Jonvn.  of  Children  i 
Diseases,  February,  1904,  p.  56. 


DISEASES  OF  THE  LYMPHATICS  361 

opened,  a  considerable  flow  of  this  fluid  (lymphorrhoea)  may  result, 
lasting  for  some  time.  They  have  been  observed  most  frequently  on 
the  inner  side  of  the  thigh  and  on  the  prepuce.  Treatment  consists 
in  excision,  or  in  laying  them  open  and  cauterizing  the  base. 

In  the  deeper  structures  large  multilocular  cystic  swellings  may 
be  produced ;  these  are  most  frequently  seen  in  the  neck,  and  the 
condition  is  often  termed  a  Cystic  Hygroma  (Fig.  116).  The  descrip- 
tion given  in  Chapter  XXXI.  would  apply  equally  well  to  a  tumour 
of  this  nature  in  any  other  part  of  the  body.  Removal  by  dissection 
is  often  very  difficult,  especially  in  old-standing  neglected  cases  ;  the 
limitations  of  the  mass  are  sometimes  very  indefinite,  and  it  may  be 
necessary  to  leave  ths  wound  open  and  pack  it,  so  as  to  ensure 
healing  by  granulation. 

Lymphangiectases  are  more  frequently  acquired  than  congenital,  but 
the  latter  condition  occurs,  and  is  then  probably  due  to  some  abnormal 
development  of  the  lymphatics  or  to  ante-natal  inflammatory  mischief. 

Macroglossia  and  macroclieilia  are  congenital  enlargements  of  the 
tongue  and  lip,  due  to  lymphatic  obstruction  and  to  an  associated  over- 
growth of  the  connective  tissues  of  the  parts. 


Fig.   116. — Cystic  Hygroma  of  Neck.     (From  a  Photograph.) 

The  patient  was  a  child  of  a  few  weeks.  The  cyst  was  opened  and  the  mass 
partially  removed.  Recurrence  ensued,  and  a  further  operation  of  a  very 
extensive  character  was  required.  As  the  lymphangiomatous  tissue  had  in- 
vaded the  sterno-mastoid  and  parotid  gland,  it  was  impracticable  to  remove  it 
totally.  The  child  finally  succumbed  to  infective  lymphangitis  and  exhaustion. 

The  condition  known  as  Chylous  Hydrocele,  in  which  there  is  an 
efl"usion  of  milky  fluid  (presumably  chyle)  into  the  tunica  vaginalis, 
is  probably  due  to  some  such  obstructive  cause.  In  a  case  under  our 
care  the  lymphatics  of  the  spermatic  cord  were  dilated  by  a  similar 
fluid  in  a  beaded  manner. 

Elephantiasis  is  a  hypertrophic  condition  of  the  subcutaneous 
tissues  and  skin  resulting  from  chronic  lymphatic  obstruction.  Two 
chief  varieties  are  described  :  (i.)  E.  arahiim,  due  to  a  development 
in  the  lymphatics  of  living  parasites,  viz.,  the  Filaria  sanguinis  hominis  ; 
(ii.)  the  non-Jilarial  type,  which  may  arise  from  many  causes,  such  as 
the  deposit  of  tuberculous  or  cancerous  material  in  lymphatic  glands  ; 


362 


A  MANUAL- OF  SURGERY 


the  obliteration  of  lymphatic  channels  in  operations  for  removing 
such  glands ;  recurrent  attacks  of  lymphangitis  in  cases  of  chronic 
eczema  or  ulcer,  leading  to  a  gradually  increasing  obliteration  of 
lymphatics.  '  The  condition  generally  affects  the  legs,  but  the  scrotum 
is  not  uncommonly  involved,  and  occasionally  the  mammee,  arms, 
or  face.  The  accompanying  illustrations  (Figs.  117  and  118)  indicate 
that  the  non-filarial  type  may  be  just  as  severe  as  the  other  (Fig.  119), 
although  this  is  unusual. 

Three  chief  phenomena  manifest  themselves  as  the  outcome  of 
such  obstruction — viz.,  (a)  Solid  or  lymphatic  oedema,  a  condition  in 
which  the  subcutaneous  tissues  become  firm,  infiltrated,  and  brawny, 


Fig.  117. — Non-filarial  Elephantiasis  of  Both  Legs. 

From   a  woman  who  had  never  been   out  of   England.     The   cause  was  not 
apparent,  but  had  been  in  action  many  years. 

but  the  fluid  cannot  be  expressed  from  them,  as  in  an  ordinary 
oedema,  and  hence  the  part  does  not  pit  on  pressure  ;  (b)  hyperplasia 
follows,  affecting  not  only  the  subcutaneous  tissues,  which  are  greatly 
thickened,  but  also  the  skin,  which  becomes  coarse  and  wart-like  in 
appearance,  (c)  The  warty  stage  is  usually  preceded  by  a  develop- 
ment of  vesicles  (dilated  lymphatics)  in  the  papillae,  and  from  these 
when  ruptured  a  considerable  flow  of  lymph  (lymphorrhcea)  may  follow. 
If  sepsis  supervenes,  chronic  ulceration  and  recurrent  lymphangitis 
may  follow. 

Elephantiasis  Arabum  {syn. :  Barbadoes  leg)  requires  but  little  notice 
here,  as  it  is  seldom  seen  in  this  country,  being  mainly  limited  to  the 


DISEASES  OF  THE  LYMPHATICS  363 

tropics,  especially  the  West  Indies  and  South  America.  The  legs, 
scrotum,  and  vulva  are  the  parts  most  frequently  attacked,  but 
the  face  or  breast  may  also  be  affected.  It  manifests  itself  as  a 
hyperplasia  of  variable  size  of  the  subcutaneous  tissues,  whilst 
the  skin  becomes  thickened  and  wart-like,  and  from  it  a  copious 
discharge  of  lymph  may  escape.  The  parts  sometimes  attain  enor- 
mous dimensions,  the  scrotum  even  reaching  to  the  ground  when 
the  patient  is  sitting  (Fig.  119).  The  disease  persists  for  many 
years,  and  is  not  directly  fatal. 


Fig.  118. — NoN-FiLARiAL  Elephantiasis  of  Scrotum,  Penis,  and  Thighs. 
(From  a  Photograph.) 

The  patient  was  a  young  man,  and  the  cause  of  the  trouble  suppuration  of  the 
inguinal  glands  after  scarlatina;  the  cicatrices  of  the  incisions  required  in 
order  to  deal  with  the  glands  are  plainly  to  be  seen.  The  scrotum  was 
much  enlarged  and  very  solid  ;  the  skin  over  it  was  covered  with  papil- 
lomatous growths,  due  to  lymphatic  dilatation.  The  skin  of  the  penis  was 
much  thickened,  and  the  subcutaneous  tissues  infiltrated.  Over  the  thio-hs 
were  scattered  numbers  of  vesicles,  which,  when  pricked,  exuded  lymph, 
and  some  of  these  were  becoming  transformed  into  solid  fibrous  growths. 
The  legs  and  feet  were  also  in  a  condition  of  solid  oedema. 

The  condition  is  due,  as  already  mentioned,  to  the  obstruction 
caused  by  the  development  of  the  Filaria  sanguinis  hominis  in  the 
lymphatics.  These  are  spread  (according  to  Manson)  by  the  ao-ency 
of  mosquitoes,  in  whose  bodies  the  intermediate  stage  is  passed. 
The  dead  mosquito,  with  its  parasitic  contents,  falls  upon  the  water, 
and  in  this  way  the  ova  find  an  entrance  into  the  human  stomach, 
where  the  young  worm  is  set  free,  bores  through  the  gastric  mucous 
membrane,  and  finally  becomes  lodged  in  the  lymphatics,  especially 
those  of  the  extremities.    Not  more  than  two  or  three  pairs  of  mature 


364 


A  MANUAL  OF  SURGERY 


filariae  are  generally  present  in  the  same  individual.  The  body  of 
the  female  worm  (which  attains  a  length  of  3  inches)  is  mainly 
occupied  by  the  reproductive  organs,  and  a  countless  number  of 
embryonic  filariae  are  produced.  Some  remain  coiled  up  in  the 
lymphatic  spaces,  and  give  rise  to  the  phenomena  of  lymphatic 
obstruction.  Others  become  uncoiled,  and  are  then  about  -^q  inch  in 
length  ;  they  find  their  way  into  the  blood-stream,  sometimes  at  night 
(F.  noctimia),  sometimes  in  the  day  (F.  diunia),  and  can  be  readily 
seen  under  the  microscope  (p.  56).  Manson  claims  that  they  are 
taken  into  the  body  of  the  mosquito  with  the  blood  which  it  abstracts, 
and  thus  a  fresh  generation  is  developed. 


Fig.  119. 


-Filarial  Elephantiasis  of  Scrotum  and  Penis 
IN  A  Japanese. 


The  Treatment  is  extremely  unsatisfactory.  In  the  y^/flm/ variety, 
if  one  can  localize  the  situation  of  the  parent  filariae,  as  has  been 
possible  in  a  few  cases,  they  should  be  excised  ;  but  even  then  the 
lymphatic  obstruction  may  persist.  This  may  be  dealt  with  in  either 
variety  by  elevation  of  the  limb  and  elastic  pressure  ;  but  when  the 
condition  is  due  to  lymphatic  obstruction  in  the  groin,  it  may  be 
possible  to  find  the  dilated  lymph  trunks  and  implant  them  into  a 
tributary  of  the  internal  saphena  vein  [lymphangeioplasty),  so  as  to 
relieve  the  limb  of  its  engorgement  with  lymph.  It  has  also  been 
suggested  to  construct  artificial  lymphatics  by  introducing  a  care- 
fully sterilized  silk  thread  through  the  subcutaneous  tissues  of  the 


DISEASES  OF  THE  LYMPHATICS  365 

thickened  area,  leaving  it  buried  therein,  and  carrying  it  up  into 
normal  tissues  (Sampson  Handley).  This  has  acted  very  satis- 
factorily in  draining  away  the  fluid  from  the  brawny  arms,  sometimes 
seen  in  the  last  stages  of  a  cancerous  breast  {q-v.),  but  it  is  of  little  avail 
in  the  lower  extremity  owing  to  the  counter-influence  of  gravity. 
Finally,  when  a  limb  is  involved,  amputation  may  be  desirable. 
When  the  scrotum  is  affected,  the  morbid  tissue  can  be  freely  dis- 
sected away,  sufficient  skin  being  left  to  cover  in  the  wound  if 
possible ;  the  penis  and  testes  must  first  be  isolated,  and  then  the 
scrotum  amputated,  a  tourniquet  being  used  to  restrain  the  bleeding. 

Affections  of  Lymphatic  G-lands. 

Acute  Lymphadenitis,  or  Inflammation  of  Lymphatic  G-lands. — The 
Cause  of  this  condition  is  almost  always  the  absorption  of  some 
irritative  material  (toxic  or  infective)  from  the  periphery.  There  is 
always  an  increased  flow  of  lymph  from  an  inflamed  part,  resulting 
in  an  enlargement  of  the  glands  to  which  the  lymph  is  carried,  which 
quickly  subsides  when  the  inflammatory  process  is  at  an  end.  In 
infective  conditions  the  enlargement  is  more  obvious  and  painful,  and 
suppuration  frequently  results;  in  fact,  the  lymphatic  glands  must 
be  looked  on  as  the  filters  by  means  of  which  Nature  eliminates 
many  sources  of  disease.  It  is  curious  that  certain  peripheral 
infective  conditions  are  not  at  all  liable  to  produce  lymphadenitis^ 
e.g.,  spreading  gangrene  and  many  forms  of  cellulitis ;  possibly  the 
acuteness  of  the  process  causes  lymphatic  thrombosis,  and  thus 
hinders  absorption. 

Pathologically,  the  condition  is  characterized  by  hyperaemia  of,  and 
exudation  into,  the  gland,  which  becomes  redder,  firmer,  and  larger 
than  usual.  Suppuration  usually  starts  in  more  than  one  spot.  A 
certain  amount  of  peri-adenitis  is  always  associated  with  it,  even  in 
the  early  stages ;  the  latter  may  be  of  little  importance,  or  be  so 
severe  and  extensive  as  to  constitute  a  diffuse  suppurative  cellulitis. 

Clinical  History. — The  glandular  trouble  may  be  associated  with 
a  typical  lymphangitis,  or  be  independent  of  it,  and  the  causative 
trouble  may  have  almost  disappeared  before  the  glands  become 
swollen.  The  local  phenomena  are  of  an  ordinary  inflammatory 
type,  the  glands  becoming  enlarged  and  tender,  and  if  superficial,  the 
skin  over  them  red  and  cedematous,  and  the  surrounding  tissues 
infiltrated  and  brawny.  When  pus  has  formed,  softening  occurs  in 
the  centre  of  the  mass,  and  fluctuation  may  become  evident;  where 
there  is  much  loose  areolar  tissue  around  the  glands,  as  in  the  axilla, 
the  pus  may  burrow  widely.  Fever,  malaise,  and  all  the  general 
phenomena  associated  with  an  acute  inflammation,  are  usually  well 
marked. 

Treatment. — The  part  must  be  kept  at  rest  and  protected  from 
injury,  and  the  offending  wound  or  causative  lesion  dealt  with  by 
such  antiseptic  measures  as  may  be  needed  to  hasten  its  restoration 
to  a  healthy  state.     Fomentations  or  poultices  are  applied  over  the 


366  A  MANUAL  OF  SURGERY 

gland,  and  the  patient,  after  the  administration  of  a  purge,  may  be 
given  quinine  and  iron,  if  necessary.  As  soon  as  pus  has  formed,  it 
should  be  let  out  by  an  incision,  and  the  wound  dressed  antiseptically. 

Special  Forms  of  Acute  Lymphadenitis. 

The  Axillary  Glands  are  usually  affected  as  a  result  of  poisoned  wounds  of  the 
hand  or  fingers,  although  other  glands  exist  lower  down  in  the  arm,  viz.,  the 
supracondyloid,  just  above  the  internal  condyle.  Boils  in  the  axilla  and  excoria- 
tions or  septic  wounds  of  the  breast  may  also  cause  an  axillary  abscess.  In  this 
region  a  suppurative  peri-adenitis  is  often  superadded,  extending  widely  under 
and  between  the  pectoral  muscles,  reaching  even  up  to  the  clavicle.  Care  must 
be  taken  in  opening  such  an  abscess  to  avoid  the  main  vessels  by  cutting  from 
above  downwards,  midway  between  the  anterior  and  posterior  axillary  folds, 
whilst  Hilton's  method  should  be  adopted  in  all  cases  where  the  pus  is  situated 
deeply. 

In  the  Groin  there  are  three  groups  of  glands  :  (i)  The  oblique  set,  running 
parallel  to  Poupart's  ligament,  and  becoming  inflamed  in  affections  of  the  penis, 
scrotum,  perineum,  anus,  buttock,  and  lower  part  of  the  abdomen  ;  (2)  a  super- 
ficial vertical  set,  running  with  the  long  saphena  vein,  and  r.-jceiving  lymph 
from  all  the  superficial  parts  of  the  limb,  except  perhaps  those  from  which  the 
blood  is  returned  by  the  external  saphena  vein,  the  popliteal  glands  receiving 
the  lymph  from  this  region  ;  and  (3)  the  deep  vertical  set,  receiving  the  deep 
lymphatics  of  the  limb.  Abscess  in  the  groin  is  opened  by  a  vertical  incision, 
so  as  to  allow  the  wound  to  gape  when  the  patient  sits,  and  prevent  pocketing 
of  matter. 

Suppuration  in  the  glands  of  the  Neck  is  exceedingly  common,  arising  most 
often  from  affections  of  the  scalp  (eczema  or  pediculosis),  ear  (otorrhoea  or 
eczema),  throat,  or  lips.  As  to  the  exact  distribution  of  the  lymphatics,  we  must 
refer  students  to  anatomical  textbooks.  When  opening  a  cervical  abscess,  care 
must  be  taken  to  avoid  important  structures,  such  as  the  external  jugular  vein, 
and  to  make  incisions  across  the  fibres  of  the  platysma  in  order  to  gain  space  for 
efficient  drainage. 

Chronic  Lymphadenitis. ^Three  chief  varieties  of  chronic  inflam- 
mation of  lymphatic  glands  are  met  with — viz.,  the  simple,  syphilitic, 
and  tuberculous. 

1.  Chronic  Simple  Lymphadenitis  is  a  condition  resulting  from  some 
peripheral  irritation,  which  is  insufficient  to  cause  an  acute  attack. 
Occasionally  it  is  due  to  blows  or  to  strains,  as  in  over-walking, 
being  then  the  outcome  of  obstruction  to  the  lymphatic  flow  from 
compression  or  rupture  of  the  efferent  vessels.  The  glands  become 
enlarged,  tender,  and  painful,  but  as  a  rule  they  are  not  adherent 
to  one  another  or  to  adjacent  structures,  and  show  but  little  tendency 
to  suppurate.  This  condition  often  precedes,  and,  indeed,  may  be 
looked  on  as  a  predisposing  cause  of,  tuberculous  lymphadenitis. 
The  Treatment  consists  in  keeping  the  part  at  rest,  and  removing,  if 
possible,  all  sources  of  local  irritation.  The  general  health  should 
also  be  attended  to,  especially  in  children  predisposed  to  the  develop- 
ment of  tuberculous  disease. 

2.  Chronic  Syphilitic  Lymphadenitis. — The  lymphatic  glands  are 
involved  in  several  ways  in  the  course  of  syphilitic  disease  :  (a)  The 
primary  lesion  is  associated  with  the  development  of  an  indolent  bubo 
in  the  nearest  lymphatic  glands  (p.  147).     {b)  In  the  second  stage, 


DISEASES  OF  THE  LYMPHATICS  367 

when  general  infection  has  occurred,  the  glands  in  many  parts  of  the 
body  are  infected  in  the  same  indolent  fashion  (p.  150).  (c)  In  the 
tertiary  period  the  lymphatic  glands  may  undergo  a  true  gummatous 
change,  or  become  enlarged  and  tender  owing  to  the  absorption  of 
infective  material  from  a  broken-down  gumma. 

3.  Clironic  Tuberculous  Lymphadenitis  occurs  most  commonly  in 
children  or  young  adults  with  an  inherited  predisposition  to  tuber- 
culous disease,  and  especially  in  those  whose  surroundings  are 
unhealthy,  and  whose  general  condition  is  deteriorated  by  insufficient 
or  bad  food  and  want  of  fresh  air.  Some  local  focus  of  irritation  is 
usually  present  in  the  form  of  pediculosis  capitis,  decayed  teeth, 
chronic  otorrhoea,  adenoids,  or  eczema  of  the  face.  As  a  result  of 
this,  neighbouring  glands  become  chronically  inflamed,  and,  as  the 
late  Sir  T.  Burdon  Sanderson  expressed  it,  'the  soil  is  thereby 
prepared  for  the  seed.'  The  bacilli  are  conveyed  to  the  gland  by  the 
blood  or  lymph,  gaining  access  through  some  breech  of  surface,  or 
even  through  a  healthy  mucous  membrane  ;  or  perhaps  they  may  be 
derived  from  some  deep  focus  of  quiescent  tubercle,  say,  in  the 
bronchial  or  mediastinal  glands.  Any  lymphoid  tissue  in  the  body 
may  become  the  seat  of  tuberculous  disease ;  but  the  glands  of  the 
neck  are  more  commonly  involved  than  any  others.  The  axillary 
and  inguinal  glands  are  not  unfrequently  affected,  whilst  tuberculous 
disease  of  those  in  the  mesentery  gives  rise  to  the  affection  known  as 
'  tabes  mesenterica.' 

The  earliest  manifestation  of  the  disease  consists  in  a  fleshy 
enlargement  of  the  glands,  which  cannot  at  first  be  distinguished, 
either  clinically  or  pathologically,  from  a  simple  chronic  hyperplasia. 
The  gland  may  be  enlarged  to  many  times  its  natural  size,  and  on 
section  looks  pinkish  m  colour,  and  is  of  firm  consistence.  Micro- 
scopically, all  that  is  noticed  is  a  great  increase  in  the  lymphoid 
corpuscles,  together  with  some  overgrowth  and  thickening  of  the 
fibrous  capsule  and  trabeculae.  When  tuberculous  infection  has 
occurred,  the  characteristic  nodules  can  be  seen  imder  the  micro- 
scope, but  there  is  at  first  no  change  in  the  naked-eye  appearances. 
Caseation  follows  sooner  or  later,  and  since  the  tuberculous  nodules 
are  often  disseminated  widely  through  the  gland,  many  caseating 
foci  will  be  found.  Should  the  case  recover  without  suppuration, 
the  gland  gradually  shrinks,  and  becomes  small,  hard,  and  often 
closely  adherent  to  surrounding  tissues,  whilst  the  caseous  material 
is  absorbed,  or  undergoes  calcification.  This  latter  change  is  most 
frequently  observed  in  the  mediastinal  and  mesenteric  glands,  and  is 
not  very  uncommon  in  the  neck. 

More  hequenily  siippuvation  ensues,  sometimes  from  a  simple  lique- 
faction of  the  caseating  material,  sometimes  from  a  superadded 
infection  with  pyogenic  organisms.  Foci  of  pus  develop  at  various 
spots  in  the  glandular  parenchyma,  and  when  once  formed,  these 
gradually  amalgamate  and  cause  the  destruction  of  the  rest  of  the 
glandular  tissue,  the  fibrous  trabeculae  remaining  longest  unaffected, 
so  that  finally  the  gland  is  represented  by  a  single  abscess  cavity 


368  A  MANUAL  OF  SURGER/ 

surrounded  by  a  pyogenic  membrane  of  the  ordinary  tuberculous  type, 
in  which  traces  of  the  capsule  can  be  observed.  Several  of  these 
abscesses  may  unite  one  with  another,  and  thus  a  large  multiloculated 
cavity  containing  pus  mixed  with  caseous  debris,  is  formed.  A 
certain  amount  of  peri-adenitis  is  almost  always  present,  though  not 
to  any  great  extent  in  the  early  stages ;  when,  however,  suppuration 
has  occurred,  the  enlarged  glands  become  adherent  to  one  another 
and  to  surrounding  structures.  In  the  more  chronic  cases  the  fibro- 
cicatricial  tissue  thus  formed  may  be  so  extensive  as  to  fix  the  mass 
firmly  to  the  deeper  parts,  such  as  the  main  vessels  and  nerves, 
rendering  removal  dangerous  and  almost  impracticable.  Important 
vessels  are  occasionally  eroded  by  an  extension  of  the  suppurative 
process,  and  this  may  lead  to  fatal  haemorrhage.  Sooner  or  later  the 
abscess,  if  left  to  itself,  bursts  at  one  or  several  spots,  giving  exit  to 
the  pus  and  caseous  debris,  and  leaving  ulcerated  openings.  The  sur- 
rounding skin  is  undermined,  thin,  and  purplish,  and  the  granulations 
sometimes  sufficiently  prominent  to  protrude  through  the  openings  as 
fungating  masses.  A  variable  amount  of  pus  escapes  from  these, 
and  the  condition  may  persist  for  many  years  if  radical  treatment  is 
not  undertaken.  Under  suitable  local  and  constitutional  measures 
these  sores  may,  and  usually  do,  heal  after  a  time,  giving  rise  to 
a  pulpy  spongy  cicatrix,  which  is  often  puckered  and  more  or  less 
keloidal,  and  may  retain  its  vascularity  for  a  much  longer  period 
than  would  a  healthy  scar.  Lymphatic  oedema  in  the  region  drained 
by  the  affected  glands  is  sometimes  observed  as  a  late  consequence 
of  this  affection. 

Treatment  in  the  early  stages  consists  mainly  in  improving  the 
general  health  by  means  of  suitable  diet  and  tonics,  such  as  cod-liver 
oil  and  syrup  of  the  iodide  of  iron,  together  with  residence  in  a 
healthy,  bracing  situation,  especially  at  the  seaside,  as,  for  instance, 
at  Margate.  AH  sources  of  local  irritation,  septic  roots  of  teeth, 
enlarged  tonsils,  adenoids,  etc.,  must  be  removed  so  as,  if  possible, 
to  prevent  infection  with  pyogenic  organisms;  and  counter-irritants, 
such  as  iodine  paint,  are  best  avoided.  Rest  of  the  affected  part 
should  be  enforced  as  m.uch  as  possible ;  in  some  cases  the  appli- 
cation of  splints  to  restrict  movement  is  advisable.  Small  doses  of 
tuberculin  (TR)  are  often  useful. 

Operative  Treatment. — Too  much  time  should  not  be  wasted  in 
palliative  measures,  inasmuch  as  the  longer  the  glands  are  left,  the 
firmer  will  be  the  adhesions  which  they  are  likely  to  contract  to 
surrounding  tissues,  and  the  more  difficult  the  dissection  for  their 
removal.  Operation  is  indicated  when  the  glands  persist  in  spite  of 
suitable  care,  and  still  more  if  they  enlarge  or  show  evidences  of 
suppuration. 

In  the  neck  every  effort  must  be  made  to  avoid  operation,  but  it  is 
wiser  to  interfere  early  and  anticipate  suppuration,  as  the  scar  of  an  . 
aseptic  operation  is  less  obvious  than  that  which  follows  the  opening 
of  an  abscess.     When  abscesses  form,  it  must  be  remembered  that 
there  is  frequently  a  deep  sub-fascial  origin,  communicating  with  the 


DISEASES  OF  THE  LYMPHATICS 


369 


superficial  subcutaneous  collection  of  pus  by  a  narrow  aperture ; . 
unless  this  deep  focus  is  dealt  with  efficiently,  the  wound  will  not 
heal.  It  may  sometimes  be  practicable  to  scrape  away  all  the  deep 
tuberculous  material  at  the  time  that  the  abscess  is  opened;  but, 
failing  that,  the  wound  is  allowed  to  heal  as  far  as  possible,  and  then 
at  a  later  date  the  whole  mass  of  glands  involved  in  the  process  is 
removed.  When  extirpation  of  glands  is  required,  the  incision  varies 
with  the  situation  of  the  mass,  but  every  precaution  is  taken  to 
minimize  the  deformity  and  scarring.  In  the  upper  part  of  the  neck, 
when  the  glands  lie  in  front  of  the  sterno-mastoid,  an  almost  trans- 
verse incision  may  be  employed,  or  one  following  the  creases  of  the 
skin  and  very  similar  to  that  for  ligature  of  the  lingual  artery 
(Fig.  120,  B).     In  the  lower  half  of  the  neck  an  incision  along  the 


-sSS*-^^ 


Fig.  120.— Incisions  for  Removal  of  Tuberculous  Gr.Axos  from  the  Neck. 

A  and  A^,  For  removal  of  glands  from  both  triangles  (Halsted's  method)  ;  B,  for 
removing  glands  from  submaxillary  and  upper  carotid  regions ;  E,  for 
removing  glands  in  lower  part  of  posterior  triangle  ;  C,  spinal  accessory 
nerve  ;  D,  site  for  division  of  sterno-mastoid. 

anterior  or  posterior  border  of  the  sterno-mastoid  (E)  will  often 
suffice,  or  if  the  glands  extend  backwards  a  transverse  one  just  above 
the  clavicle  (A^). 

When  enlarged  glands  are  present  both  in  front  of  and  behind  the  sterno-mastoid, 
as  well  as  beneath  it,  their  removal  is  perhaps  most  satisfactorily  accomplished 
by  a  method  suggested  by  Halsted.  The  incision  commences  close  to  the  tip  of 
the  mastoid  process,  and,  passing  forwards  just  behind  the  jaw,  sweeps  across 
the  neck  to  the  middle  of  the  clavicle  (Fig.  120,  A)  ;  a  second  incision  runs 
transversely  just  above  the  clavicle  (A^).  The  flaps  thus  marked  out  are  dissected 
up  so  as  to  lay  bare  the  sterno-mastoid  and  the  enlarged  glands.  The  deep 
dissection  commences  from  below  and  behind.  The  supraclavicular  triangle  is 
first  cleared,  the  omo-hyoid  muscle  being  divided,  but  sutures  are  left  on  the  ends 
for  identification.  The  anterior  end  is  drawn  up,  and  serves  to  raise  the  sterno- 
mastoid,  which  is  then  divided  obliquely  (D)  below  the  spinal  accessory  nerve  (C). 
The  divided  ends  are  turned  up  and  down  so  as  to  expose  freely  the  glands  lying 

24 


370  A  MANUAL  OF  SURGERY 

on  the  carotid  sheath,  which  are  dealt  with  from  below  upwards.  Special  care 
must  be  taken  of  the  nerves  and  of  the  internal  jugular,  but  it  is  better  to  tie  and 
remove  this  structure  than  to  leave  it  in  the  wound  with  a  number  of  lateral 
ligatures  applied.  During  the  vomiting  that  is  almost  certain  to  follow  such  an 
extensive  dissection,  lateral  ligatures  would  very  possibly  be  forced  off  by  the 
suddenly  increased  intravenous  tension  thereby  induced.  "When  all  the  glands 
have  been  removed,  the  divided  muscles  are  carefully  replaced  and  sutured 
together,  and  divided  fascise,  etc.,  approximated  by  buried  sutures.  In  this,  as 
in  all  neck  operations,  the  skin  is  brought  together  by  Halsted's  intradermic 
suture,  and  it  is  wonderful  how  little  scarring  and  deformity  follow  this  extensive 
procedure. 

The  pve-aiiviculav  gland  lying  on  the  capsule  of  the  parotid,  is  some- 
times affected,  and  may  cause  facial  paralysis,  either  as  a  result  of  the 
sclerosing  peri-adenitis,  or  from  injudicious  surgery.  Any  incisions 
made  with  a  view  to  remove  the  gland  or  to  open  an  abscess  therein 
should  be  made  in  the  direction  of  the  fibres  of  the  facial  nerve — i.e., 
horizontally. 

In  the  groin,  tuberculous  glands  are  often  mistaken  for  some  condi- 
tion due  to  venereal  disease.  The  history  of  onset  and  the  extreme 
chronicity  should  suffice  to  establish  a  diagnosis.  The  iliac  glands 
will  often  be  found  similarly  affected,  and  operations  in  this  region  are 
sometimes  very  extensive  in  consequence.  Well-marked  peri-adenitis 
is  usually  present  in  the  iliac  fossa,  and  the  glands  may  be  very  adherent. 
Atrophy  of  the  testicle  sometimes  follows,  either  from  division  of  the 
spermatic  vessels,  or  from  their  implication  in  the  cicatrix. 

Tumours  of  Lymphatic  Glands. 

The  primary  new  growths  occurring  in  lymphatic  glands  are  Lymph- 
adenoma,  or  Hodgkin's  disease.  Lymphatic  Leucocythsemia,  and 
Lympho-sarcoma.  The  structure  of  the  growths  in  these  three  con- 
ditions is  very  similar,  and  their  clinical  histories  have  a  certain 
resemblance,  so  that  it  may  be  difficult  to  refer  a  given  case  to  its 
proper  group.  Methodical  examination  of  the  blood  in  such  cases 
has  thrown  much  light  on  the  subject,  but  rendered  it  at  the  same 
time  even  more  complex. 

Lymphadenoma,  or  Hodgkin's  disease,  is  characterized  by  a  pro- 
gressive enlargement  of  the  lymphatic  glands  and  of  the  lymphoid 
tissue  of  the  spleen,  liver,  and  other  organs.  The  affected  glands 
and  the  masses  in  the  viscera  are  quite  characteristic  in  structure, 
and  have  a  very  different  appearance  from  that  seen  in  simple 
hyperplasia  or  in  infective  processes.  The  gland  is  homogeneous  on 
section,  the  distinction  between  cortex  and  medulla  being  lost.  The 
amount  of  the  stroma  of  the  gland  varies  considerably  ;  if  it  is  not 
very  abundant  the  glands  remain  soft,  but  sometimes  the  stroma  is 
much  hypertrophied,  and  then  the  glands  become  hard.  One  type 
does  not  appear  to  pass  into  the  other,  and  the  soft  form  is,  in  most 
cases,  more  malignant  and  more  rapid  in  growth  than  the  hard. 

Hodgkin's  disease  is  most  common  in  young  adults,  but  no  age  is 
exempt ;  it  is  decidedly  more  common  in  males  than  in  females.  In 
some  cases  the  cause  of  the  original  enlargement  of  glands  is  some 


DISEASES  OF  THE  LYMPHATICS  371 

inflammatory  lesion,  such  as  otitis  media  or  dental  caries,  but  often 
no  such  origin  can  be  traced.  The  glands  first  affected  are  usually 
the  cervical,  and  the  disease  may  remain  limited  to  a  larger  or 
smaller  group  of  these  for  a  considerable  time  before  other  mani- 
festations show  themselves ;  this  condition  is  sometimes  termed 
benign  or  localized  lymphadenoma.  In  other  cases  internal  glands 
become  affected  first,  and  this  most  commonly  in  the  mediastinal 
group,  the  retroperitoneal  glands  coming  next  in  order  of  frequency. 
When  the  disease  is  more  advanced,  adenoid  tissue  in  any  part  of 
the  body  may  be  affected.  The  spleen  is  usually  somewhat  enlarged, 
and  in  about  half  the  cases  presents  localized  grayish-white  tumours 
(the  hard-hake  spleen).  Similar  growths  may  occur  in  the  liver,  kidneys, 
etc.,  or  in  the  skin. 

The  early  symptoms  are  slight,  the  only  thing  noticed  being  the 
glandular  enlargement.  In  this  stage  the  glands  are  soft  and  elastic, 
and  not  adherent  to  the  skin  or  to  one  another ;  they  have  little  or  no 
tendency  to  caseate  or  suppurate.  There  may  be  slight  irregular 
pyrexia,  or  a  continuous  fever,  but  no  blood  changes. 

When  the  internal  glands  are  first  affected,  the  earliest  symptoms 
may  be  those  of  pressure.  This  is  most  marked  in  the  mediastinal 
group  of  cases,  in  which  the  symptoms  are  those  of  aortic  aneurism 
or  thoracic  tumour.  In  particular,  pressure  on  the  superior  vena  cava 
is  noted,  leading  to  engorgement  of  the  superficial  thoracic  veins. 

In  the  later  stages  the  glands  often  fuse  together,  forming  hard 
masses  of  large  size,  and  the  disease  becomes  generalized.  The 
blood  shows  a  moderate  grade  of  anaemia  of  the  secondary  type,  with 
a  slight  increase  of  leucocytes,  especially  of  the  lymphocytes.  The 
fever  is  more  marked,  and  may  appear  more  or  less  periodically  for 
days  at  a  time,  perhaps  conjoined  with  swelling  and  pain  in  the 
affected  glands.     In  the  later  stages  there  is  often  severe  itching. 

Diagnosis. — (i)  From  lymphatic  leucocythcBmia  (pp.  56,  372)  Hodgkin's 
disease  is  recognised  by  the  entire  absence  of  blood  changes  in  the 
early  stages,  and  by  the  presence  merely  of  a  secondary  anaemia  in 
the  later.  Moreover,  lymphadenoma  usually  limits  itself  to  regions 
in  which  adenoid  tissue  is  normally  present ;  leucocythaemia  may 
develop  new  growths  in  any  part  of  the  body.  (2)  From  lympho- 
sarcoma it  is  known  by  the  fact  that  it  is  almost  invariably  limited  to 
the  glands,  and  does  not  infiltrate  surrounding  tissues.  Lympho- 
sarcoma is  characterized  chiefly  by  its  tendency  to  infiltrate,  and  also 
by  producing  secondary  deposits  in  tissues  which  are  not  rich  in 
adenoid  tissue.  (3)  From  tuberculous  disease  of  glands  the  diagnosis 
is  often  difficult.  Tubercle  is  more  common  in  the  very  young,  and 
is  more  frequently  bilateral.  The  glands  have  a  greater  tendency  to 
fuse  together  as  a  result  of  peri-adenitis,  and  to  suppurate.  In 
doubtful  cases  microscopic  examination  of  an  excised  gland  may  be 
required  to  settle  the  diagnosis. 

The  Treatment  of  Hodgkin's  disease  is  unsatisfactory.  Arsenic  in 
increasing  doses  is  of  the  greatest  value,  but  if  the  glands  resist  such 
treatment  they  should  be  excised,  when  accessible.  The  spleen  has 
also  been  removed  with  benefit,  when  enlarged. 


372  A  MANUAL  OF  SURGERY 

Lymphatic  Leucocythsemia  is  of  little  surgical  interest  except  in  so 
far  as  it  simulates  Hodgkin's  disease.  The  symptoms  are  much 
more  severe  than  in  the  latter,  and  marked  blood  changes  are 
present ;  the  number  of  the  leucocytes  is  enormously  increased, 
reaching  1^0,000  or  more  per  cubic  millimetre,  and  there  is  a  great 
preponderance  of  lymphocytes,  which  constitute  from  go  to  99  per 
cent,  of  all  cells  present.  There  is  also  anaemia,  often  of  some 
severity  (pp.  56  and  58).  Arsenic  is  valuable,  and  operative  treatment 
useless.  Recently  X-ray  treatment  has  been  employed  to  the  spleen 
and  ends  of  the  long  bones  with  temporary  benefit. 

Lympho- sarcoma. — This  term  has  been  used  with  very  different 
meanings,  but  is  best  restricted  to  tumours  which  have  a  structure 
approximating  to  that  of  adenoid  tissue — i.e.,  which  consist  of  small 
round  cells,  resembling,  if  not  identical  with,  ordinary  lymphocytes, 
set  in  a  reticulated  stroma  similar  to  that  of  the  lymphatic  glands, 
Peyer's  patches,  etc. ;  there  is  no  distinction  between  cortex  and 
medulla.  In  some  cases  they  are  very  difficult  to  distinguish  from 
chronic  granulomatous  swellings.  In  others  they  closely  resemble 
a  small  round-celled  sarcoma,  except  that  the  stroma  is  more  obvious. 
Their  sarcomatous  nature  is  based  rather  on  clinical  than  on  histo- 
logical characters — viz.,  on  the  fact  that  they  invade  and  destroy 
surrounding  tissues. 

Lympho-sarcoma  may  commence  in  any  part  of  the  body,  but  in 
the  vast  majority  of  cases  it  originates  in  pre-existing  adenoid  tissue, 
most  commonly  in  the  glands  in  the  root  of  the  neck,  the  tonsil,  or 
the  mediastinum.  It  may  also  affect  the  intestines  (commencing 
probably  in  the  Peyer's  patches)  or  the  testis.  When  commencing 
in  a  region  where  its  development  can  be  followed,  it  is  seen  to  form 
a  rapidly-growing  tumour,  which  is  at  first  firm,  elastic,  and  painless ; 
later  on,  however,  as  it  increases  in  size,  it  becomes  tender,  and  may 
cause  great  pain  from  pressure  on,  or  implication  of,  nerves.  It 
early  contracts  adhesions  to  surrounding  parts,  and  gives  rise  to 
secondary  growths  in  neighbouring  glands  by  direct  transmission. 
The  superjacent  skin  is  at  first  unaltered  in  colour  and  texture,  but 
as  the  tumour  increases,  it  becomes  congested  and  shiny,  and  con- 
tains a  network  of  dilated  veins.  Finally,  it  is  involved  in  the 
growth,  and  ulcerates,  an  occurrence  usually  followed  by  the  sprout- 
ing up  of  a  bleeding  fungating  mass,  similar  in  character  to  that 
formed  by  any  other  rapidly-growing  malignant  tumour.  Dissemina- 
tion of  the  growth  throughout  the  viscera  follows,  death  resulting 
from  exhaustion  and  cachexia. 

The  Treatment  consists  in  the  removal  of  the  mass,  where  prac- 
ticable, without  delay.  If,  however,  extensive  adhesions  exist,  this 
becomes  absolutely  impossible. 

Secondary  Growths  in  Lymphatic  Glands  are  a  special  feature  of 
all  cancerous  tumours.  In  the  sarcomata  they  are  less  common, 
but  are  always  present  in  the  case  of  melanotic  sarcoma,  lympho- 
sarcoma, and  usually  in  sarcoma  of  the  testis,  tonsil,  and  thyroid. 
The  special  characteristics  of  these  are  noted  elsewhere. 


CHAPTER  XV. 
AFrECTIONS   OF   NERVES. 

Injuries  of  Nerves. 

The  simplest  and  most  common  forms  of  injury  to  which  nerves  are 
liable  are  Contusions  and  Strains,  causing  a  sensation  of  tingling, 
or  pins  and  needles,  which  usually  wears  off  in  the  course  of  a  few 
hours.  In  severe  cases  variable  degrees  of  loss  of  power  and  sensa- 
tion may  ensue,  and  in  hysterical  women  more  or  less  neuralgia.  In 
patients  suffering  from  gout,  syphilis,  or  rheumatism,  a  chronic  peri- 
pheral neuritis  is  readily  induced,  often  of  a  somewhat  intractable 
type,  and  this  even  develops  in  healthy  individuals.  Treatment 
consists  in  gentle  friction  with  stimulating  liniments. 

Rupture  of  nerves  without  an  external  wound  only  occurs  in  con- 
nection with  severe  injuries,  such  as  dislocations  or  fractures,  and 
even  then  total  division  is  rare,  the  sheath  retaining  its  integrity, 
although  the  axis  cylinders  may  have  given  way.  Immediate  paralysis 
and  loss  of  sensation  usually  follow,  and  may  persist  for  a  time, 
although  repair  not  unfrequently  occurs,  since  the  sheath  remains 
intact.  The  doubt  always  existing  as  to  the  condition  of  the  sheath 
regulates  the  Treatment  which  must  be  followed,  viz.,  one  of  ex- 
pectancy. Friction  and  electricity  should  be  applied  to  the  parts, 
and  only  when  these  have  failed  should  operation  be  undertaken. 
Secondary  nerve  suture  under  these  circumstances  is  not  a  very 
successful  proceeding. 

Compression  of  a  nerve  is  usually  due  to  the  presence  of  a  tumouir 
or  aneurism,  or  to  some  displacement  or  inflammation  of  bones ;  in 
fractures  a  nerve  may  be  included  in  the  callus  formed  in  the 
process  of  repair,  the  symptoms  not  appearing  till  four  or  five 
weeks  after  the  injury ;  or  it  may  be  met  with  in  the  form  of 
crutch  palsy,  or  as  a  result  of  splint  pressure.  The  early  symptoms 
are  those  of  irritation,  e.g.,  cramp  and  spasm  of  muscles  or  neuralgic 
pain;  whilst  later*  on  paralysis  and  anaesthesia  appear,  combined 
sometimes  with  trophic  phenomena.  If  the  compressing  cause 
can  be  removed,  recovery,  at  any  rate  of  a  partial  character, 
follows  in  time  under  suitable  treatment,  such  as  massage  and 
electricity. 

373 


374  '    ^  MANUAL  OF  SURGERY 

Total  Division  of  a  Nerve.* — The  Immediate  Effects  are  :  {a)  Para- 
lysis of  the  muscles  supplied  by  the  nerve;  (b)  complete  anaesthesia  of 
the  parts  supplied  by  it,  which,  however,  is  not  necessarily  permanent, 
since  sensation  may  be  conveyed  by  collateral  trunks,  the  anaesthetic 
area  passing  through  gradual  stages  of  partial  sensation  before  re- 
covery is  complete,  [c)  Vasomotor  paralysis  is  also  produced,  the 
limb  becoming  hyperaemic  and  warmer  for  a  few  days,  and  then 
subsequently  colder  and  insufficiently  supplied  with  blood,  {d)  The 
excito-secretory  nerves  are  paralyzed  so  that  glands  lose  their  func- 
tions for  a  time. 

The  Secondary  Effects  vary  with  the  character  of  the  nerve  injured, 
and  are  much  more  complicated  than  the  fornier. 

I.  Changes  in  the  Nerve. — Locally,  the  two  ends  retract  very  slightly, 
perhaps  not  more  than  the  twelfth  of  an  inch,  and  the  space  thus 
formed  fills  with  blood,  which  is  quickly  absorbed  and  replaced  by 
granulation  tissue,  and  this  in  turn  by  a  bulb-like  mass  of  fibro- 
cicatricial  tissue  [traumatic  neuroma),  within  which  are  found  spaces 
filled  with  fine  nervous  fibrillae  coiled  up  in  loops  and  developed  from 
the  '  neurilemma  cells,  which,  taking  on  an  active  neuroblastic  func- 
tion, secrete  short  lengths  of  axis  cylinders  and  of  medullary  sheaths ; 
and  these,  linking  themselves  together  into  chains,  form  continuous 
axis  cylinders  and  medullary  sheaths.'  t  After  an  amputation,  most 
of  the  divided  nerves  are  found  to  have  developed  these  typical 
bulbous  ends  (Fig.  121),  whilst  in  nerves  accidentally  severed  in 
their  continuity  the  bulbous  mass  which  forms  on  the  upper  end  is 
separated  by  an  interval  from  the  atrophied  lower  end,  though  there 
is  usually  a  fibrous  connection  between  the  two.  These  bulbs  are 
often  the  seat  of  severe  neuralgia.  In  a  few  rare  instances  immediate 
union  of  a  divided  nerve  is  supposed  to  have  occurred,  as  indicated 
by  total  and  rapid  restoration  of  function. 

Peripherally,  the  so-called  Wallerian  degeneration  commences  about 
the  fourth  day  after  the  accident,  in  consequence  of  the  separation 
of  the  nerve  from  its  trophic  centres.  It  first  shows  itself  in  the 
medullary  substance,  which  undergoes  a  form  of  segmentation,  be- 
coming broken  up  into  irregular  masses  of  myeline,  which  are 
absorbed  by  leucocytes  or  connective-tissue  cells,  and  disappear 
entirely  in  about  a  month.  The  axis  cylinders  also  degenerate  and 
disappear.  The  neurilemma  cells  proliferate  in  columns  and  form 
a  fibro-cellular  rod,  which  represents  the  nerve,  and  early  loses  all 
power  of  conducting  nervous  or  electric  stimuli,  although  attempts 
at  regeneration  are  made  at  both  ends. 

Proximally,  degeneration  of  the  medullary  sheath  occurs,  similar  to 
that  which  is  seen  in  the  distal  portion,  but  only  extending  as  far  as 
the  next  node  of  Ranvier.     It  is  of  but  little  significance. 

•  For  an  elaborate  investigation  of  this  subject,  see  Head  and  Sherren  on  '  The 
Consequences  of  Injury  to  the  Peripheral  Nerves  in  Man,'  in  Brain,  Summer 
Number,  1905,  part  ex. 

t  See  Ballance  and  Purves  Stewart,  '  The  Healing  of  Nerves  '  ;  Macmillan 
and  Co.,  1901. 


AFFECTIONS  OF  NERVES 


375 


2.  Changes  in  the  Muscles. — Complete  paralysis  of  motion  neces- 
sarily occurs  when  a  motor  nerve  has  been  divided,  and  the  muscles 
involved  slowly  waste  and  undergo  degeneration.  The  atrophy  is 
not  noticed  at  first,  and  is  not  so  rapid  as  that  arising  from  infantile 
palsy,  since  it  is  simply  due  to  separation  from  the  trophic  centres, 
and  not  to  their  destruction.  Deformity  may  ensue,  owing  to  the 
unbalanced  action  of  opposing  groups  of  muscles.  The  electrical 
changes,  too,  are  important.  The  faradic  current  rapidly  loses  its 
power  over  the  paralyzed  muscles,  and  its  effects  totally  disappear 
in  two  or  three  weeks,  v/hilst  the  galvanic  excitability  remains  for 
weeks  or  months,  and  even  then  only  slowly  diminishes,  so  that  a 
condition  develops  in  which  the  galvanic  current  produces  a  much 
greater  contraction  than  the  faradic 
(reaction  of  degeneration).  As  long  as 
this  phenomenon  remains,  there  is  a 
hope  that  restoration  of  the  continuity 
of  the  nerve  may  be  followed  by  re- 
storation of  function ;  but  when  the 
muscles  react  neither  to  galvanic  nor  to 
faradic  stimuli,  the  case  may  be  looked 
upon  as  beyond  repair. 

3.  Various  modifications  of  Sensation 
are  produced.  Head  and  Sherren* 
have  demonstrated  that  different  types 
of  sensory  impulse  are  carried  by 
separate  groups  of  nerve-fibres,  and 
that  the  peripheral  distribution  of  these 
varies  considerably,  (a)  Deep  sensation 
consists  in  the  appreciation  of  pressure, 
including  heavy  touch  and  painful  pres- 
sure, and  in  the  recognition  of  the 
positions  and  movements  of  joints  and 
muscles.  These  stimuli  are  carried 
by  motor  nerves,  and  distributed  to 
muscles,  tendons,  ligaments,  etc.  Sec- 
tion of  all  the  sensory  nerves  to  the  skin  of  a  part  does  not  destroy  this 
form  of  sensation,  (h)  Protopathic  sensation  takes  cognisance  of  painful 
cutaneous  stimuli,  and  of  the  effects  of  temperatures  below  20°  and 
above  50°  C.  The  distribution  is  somewhat  indefinite  and  diffuse, 
following  rather  the  nerve-root  areas  than  those  of  the  peripheral 
nerves.  The  superficial  extent  supplied  by  a  particular  nerve  is  only 
recognised  when  all  other  sensory  nerves  to  the  part  are  divided 
(Figs.  122  and  123).  The  overlapping  of  these  areas  will  explain  the 
persistence  of  certain  forms  of  sensation  when  the  nerve  apparently 
supplying  that  area  has  been  divided.  (c)  Epicritic  sensation 
includes  the  appreciation  of  light  touch  (as  by  a  wisp  of  wool),  the 
localization  of  stimuli,  the  recognition  of  moderate  degrees  of  tempera- 
ture  (between  20°  and  40°   C.),  and  the   power  of  discriminating 

*  Op.  cit.     James  Sherren,  '  Injuries  of  Nerves  and  their  Treatment,'  1908. 


Fig.  121. — Traumatic  Neuroma 
OF  Posterior  Tibial  Nerve 
AFTER  Amputation  of  Leg. 
(From  King's  College  Hos- 
pital Museum.) 


376 


A  MANUAL  OF  SURGERY 


between  two  stimuli  simultaneously  applied,  as  by  the  points  of  a 
compass  ;  its  distribution  corresponds  with  fair  accuracy  to  that  of  the 
peripheral  nerves. 

Section  of  a  purely  sensory  nerve  causes  loss  of  the  epicritic  and 
protopathic  forms  of  sensation  only,  but  the  area  over  which  the 
epicritic  sense  is  lost  is  greater  than  that  over  which  protopathic 
sensation  is  absent,  owing  to  the  overlapping  of  the  latter  by 
neighbouring  nerve  areas.  Section  of  a  mixed  nerve  causes  loss 
of  all  three  types  of  sensation  in  any  area  exclusively  supplied  by 
that  nerve,  but  where  there  is  much  anastomosis  with  neighbouring 
nerves  protopathic  sensation  is  but  little  affected.  Section  of  a 
posterior  nerve-root  affects  protopathic  sensation  more  extensively 
than  the  epicritic  sense.  In  incomplete  division  or  injury  of  sensory 
nerves,  epicritic  sensation  is  abolished  more  extensively  than 
protopathic. 

4.  The  blood-supply  to  a  paralyzed  part  is  diminished,  and  the 
circulation  feeble ;   consequently,  the  blood  often  stagnates  in  the 


Fig.   122,  Fig.  123. 

Fig.  122  indicates  the  area  of  protopathic  sensation  supplied  by  the  median  nerve, 

as  determined  by  section  of  all  other  sensory  nerves  to  the  hand. 
Fig.  123.  Ditto  for  ulnar  nerve.     (After  Sherren.) 

extremities,  which  become  cold  and  their  vitality  lowered.  Chilblains 
are  readily  produced,  and  any  exposure  to  cold  or  heat  may  result  in 
vesication  or  even  sloughing.  Wounds  heal  badly,  and  ulceration 
from  slight  irritants  is  very  likely  to  occur,  e.g.,  corneal  ulceration 
after  division  of  the  fifth  nerve,  and  perforating  ulcers  of  the  foot. 
Atrophy  of  the  smaller  bones  may  follow,  and  ankylosis  of  the 
terminal  joints  of  the  fingers  or  toes.  In  a  growing  child  the 
development  of  the  part  is  always  more  or  less  impaired.  If, 
however,  the  nerve  is  partially  divided  and  the  ends  irritated,  more 
serious  changes  occur.  The  skin  becomes  thin,  atrophic,  bluish-red, 
and  shiny  ('glossy  skin'  of  Weir  Mitchell),  or  it  may  be  rough  and 
covered  with  scales,  or  even  oedematous.  The  cutaneous  appen- 
dages are  also  involved,  the  hairs  falling  out,  the  nails  becoming 
rough,  brittle,  and  scaly,  and  the  sebaceous  and  sweat  glands  either 
discharging  an  abundant  secretion,  or  remaining  absolutely  function- 
less. 


AFFECTIONS  OF  NERVES  377 

5.  Finally,  in  a  few  cases  changes  have  developed  in  the  central 
nervous  system  which  are  of  extreme  interest.  In  the  early  stages 
reflex  spasms  or  paralyses  are  sometimes  met  with  as  temporary 
phenomena ;  but  at  a  later  date  more  serious  symptoms  may  result. 
Thus,  in  a  glass  wound  of  the  median  nerve,  a  healthy  man  treated 
at  hospital  developed  a  typical  epileptic  fit  whenever  the  neuralgic 
bulbous  end  was  touched.  The  bulb  was  excised,  and  the  nerve 
cleanly  sutured,  but  without  effect,  the  epilepsy  and  pain  still  remain- 
ing. The  median  nerve  was  divided  above  the  elbow,  and  a  portion 
removed,  but  without  benefit.  Finally,  the  patient  passed  into  a 
condition  of  chronic  dementia,  and  died,  no  obvious  lesions  being 
found  on  post-mortem  examination. 

Regeneration  of  a  divided  nerve  must  necessarily  occur  if  restoration 
of  function  is  to  be  obtained.  Attempts  at  regeneration  are  always 
evident  in  the  distal  segment,  whether  or  not  it  has  been  sutured  to 
the  upper  end,  but  in  the  latter  case  the  phenomena  are  later  in 
appearance  and  are  never  carried  to  perfection,  owing  to  the  inter- 
vention of  the  end-bulb.  Considerable  discussion  has  arisen  as  to 
whether  the  new  axis  cylinders  grow  downwards  from  the  central 
end  to  the  peripheral,  or  whether  they  are  developed  in  the  distal 
segment.  Ballance  and  Purves  Stewart,  who  favour  the  latter 
theory,  state  that  the  proliferated  neurilemma  cells  always  retain 
their  longitudinal  direction,  and  that  about  three  or  four  weeks  after 
the  division  (a  little  later,  if  no  operation)  thin  beaded  threads  begin 
to  show  themselves  along  one  side  of  such  a  spindle-shaped  cell, 
and,  gradually  growing  downwards,  stretch  out  towards  their  nearest 
neighbours.  The  union  of  these  small  segments  constitutes  the  new 
axis  cylinder,  which  is  gradually  covered  in  by  a  medullary  sheath, 
also  apparently  the  product  of  the  neurilemma  cells,  and  finally  joins 
with  the  central  end  of  the  nerve.  Halliburton  and  Edmunds,  and 
others  of  the  opposing  school,  teach  that  regeneration  of  the  axis 
cylinders  always  proceeds  from  above  downwards,  the  new  fibrillae 
forcing  their  way  down  along  the  sheath  of  the  nerve,  and  look  on  the 
changes  in  the  peripheral  end  as  nierely  preparatory — and  this  opinion 
is  probably  correct.  In  either  case  the  process  is  slow  and  takes 
many  months  to  reach  completion.  Clinically,  the  earliest  evidence 
of  regeneration  is  a  slight  return  of  sensation,  which  is  at  first  proto- 
pathic,  and  only  slowly  becomes  of  an  epicritic  type.  Motion  is 
generally  much  later  in  its  restoration  than  sensation,  and  may  never 
be  entirely  recovered.  Under  very  favourable  circumstances  it  is 
possible  for  an  interval  even  as  great  as  i|-  inches  to  be  bridged  over 
by  this  process,  but  such  an  event  is  very  unusual.  The  use  of  a 
nerve-graft  under  these  conditions  may  direct  the  energies  of  the 
neuroblastic  cells,  but  the  graft  is  itself  quite  passive,  being  invaded 
by  neurilemma  cells. 

The  Treatment  of  a  divided  nerve  depends  upon  its  size  and  function. 
If  small  and  of  slight  importance,  no  special  treatment  is  required ; 
but  any  of  the  main  nerves  of  the  extremities  must  be  dealt  with  at 
once  by  Primary  Nerve  Suture.     This  is  best  accomplished  by  using 


378  A  MANUAL  OF  SURGERY 

a  domestic  sewing  needle  without  cutting  edges,  or  a  fine  Hagedorn 
needle,  and  the  finest  chromicized  catgut ;  one  or  more  stitches  should 
pass  through  the  nerve,  and  the  rest  merely  through  the  sheath. 
Absolute  asepsis  is  essential  in  order  to  obtain  satisfactory  results. 
It  is  most  desirable  that  the  nerve  should  be  protected  from  the 
pressure  of  adhesions  by  wrapping  it  in  gold-beater's  skin  or  Cargile 
membrane.  In  wounds  involving  the  nerves  about  the  wrist  the  deep 
fascia  should  also  be  carefully  sutured  to  prevent  the  formation  of 
adhesions  between  the  nerves  and  tendons  to  the  skin,  whereby 
subsequent  mobility  would  be  impaired. 

If  the  wound  has  been  inflicted  months  before, and  a  bulb  has  formed, 
Secondary  Nerve  Suture  must  be  employed.  The  nerve  is  first  ex- 
posed by  a  free  incision  through  the  cicatrix,  the  two  ends  identified 
and  isolated,  and  the  fibrous  tissue  of  the  bulb  removed  to  a  sufficient 
extent  to  expose  healthy  nerve  fibrillse ;  the  divided  ends  are  then 
brought  together  with  as  little  tension  as  possible.  To  bridge  the  gap 
traction  upon  each  end  of  the  nerve  may  be  employed  to  stretch  it, 
and  the  limb  subsequently  placed  in  such  a  position  as  to  relax  the 
parts — e.g.,  the  wrist  flexed  to  a  right  angle,  or  the  elbow  bent  (except 
when  dealing  with  the  ulnar  nerve  above  the  elbow,  flexion  of  which 
increases  the  tension  on  the  nerve).  Resection  of  a  segment  of  bone 
may  be  justifiable  in  certain  cases  to  allow  the  divided  ends  to  be 
approximated. 

Nerve-grafting,  in  order  to  bridge  over  a  defect,  has  not  up  to  the 
present  been  followed  by  much  success.  A  nerve  similar  in  size 
to  that  to  be  operated  on  is  removed  from  an  animal  just  previously 
killed,  and  carefully  stitched  in  position.  Since  it  merely  acts  as  a 
carrier  to  the  neuroblastic  cells,  the  same  result  would  possibly  be 
obtained  by  passing  several  fine  strands  of  catgut  from  one  end  to  the 
other. 

Nerve-anastomosis  has  been  utilized  in  a  few  cases  of  facial  paralysis, 
and  in  a  few  other  instances  in  order  to  restore  movement.  A 
suitably  placed  motor  nerve  is  laid  bare,  and  either  the  whole  trunk 
or  a  portion  of  it  united  to  the  divided  end  of  the  affected  nerve ;  in 
time  motor  phenomena  have  manifested  themselves  with  some  degree 
of  benefit. 

During  the  time  that  the  paralysis  continues,  the  limb  must  be 
massaged,  the  fingers  or  toes  worked  daily  to  keep  them  from  getting 
stifT,  and  the  muscles  treated  with  electricity,  and  preferably  by  means 
of  the  electric  bath,  one  electrode  being  placed  in  a  basin  of  warm 
saline  solution,  and  the  other  against  the  patient's  back,  and  the 
affected  limb  dipped  in  the  water  till  it  becomes  of  a  bright  red  colour. 
In  the  intervals  the  paralyzed  muscles  should  be  kept  relaxed  by 
suitable  splints  or  apparatus  so  as  to  prevent  over-stretching  by 
opposing  unbalanced  muscles,  which  would  subsequently  impair 
their  utility.     Ansesthetic  parts  must  also  be  protected  from  pressure. 

In  many  cases  where  the  original  wound  has  been  complicated  with 
spreading  septic  inflammation  the  impaired  mobility  is  as  much  due 
to  the  inflammatory  adhesions  of  joints  and  tendons  as  to  paralysis. 


AFFECTIONS  OF  NERVES  379 


Inflammation  of  Nerves. 


Acute  Neuritis  is  not  very  common.  It  is  usually  due  to  injury, 
gout,  or  rheumatism,  but  is  occasionally  observed  in  connection  with 
infected  wounds.  The  nerve  may  sometimes  be  felt  to  be  swollen  or 
tender,  whilst  severe  pain  of  a  neuralgic  type  is  often  experienced. 
On  microscopic  examination  the  ordinary  signs  of  inflammation  are 
well  marked,  though  mainly  in  the  sheath.  The  Treatment  consists 
of  rest  to  the  limb,  together  with  leeching  or  dry-cupping  over  the 
course  of  the  nerve,  combined  with  belladonna .  fomentations  and 
suitable  general  therapeutic  measures. 

Chronic  Neuritis,  or  Perineuritis,  is  much  more  common  than  the 
former.  It  consists  pathologically  in  an  increase  of  all  the  connective 
tissue  of  a  nerve,  both  around  it  and  between  the  fasciculi,  with  com- 
pression of  the  vessels  and  nerve-fibres.  It  may  result  from  injury, 
such  as  sprains,  strains,  or  pressure,  especially  when  the  patient  is 
suffering  from  syphilis,  rheumatism,  or  gout,  and  is  met  with  after 
influenza  and  in  various  toxic  conditions,  e.g.,  alcoholism,  diabetes, 
malaria,  etc.  It  is  very  common  in  the  fifth  nerve,  and  in  the 
branches  of  the  brachial  plexus.  The  Symptoms  vary  a  good  deal 
with  the  nerve  affected.  Occasionally  it  can  be  felt  thickened  and 
tender  on  pressure,  whilst  more  or  less  severe  neuralgia  results, 
accompanied  by  loss  of  power  in  the  case  of  a  motor  or  mixed  nerve. 
Trophic  lesions  may  also  be  induced,  such  as  perforating  ulcer,  or 
ankylosis  of  the  terminal  joints  of  fingers  or  toes. 

The  Treatment  in  the  early  stages  consists  in  the  administration  of 
antidiathetic  remedies,  and,  indeed,  iodide  of  potassium,  with  or  with- 
out mercury,  is  generally  applicable.  Locally,  prolonged  rest  is 
needed,  with  counter-irritation  in  the  form  of  blisters,  and  later  on 
massage.  If  there  is  any  paresis,  the  muscles  must  be  stimulated 
daily  by  the  faradic  current  or  electric  bath ;  radiant  heat  baths  are 
also  extremely  valuable,  and  ionic  medication  (p.  47)  with  iodine. 
Excessive  pain  is  combated  by  the  use  of  aspirin  or  other  drugs,  or 
by  administering  hypodermically  morphia  or  atropine.  Failing  these, 
acupuncture  may  be  adopted,  in  which  needles  are  passed  into  the 
substance  of  the  nerve,  and  allowed  to  remain  for  a  few  moments  ; 
this  probably  acts  by  relieving  the  inflammatory  tension  within  the 
sheath.  Various  operative  measures  dealt  with  under  neuralgia  may 
be  called  for  in  severe  and  protracted  cases. 

For  Tumours  of  nerves,  see  p.  203. 

Neuralgia. 

Neuralgia  is  a  condition  which  either  the  physician  or  the  surgeon 
may  be  called  upon  to  treat ;  it  is  exceedingly  common,  and  may  be 
one  of  the  most  terrible  afflictions  to  which  the  human  frame  is 
subject.  It  is  characterized  by  paroxysmal  or  intermittent  pain  of  a 
darting  or  stabbing  type,  which  follows  the  course  of  some  particular 
nerve  or  nerves,  especially  the  trigeminal.     The  attack  usually  com- 


3So  A  MANUAL  OF  SURGERY 

mences  suddenly,  and  the  pain  steadily  increases  until  it  reaches  a 
climax,  and  then  gradually  or  rapidly  subsides.  These  paroxysms 
may  last  minutes  or  hours,  and  may  recur  at  varying  intervals,  either 
a  few  in  a  day  or  many  in  an  hour  ;  they  may  be  induced  by  sudden 
noises,  a  draught  of  air,  etc.  Moreover,  pressure  over  the  affected 
trunks  may  originate,  relieve,  or  increase  the  pain,  whilst  the  skin 
affected  by  them  is  often  intensely  tender,  and  even  hyperaemic  and 
cedematous  (the  points  douloureux  of  Valleix).  Occasionally  adjacent 
muscles  become  spasmodically  and  sympathetically  contracted  during 
the  attack,  whilst  excessive  secretion,  such  as  from  the  lachrymal  or 
sweat  glands,  is  also  induced.  Herpes  is  sometimes  met  with  in  the 
area  of  distribution  of  the  affected  nerve  {e.g.,  shingles  in  connection 
with  intercostal  neuralgia).  Neuralgic  manifestations  may  occur  in 
any  sensory  or  mixed  nerve,  such  as  the  intercostals  or  sciatic,  or  in 
complex  bodies,  such  as  the  breast,  testis,  or  the  larger  joints. 

The  Causes  of  neuralgia  are  very  diverse,  and  the  surgeon  often 
has  to  look  far  afield  in  order  to  find  them.  Thus,  as  predisposing  causes 
may  be  mentioned  the  hysterical  temperament,  anaemia,  and  depress- 
ing circumstances  of  all  kinds,  especially  mental  anxiety  and  worry. 
The  direct  causes  may  be  toxic — e.g.,  malaria,  influenza,  lead,  or 
mercury;  reflex — ^.g.,  ovarian  disease,  worms,  etc.;  central,  from 
disease  of  the  spinal  cord  or  brain  ;  radical,  from  pressure  on  the 
nerve-roots  as  they  emerge  from  the  spinal  canal  or  cranium  ;  or 
peripheral,  owing  to  lesions  of  the  trimks  induced  either  by  trauma, 
inflammation,  or  new  growths. 

Treatment  consists  primarily  in  attention  to  the  general  health,  and 
the  local  application  of  counter-irritants  and  sedatives.  Iron  and 
arsenic  may  be  given  to  anaemic  patients ;  anti-spasmodics,  such  as 
valerianate  of  zinc,  to  hysterical  women ;  quinine  or  arsenic  for 
malaria ;  whilst  sea-bathing  or  change  of  air  is  often  advisable. 
Iodide  of  potassium  and  mercury  are  beneficial  in  all  cases  due  to 
syphilis.  When  the  pain  is  excessive,  morphia,  even  in  large  doses, 
may  be  required.  Empirical  remedies,  such  as  aspirin,  antipyrine, 
phenacetin,  menthol,  and  croton-chloral  hydrate  will  sometimes  do 
good.  Neuralgia  is  a  favourable  field  for  hydro-  or  electro-therapy, 
or  for  ionic  medication  (p.  47)  with  cocaine  or  other  drugs. 

When,  however,  medicinal  agents  fail,  surgical  measures  are 
indicated  in  order  to  allay  the  patient's  sufferings.  The  following 
are  the  more  usual  methods  adopted : 

I.  In  purely  Sensory  Nerves,  such  as  the  trigeminal,  destruction 
of  the  nerve  tissue  by  the  injection  into  the  trunk  of  alcohol  (70  per 
cent.)  has  been  much  used  recently.  Simple  division  or  neurotomy 
has  often  been  resorted  to,  but  the  relief  gained  is  of  a  most  temporary 
nature,  since  sensory  nerves  readily  unite  after  division,  and  sensation 
is  rapidly  restored  ;  hence  the  operation  has  fallen  into  discredit.  A 
more  satisfactory  proceeding  is  neurectomy,  or  the  removal  of  a  portion 
of  the  nerve  trunk,  which  does  temporary  good  even  in  cases  due  to 
central  causes,  probably  by  placing  the  centre  in  a  condition  of  rest 
through  the  exclusion  of  afferent  stimuli.     As  large  a  portion  of  the 


AFFECTIONS  OF  NERVES  381 

affected  nerve  should  be  removed  as  possible,  and  Thiersch  suggested 
a  plan  of  nerve  extraction  in  which  the  trunk  is  laid  bare  at  a  suitable 
spot,  and  then  grasped  with  forceps  and  twisted  out. 

Finally,  if  all  such  measures  have  failed,  the  roots  of  the  nerves 
may  be  divided  either  within  the  skull  or  in  the  spinal  canal,  or  the 
ganglia  connected  with  their  roots  may  be  removed. 

2.  In  a  Mixed  Nerve,  conveying  motor  as  well  as  sensory  stimuli, 
nerve- stretching  has  to  be  mainly  relied  upon.  The  trunk  is  laid  bare, 
and  traction  exercised,  both  centrally  and  peripherally,  by  means  of 
a  blunt  hook  if  the  nerve  is  small,  or  by  the  finger  placed  under  it  if 
large.  The  clinical  effect  is  to  abolish  the  conductivity  of  the  nerve 
for  a  time,  either  completely  or  partially ;  but  since  it  is  not  divided, 
repair  and  restoration  of  function  follow.  The  elasticity  and  extensi- 
bility of  the  nerves  are  considerable,  and  the  force  needed  to  cause 
their  rupture  has  been  accurately  estimated.  It  varies  much  in 
different  individuals,  and  allowance  must  be  made  for  this  in  all 
operations.  Thus,  the  sciatic  nerve  will  stand  about  as  much  traction 
as  an  ordinary  man  can  make  with  his  finger  and  thumb  ;  it  should 
be  applied  steadily  and  continuously,  not  in  a  series  of  jerks.  The 
effect  of  stretching  is  to  free  the  nerve  from  external  inflammatory 
adhesions,  and  to  alter  the  relations  between  the  sheath  and  its 
contents.  The  perineurium  has  its  fibrillae,  which  are  naturally 
wavy,  straightened  out,  thereby  compressing  the  lymphatic  spaces 
between  the  fibres,  and  possibly  rupturing  the  nervi  nervorum.  The 
nerve  becomes  hypersemic,  and  the  medullary  sheath  of  the  tubules 
may  be  irregularly  broken  up. 

Affections  of  Special  Nerves. 

The  Cranial  Nerves. — The  Olfactory  Nerve  may  be  involved  in 
fractures  extending  across  the  cribriform  plate  of  the  ethmoid,  or  in 
severe  cases  of  contusion  of  the  anterior  lobes  of  the  brain  without 
fracture,' resulting  in  loss  of  smell  (anosmia). 

The  Optic  Nerve  is  sometimes  ruptured  in  fractures  of  the  base  of 
the  skull  running  into  the  optic  foramen,  leading  to  sudden  irre- 
mediable blindness ;  or  it  may  be  compressed  by  effused  blood  or 
inflammatory  exudation,  either  within  or  outside  of  its  sheath,  causing 
more  or  less  complete  loss  of  vision  preceded  by  optic  neuritis  [i.e., 
inflammation  of  the  intra-ocular  termination  of  the  nerve,  or  papillitis) ; 
but  if  the  haemorrhage  has  not  been  very  extensive,  vision  may  be  in 
measure  restored.  Orbital  cellulitis  not  unfrequently  causes  pressure 
on  the  nerve,  either  immediately  as  a  result  of  the  inflammation,  or 
subsequently  by  cicatricial  contraction.  Syphilitic  disease  of  the 
sheath,  or  the  formation  of  a  gumma  in  its  neighbourhood,  or  intra- 
orbital aneurisms  or  tumours,  may  likewise  induce  amblyopia  from 
pressure  on  the  trunk. 

The  Third  Nerve  [motor  oculi)  being  entirely  motor,  paralytic 
symptoms  are  those  to  be  looked  for.  They  may  arise  from  central 
causes,  such  as  syphilitic  or  degenerative  changes  in  the  floor  of  the 


3^2  A  MANUAL  OF  SURGERY 

third  ventricle ;  or  from  peripheral  lesions,  such  as  aneurisms, 
tumours,  gummata,  trauma,  etc.,  either  in  the  orbit,  sphenoidal 
fissure,  or  base  of  the  skull.  The  Symptoms  of  complete  paralysis 
are  as  follows  :  {a)  Ptosis,  or  drooping  of  the  upper  eyelid,  from  loss 
of  power  in  the  levator  palpebrae  ;  (b)  external  strabismus,  or  squint, 
from  paralysis  of  the  inner,  upper,  or  lower  recti,  the  eye  being  also 
directed  a  little  downwards  from  paralysis  of  the  inferior  oblique; 

(c)  mydriasis,  or  dilatation  of   the   pupil,   from   palsy  of   the   iris ; 

(d)  loss  of  accommodation,  from  the  ciliary  muscle  being  paralyzed ; 
•and  (e)  some  slight  protrusion  of  the  eyeball  (exophthalmos),  owing 

to  most  of  its  muscles  being  flaccid  and  relaxed.  In  consequence, 
however,  of  its  close  proximity  to  the  fourth,  fifth,  and  sixth  nerves 
in  the  walls  of  the  cavernous  sinus  and  sphenoidal  fissure,  symptoms 
referable  to  these  trunks  are  often  associated  with  the  above,  as  also 
venous  congestion  of  the  eye  and  orbit  from  pressure  on  the  sinus. 
Should  the  eyeball  be  totally  immobilized  from  paralysis  of  all  its 
muscles  without  venous  congestion,  the  condition  is  known  as 
ophthalmoplegia  externa,  and  is  always  due  to  central  disease  affect- 
ing the  floor  of  the  third  ventricle,  and  probably  of  syphilitic  or 
tabetic  origin.  The  Treatment  in  most  cases  consists  in  the  ad- 
ministration of  mercury  and  iodide  of  potassium. 

Paralysis  of  the  Fourth  Nerve  {Pathetic),  which  supplies  the  superior 
oblique  muscle,  results  in  defective  movement  of  the  eyeball  dowm- 
wards  and  outwards. 

The  Fifth  or  Trigeminal  Nerve  is  occasionally  torn  in  head  injuries, 
giving  rise  to  anaesthesia,  with  perhaps  ulceration  of  the  cornea ;  but 
such  cases  are  exceedingly  rare.  Much  more  common  is  the  affection 
known  as  trigeminal  neuralgia,  or  tic-douloureux,  which  occurs  in  old 
people,  particularly  women.  It  is  to  be  distinguished  from  the 
simpler  forms  of  neuralgia  due  to  some  local  irritation  or  general 
weakness  by  the  paroxysmal  character  and  violence  of  the  pain ; 
hence  the  term  '  epileptiform  tic '  has  been  applied  to  it,  and  not 
inaptly  represents  its-  terrible  nature.  As  a  rule,  it  commences  in 
the  infra-orbital  or  inferior  dental  branches,  radiating  thence  to  all 
the  other  divisions  of  the  nerve.  The  paroxysms  are  not  very 
frequent  at  first,  but  they  increase  both  in  number  and  severity, 
until  at  last  the  patient,  utterly  prostrate,  either  becomes  a  morphia 
habitue,  or  may  even  attempt  suicide.  The  condition  is  often 
influenced  considerably  by  the  general  health,  and  intermissions  of 
varying  length  occur.  The  attacks  are  accompanied  by  twitching  of 
the  muscles  of  the  face,  and  even  of  the  neck ;  also  by  unilateral 
sweating  and  hypersemia  of  the  head,  and  the  development  of  such 
marked  '  points  douloureux,'  that  possibly  the  patient  cannot  brush 
his  hair  or  wash  his  face  on  the  affected  side,  which  becomes  dirty, 
and  is  often  shiny  from  trophic  changes.  Lachrymation  is  a  marked 
feature  during  the  attacks,  and  there  may  be  a  considerable  increase 
in  the  salivary  secretion,  as  also  in  that  of  nasal  mucus. 

The  Cause  of  the  neuralgia  is  unknoAvn ;  in  a  few  cases  tumours 
of   an  endotheliomatous   character   have    been  found  involvins:  the 


AFFECTIONS  OF  NERVES  383 

ganglion,  but  in  the  great  majority  nothing  abnormal  can  be  found 
either  in  the  ganglion  or  its  branches. 

In  the  Treatment  of  epileptiform  tic  all  sources  of  reflex  irritation 
should  be  relieved  or  treated,  such  as  carious  teeth,  errors  of  refrac- 
tion, intranasal  trouble,  ovaritis,  etc.  A  word  of  warning  is  needed 
against  the  wholesale  extraction  of  healthy  teeth  for  this  affection, 
which  may,  indeed,  be  aggravated  rather  than  improved  by  such 
treatment.  The  various  analgesic  remedies  will,  of  course,  be  em- 
ployed, but  morphia  is  often  the  only  drug  that  gives  relief.  In  most 
cases  Operative  Measures  sooner  or  later  are  required.  Alcohol 
injections*  by  Schlosser's  method  is  reported  to  give  good  results, 
but  further  experience  is  required  to  demonstrate  the  permanence  of 
the  relief  from  pain.  Neurotomy  and  nerve-stretching  only  give 
temporary  relief,  and  excision  even  of  large  portions  of  the  nerve- 
trunks  is  frequently  followed  by  recurrence.  The  only  procedure 
that  holds  out  any  certain  hope  of  cure  is  removal  of  the  Gasserian 
ganglion,  or,  at  any  rate,  of  its  lower  half;  the  facts  that  the  first 
division  of  the  nerve  is  often  not  involved  in  trigeminal  tic,  that  the 
nutrition  of  the  eyeball  is  largely  dependent  on  the  maintenance  of 
its  nerve-supply,  and  that  the  upper  part  of  the  ganglion  is  intimately 
adherent  to  the  outer  wall  of  the  cavernous  sinus,  have  determined 
the  practice  of  leaving  intact  the  ophthalmic  portion  of  the  ganglion 
in  the  majority  of  cases.  The  results  of  this  operation  have  been 
very  gratifying,  and  have  improved  with  increased  practice  and 
modern  methods.  At  the  same  time  it  must  not  be  looked  on  as 
devoid  of  operative  dangers  or  risks  ;  and  hence,  if  the  neuralgia  is 
definitely  limited  to  one  division  only,  injection  with  alcohol,  or  an 
intra-  or  extra-cranial  neurectomy  is  advisable  before  attacking  the 
ganglion ;  recurrence  after  such  an  operation,  or  the  primary  involve- 
ment of  two  divisions,  indicates  the  major  operation. 

The  Supra-orbital  Nerve  does  not  very  commonly  require  operation,  since 
neuralgia  of  this  trunk  is  usually  distinct  from  epileptiform  tic,  and  more  amen- 
able to  therapeutic  measures.  The  pain  often  recurs  about  the  same  time  each 
day  (hence  the  terra  brow  ague),  and  may  be  treated  by  giving  a  pill  containing 
ferri  sulph.  i  grain,  quininae  disulph.  2  grains,  and  morphin.  hydrochlor. 
-^^  grain,  four  hours  before  the  attack  is  expected,  and  repeating  it  every  hour 
till  six  pills  in  all  have  been  taken.  Should  the  pain  persist,  neurectomy  may 
be  undertaken.  The  nerve  emerges  from  the  orbit  through  the  supra-orbital 
notch,  lying  at  the  junction  of  the  inner  and  middle  thirds  of  the  upper  margin  ; 
it  is  reached  by  an  incision  following  the  course  of  the  eyebrow,  through  which 
the  orbicularis  is  divided  along  the  line  of  its  fibres  (Fig.  124,  a).  By  incising  the 
periosteum  and  depressing  it,  together  with  the  orbital  fat,  the  nerve  can  be 
followed  back  for  some  distance,  and  a  considerable  portion  removed. 

The  Infra-orbital  Nerve  emerges  from  the  foramen  of  the  same  name  at  a  spot 
about  \  inch  below  the  centre  of  the  lower  margin  of  the  orbit.  It  can  be 
reached  and  divided  by  a  horizontal  or  curved  incision  placed  over  this  site 
(Fig.  124,  c)  ;  but  since  such  an  operation  is  unlikely  to  give  more  than  temporary 
relief,  the  root  of  the  second  division  should  be  at  once  attacked  if  operative  pro- 
cedures are  necessary.     It  is  most  desirable  to  divide  the  nerve  behind  Meckel's 

*  For  details  and  methods  of  injecting  the  various  branches  of  the  fifth  nerve, 
see  Purves  Stewart,  Brit.  Med.  Journ.,  September  25,  igog. 


384 


A  MANUAL  OF  SURGERY 


ganglion,  and  hence  the  operations  which  are  performed  from  the  face  (either 
Wagner's,  which  follows  the  floor  of  the  orbit,  or  Carnochan's,  which  traverses 
the  antrum)  are  objectionable,  whilst  they  are  almost  certain  to  leave  ugly 
cicatrices  (Fig.  124,  d). 

The  pterygoid,  or,  as  it  is  called,  the  Braun-Lossen  operation,  is  without  doubt 
the  best  extracranial  method  for  dealing  with  the  root  of  the  second  division. 
The  incision  commences  at  the  external  angular  process  of  the  frontal  bone, 
follows  the  upper  border  of  the  zygoma,  and  curves  downwards  in  front  of  the 
ear  to  reach  the  angle  of  the  lower  jaw  (Fig.  105,  B).  The  flap  thus  marked  out 
is  dissected  forwards,  temporarily  fixed  by  a  suture  to  the  nose  and  protected  with 
gauze.  The  zygoma  is  exposed  by  a  horizontal  incision  through  the  periosteum, 
and  drilled  front  and  back  so  as  to  carry  silver  wires  in  the  subsequent  suturing 
up  ;    it   is  then  sawn  through  and  turned  down,  together  with   the   masseter. 

The  mouth  is  slightly  opened,  and  the  tem- 
poral tendon  pulled  backwards  so  as  to 
expose  the  pterygo-maxillary  fissure,  al- 
though the  coronoid  process  sometimes 
needs  partial  or  complete  removal.  The 
internal  maxillary  vessels  are  then,  if  pos- 
sible, secured  by  ligatures  and  divided. 
The  root  of  the  second  division  of  the  fifth 
nerve  can  be  hooked  up  on  an  aneurism 
needle  as  it  emerges  from  the  foramen 
rotundum,  and  divided.  By  dividing  the 
nerve  also,  as  it  emerges  from  the  infra- 
orbital foramen  through  an  incision  in  the 
face,  the  whole  trunk  is  set  free,  and  can  be 
removed  by  traction,  all  the  dental  branches 
being  torn  across.  The  displaced  structures 
are  then  put  back  in  position,  the  zygoma 
is  sutured  with  silver  wire,  and  the  incision 
in  the  skin  closed.  The  results  gained  by 
this  method  have  been  very  satisfactory, 
the  scar  being  scarcely  evident,  and  the 
movement  of  the  jaw  not  impaired. 

It  is  probable  that  an  intracranial  section 
of  the  root  of  the  second  division,  followed  by 
filling  the  foramen  rotundum  from  inside  by 
liquid  rubber  or  gold-foil,  will  give  equally 
good  or  better  results  with  less  risk  and 
deformity.  The  Hartley-Krause  plan  of 
procedure  for  removal  of  the  Gasserian 
ganglion  is  followed  as  far  as  is  needful. 

In  the  third  division  trigeminal  tic  usually 
affects  the  lingual  and  inferior  dental 
branches,  and  should  be  dealt  with  by 
dividing  the  trunk  of  the  third  division  at 
the  foramen  ovale  by  intracranial  or  extra- 
cranial section. 

The  Inferior  Dental  Nerve  is  sometimes,  however,  the  seat  of  neuralgia,  due  to 
compression  in  its  bony  canal  as  a  result  of  dental  troubles.  It  may  then  suffice 
to  trephine  the  inferior  maxilla,  making  the  necessary  incision  along  its  lower 
border,  and  remove  half  its  thickness,  so  as  to  expose  the  nerve  in  its  canal. 

Extracranial  section  of  the  third  division  at  the  foramen  ovale  is  best  accom- 
plished in  the  following  manner :  A  flap  of  skin  and  subcutaneous  tissue  is 
reflected  forwards  from  the  parotid  region,  extending  from  the  zygoma  above 
to  the  angle  of  the  jaw  below  (Fig.  105,  B),  exposing  thus  the  parotid  gland  with 
the  socia  parotidis  and  the  masseter  muscle,  covered  by  fascia.  If  the  incision 
is  kept  strictly  to  the  subcutaneous  tissues,  the  facial  nerve  is  in  no  way 
endangered.  The  masseter  is  then  divided  transversely  immediately  below  the 
socia  parotidis,  and  the  vertical  ramus  of  the  inferior  maxilla  cleared  of  muscle 


Fig.  124. 

a.  Incision  for  division  of  supra- 
orbital nerve  ;  i,  line  indicating 
position  of  supra  -  trochlear 
nerve,  passing  from  angle  of 
mouth  through  the  inner  can- 
thus  ;  the  short  cross-line  at  its 
upper  end  is  the  incision  re- 
quired to  expose  it ;  c,  position 
of  infra-orbital  nerve  and  in- 
cision ;  d,  Carnochan's  in- 
cision for  neurectomy  of  the 
second  division. 


AFFECTIONS  OF  NERVES  385 

and  periosteum  to  a  sufficient  extent  to  allow  the  application  of  a  f -inch  trephine 
just  below  the  sigmoid  notch,  the  remaining  bridge  of  bone  being  subsequently 
removed  by  cutting  pliers  ;  enough  bone  is  left  in  front  and  behind  to  preserve 
the  continuity  of  the  jaw.  The  fibres  of  the  external  pterygoid  muscle  can  now 
be  seen  crossing  the  upper  part  of  the  wound  horizontally,  and  over  it  the 
internal  maxillary  artery  sometimes  courses.  The  lingual  and  dental  nerves  are 
usually  found  close  together,  emerging  from  under  the  outer  pterygoid  muscle, 
and  lying  between  the  internal  pterygoid  and  the  bone.  The  peripheral  portions 
should  be  twisted  or  pulled  up,  and  divided  below  as  far  down  as  possible,  whilst 
by  retracting  the  external  pterygoid  outwards,  the  foramen  ovale  can  be  seen,  if 
electric  illumination  is  employed,  and  the  nerve-trunks  divided  at  the  point  of 
exit.  The  wound  usually  heals  well,  and  leaves  but  little  scar,  although  some 
impairment  in  the  mobility  of  the  jaw  may  result  from  the  cicatrization  following 
disturbance  of  the  muscles  and  tissues. 

Removal  of  the  Gasserian  ganglion  is  now  usually  undertaken  through  the  tem- 
poral region  by  some  modification  of  what  is  known  as  the  Hartley-Krause 
method.  The  pterygoid  route  *  originally  followed  in  the  pioneer  operations  by 
the  late  Mr.  William  Rose  must  be  acknowledged  to  give  insufficient  exposure  to 
ensure  satisfactory  removal  of  the  ganglion,  and  has  now  been  discarded. 

The  Hartley-Krause  operation  was  devised  independently  by  the  two  surgeons 
v/hose  names  are  associated  with  it.  An  O-shaped  flap  is  marked  out  in  the  tem- 
poral region,  the  base  situated  just  above  the  zygoma.  Through  this  the  sub- 
jacent bone  is  removed,  exposing  the  dura  mater,  which  is  gently  stripped  up 
from  the  middle  fossa  of  the  skull  as  far  as  the  cavernous  sinus.  The  middle 
meningeal  artery  is  exposed  and  tied  just  above  the  foramen  spinosum,  or  the 
foramen  may  be  plugged  with  purified  sponge  or  wax.  Haemorrhage  from  the 
small  vessels,  especially  the  veins,  of  the  dura  mater  is  sometimes  profuse,  but 
usually  ceases  upon  gentle  pressure.  The  dura  mater  and  temporo-sphenoidal 
lobe  of  the  brain  are  held  up  by  suitably-shaped  spatulse,  and  the  second  and 
third  divisions  of  the  nerve  are  seen  running  from  the  ganglion  to  their  foramina, 
where  they  are  cut  across.  The  dural  sheath  of  the  ganglion  (cavum  Meckelii)  is 
opened,  the  ganglion  itself  detached  from  the  bone,  and  as  much  of  it  as  is  thought 
necessary  removed.  The  cavernous  sinus  may  be  wounded  in  this  stage,  or  the 
dura  itself  give  way  and  cerebrospinal  fluid  escape.  Removal  of  the  spatulas 
allows  the  brain  to  re-expand,  and  the  wound  can  then  be  closed. 

Special  care  must  be  taken  of  the  eye,  as  its  nutrition  is  likely  to  suffer.  The 
conjunctival  sac  should  be  washed  out  before  operation  with  warm  sublimate 
solution  (i  in  2,000),  and  the  lids  stitched  together.  These  stitches  are  removed 
on  the  fourth  or  fifth  day,  and  the  conjunctiva  washed  with  warm  boracic  lotion, 
but  a  pad  should  be  kept  over  the  eye  for  a  fortnight. 

The  Sixth  Nerve  may  be  torn  or  compressed,  either  in  its  intra- 
cranial course  along  the  inner  wall  of  the  cavernous  sinus,  or  as  it 
passes  through  the  sphenoidal  fissure,  or  in  the  orbit,  as  a  result  of 
penetrating  wounds  or  blows.  Its  division  causes  paralysis  of  the 
external  rectus  and  consequent  internal  strabismus. 

The  Seventh  or  Facial  Nerve  may  be  paralyzed  from  a  great  variety 
of  causes,  which  may  be  described  under  the  following  headings : 

{a)  Intracranial  Lesions. — If  simply  cortical,  as  from  pressure,  haemor- 
rhage, degeneration,  etc.,  a  limited  portion  of  the  opposite  side  of  the 
face  is  usually  involved.  If  subcortical,  or  in  the  corona  radiata  or 
corpus  striatum,  as  from  haemorrhage,  or  softening  due  to  carotid 
thrombosis  or  embolus,  the  paralysis  appears  on  the  opposite  side 

*  For  a  description  of  this  operation,  see  Rose,  *  On  the  Surgical  Treatment 
of  Trigeminal  Neuralgia  '  (Lettsomian  Lectures,  1S92)  .-  Bailliere,  Tindall  and 
Cox ;  and  J.  Hutchinson,  '  The  Surgical  Treatment  of  Facial  Neuralgia ' : 
Bale,  Sons  and  Danielsson,  Limited. 

25 


386  A  MANUAL  OF  SURGERY 

together  with  hemiplegia,  but  only  the  lower  half  of  the  face  is  palsied, 
the  associated  movements  of  the  eyelids  being  left.  If  the  lesion  is 
situated  in  the  pons,  the  deep  facial  centres  may  be  implicated,  and 
then  paralysis  with  rapid  atrophy  of  the  facial  muscles  ensues  on  the 
same  side  as  the  lesion,  together  with  loss  of  power  of  the  opposite 
arm  and  leg  (crossed  paralysis).  If  the  root  of  the  nerve  between  the 
centres  and  the  internal  auditory  meatus  is  involved,  the  whole  of  the 
same  side  of  the  face  is  paralyzed,  accompanied,  as  a  rule,  by  deafness. 

(b)  Cranial  Lesions. — There  are  two  not  uncommon  causes  grouped 
under  this  heading,  viz.,  (i.)  fracture  of  the  base  of  the  skull,  involving 
the  petrous  portion  of  the  temporal  bone,  the  paralysis  supervening 
either  immediately  after  the  injury  from  laceration,  a  rare  phenomenon, 
or  some  weeks  later  from  implication  in  organizing  blood-clot  or 
callus,  the  usual  cause  ;  or  (ii.)  as  a  complication  of  chronic  otorrhoea, 
and  then  due  to  compression  or  inflammation  of  the  nerve  in  the 
aqueductus  Fallopii.  In  both  these  forms  the  palsy  is  complete  on 
the  side  affected,  and  owing  to  the  communication  of  the  facial  with 
the  petrosal  nerves  in  this  part  of  its  course,  there  may  be  unilateraJ 
drooping  of  the  velum  palati,  the  uvula  being  deflected  towards  the 
sound  side. 

{c)  Extracranial  lesions  from  injury,  inflammation  from  exposure  to 
cold,  or  the  pressure  of  a  tumour,  e.g.,  malignant  disease  of  the  parotid. 
This  variety  has  been  called  '  Bell's  palsy,'  and  is  usually  characterized 
by  the  whole  side  of  the  face  being  affected,  but  without  implication 
of  the  palate  or  uvula. 

The  general  Signs  of  facial  paralysis  (Fig.  125)  are  as  follows:  The 
side  of  the  face  is  immobile  and  expressionless,  all  the  natural  folds 
and  wrinkles  being  lost ;  the  eye  cannot  be  completely  closed,  and  on 
attempting  to  do  so  (Fig.  126)  the  eyeball  is  usually  seen  to  roll 
upwards  and  outwards ;  ulceration,  and  even  perforation,  of  the 
cornea  may  result  from  this  exposure.  From  the  drooping  and 
relaxation  of  the  lower  eyelid,  the  apposition  of  the  punctum  lachry- 
male  to  the  conjunctiva  is  imperfect,  and  thus  tears  escape  over  the 
face  (epiphora),  a  condition  aggravated  by  the  loss  of  the  suction- 
like action  of  the  lachrymal  sac,  owing  to  the  associated  paralysis  of 
the  tendo  oculi  and  tensor  tarsi.  On  attempting  to  move  the  face,  as 
in  laughing  or  showing  the  teeth,  the  muscles  on  the  non-paralyzed 
side  are  alone  contracted,  and  marked  asymmetry  results  from  the 
drawing  over  of  the  opposite  side.  The  lips  cannot  be  closed  firmly, 
and  hence  whistling  and  such-like  actions  are  prevented.  Food 
collects  between  the  cheek  and  the  teeth,  owing  to  paralysis  of  the 
buccinator,  and  the  patient  after  a  meal  has  to  clear  out  the  debris 
with  a  spoon  or  his  fingers. 

The  Treatment  of  facial  paralysis  can  rarely  be  directed  to  its 
cause.  In  cases  due  to  cold  medical  treatment,  including  massage 
and  electricity,  will  be  required;  in  a  few  other  cases  surgical 
measures  with  a  view  to  remove  some  obvious  cause  of  pressure  may 
be  necessary.  Where  the  paralysis  cannot  thus  be  dealt  with, 
and  persists,  nerve  anastomosis  may  be  undertaken,  the  whole  or  a 


AFFECTIONS  OF  NERVES 


387 


portion  of  the  spinal  accessory  or  hypoglossal  nerve  being  united  to 
the  divided  peripheral  end  of  the  facial  nerve.  The  results  hitherto 
obtained  in  a  few  cases  have  been  encouraging ;  facial  movements 
slowly  return,  but  are  first  elicited  by  and  accompanied  with  move- 
ments of  the  shoulder  or  tongue  ;  in  time,  however,  they  become 
more  independent,  but  are  rarely  quite  free.  However,  the  operation 
gives  a  certain  amount  of  muscular  power,  and  may  remove  the  facial 
asymmetry  so  characteristic  of  this  lesion. 

Facial  Tic  (or  histrionic  spasm)  consists  of  a  clonic  contraction  of 
the  facial  muscles,  due  to  some  lesions  of  the  centre  in  the  pons  or 
cortex.  The  condition  causes  great  discomfort  to  the  patient,  and 
may  involve  the  whole  side  of  the  face,  or  merely  one  part  of  it,  such 


Figs.  125  and  126. — Right-sided  Facial  Paralysis. 
On  the  left  hand  the  face  is  in  a  position  of  rest ;  on  the  right  hand  an  attempt  has 
been  made  to  close  the  eyes,  that  on  the  paralyzed  side  remaining  open,  and 
the  eyeball  rolling  upwards  and  outwards,  whilst  the  asymmetry  of  the  face 
becomes  more  manifest. 

as  the  orbicularis  oculi.  Treatment  consists  in  the  administration  of 
nerve  tonics  or  antispasmodics,  and,  failing  that,  stretching,  or  even 
in  severe  cases  division,  of  the  facial  nerve  has  been  employed,  but  is 
most  unsatisfactory. 

Operation. — The  facial  nerve  is  exposed  immediately  below  the  ear,  its  position 
being  indicated  by  a  horizontal  line  drawn  from  the  middle  of  the  anterior  border 
of  the  mastoid  process,  and  usually  corresponding  to  the  point  where  the  mastoid 
meets  the  lobule  of  the  ear.  The  incision  extends  from  just  behind  the  external 
meatus  along  the  anterior  border  of  the  sterno-mastoid  muscle  to  the  level  of  the 
angle  of  the  jaw.  The  parotid  gland  is  separated  from  the  muscle,  and  both  are 
well  retracted,  exposing  by  this  means  the  posterior  belly  of  the  digastric.  The 
facial  nerve  is  found  above  this,  running  directly  forwards  from  the  centre  of  the 
mastoid  process.    The  great  auricular  nerve  is  divided  in  the  superficial  incision, 


388  A  MANUAL  OF  SURGERY 

■} 
and  the  posterior  auricular  vessels  will  require  a  ligature.  The  internal  jugular 
vein  is  close  to  the  posterior  margin  of  the  wound.  The  operation  is  a  deep  one, 
and  by  no  means  easy  in  a  patient  with  a  thick  neck.  The  effect  of  stretching  the 
nerve  is  to  paralyze  it  temporarily,  but  the  ultimate  results  have  been  by  no  means 
encouraging,  only  one  case  out  of  twenty  collected  by  Godlee  being  successful. 

The  Auditory  Nerve  may  be  injured  in  fractures  of  the  base  of  the 
skull,  either  one  or  both  sides  being  involved.  Incurable  deafness 
usually  results,  often  associated  with  facial  palsy. 

It  is  a  little  doubtful  what  effect  would  be  produced  by  injury  of 
the  Grlosso-pliaryngeal  Nerve,  but  in  one  case  in  which  it  was  supposed 
to  be  compressed  the  patient  suffered  from  difficulty  in  swallowing 
and  speaking,  together  with  persistent  ulceration  of  the  tongue ;  death 
resulted  from  oedema  of  the  glottis. 

A  severe  injury  to  the  Pneumogastric  Nerve  may  prove  rapidly  fatal, 
but  less  serious  lesions  result  in  palpitation,  vomiting,  and  a  sense  of 
suffocation  ;  such  phenomena  sometimes  manifest  themselves  after 
head  injuries,  especially  fractures  involving  the  posterior  fossa,  and 
indicate  that  the  jugular  foramen  has  been  encroached  on.  The  nerve 
is  also  exposed  to  injury  in  operations  about  the  neck,  e.g.,  ligature  of 
the  carotid,  or  removal  of  tuberculous  glands.  Irritation  causes 
vomiting,  coughing,  or  perhaps  a  temporary  inhibition  of  the  heart's 
action ;  one-sided  division  sometimes  does  comparatively  little  harm, 
but  if  both  nerves  are  divided,  death  results  from  laryngeal  paralysis 
or  from  such  complications  as  oedema  or  congestion  of  the  lungs. 
When  the  vagus  is  injured  in  the  lower  part  of  the  neck  or  com- 
pressed by  an  aneurism,  or  if  the  recurrent  laryngeal  nerve  is  divided 
or  compressed,  hoarseness  or  partial  aphonia  is  produced,  from 
paralysis  either  of  all  the  muscles  on  one  side  of  the  larynx,  or  in 
slighter  cases  of  the  abductor  only  (crico-arytenoideus  posticus). 

The  Spinal  Accessory  Nerve  may  be  irritated,  either  at  its  exit  from 
the  skull  by  a  fracture  running  through  the  jugular  foramen,  or  in 
its  peripheral  course  by  inflamed  lymphatic  glands,  etc.  It  is  not 
unfrequently  divided  in  operations  for  the  removal  of  tuberculous 
glands,  and  may  cause  serious  deformity  from  drooping  of  the 
shoulder.  Clonic  spasm  of  the  sterno-mastoid  and  trapezius  is 
generally  due  to  central  changes,  and  it  is  for  this  form  of  spasmodic 
torticollis  that  stvetching  or  division  of  the  spinal  accessory  nerve  is 
employed. 

Operation. — The  nerve  runs  downwards  and  backwards  at  right  angles  to  the 
centre  of  a  line  passing  from  the  angle  of  the  jaw  to  the  apex  of  the  mastoid 
process  ;  it  enters  the  deep  aspect  of  the  sterno-mastoid  about  3  inches  below 
that  spot.  An  incision  is  made  along  the  anterior  border  of  the  sterno-mastoid, 
reaching  from  the  ear  to  the  cornu  of  the  hyoid  bone.  The  fascia  is  divided, 
and  the  muscle  drawn  backwards  to  expose  the  posterior  belly  of  the  digastric, 
from  under  the  lower  border  of  which  the  nerve  emerges,  passing  first  in  front 
and  then  below  the  transverse  process  of  the  atlas,  which  can  be  readily  felt. 
The  operation  has  not  given  good  results,  since,  even  if  the  twitching  of  the  head 
and  neck  ceases,  the  spasmodic  phenomena  often  recur  elsewhere. 

The  Hypoglossal  Nerve  may  be  accidentally  divided  in  an  operation, 
or  compressed  by  an  aneurism  of  the  external  carotid,  or  by  a  new 


AFFECTIONS  OF  NERVES  389 

growth.     Unilateral  paralysis  or  weakness  of  the  tongue  results,  the 
organ,  when  protruded,  being  directed  towards  the  paralyzed  side. 

The  Spinal  Nerves. 

The  nerves  constituting  the  Cervical  Plexus  are  exposed  to  injury 
either  from  blows,  dislocations  of  the  cervical  spine,  penetrating 
wounds,  or  during  operations.  No  very  serious  results  follow,  except 
in  the  case  of  the  Phrenic  Nerve,  division  of  which  may  cause  instant 
death  by  paralysis  of  the  diaphragm,  although  when  but  one  nerve  is 
divided,  the  patient  can  survive.  Irritation  of  the  nerve  gives  rise  to 
spasmodic  cough  or  hiccough. 

The  Brachial  Plexus  may  be  divided  by  cuts  or  stabs,  especially  in 
the  lower  part  of  the  posterior  triangle,  and  the  accident  will  be 
characterized  by  the  motor  or  sensory  phenomena  corresponding  to 
the  particular  nerves  involved  ;  obviously  the  upper  nerves  of  the 
plexus  are  most  exposed  to  this  form  of  injury.  Treatment  consists 
in  laying  the  parts  open  by  a  suitable  incision,  finding  the  divided 
ends,  and  performing  primary  nerve  suture. 

Tears  or  contusions  of  the  plexus,  a  more  common  accident,  may  be 
complete  or  partial,  and  result  from  injuries  in  which  the  arm  is 
dragged  suddenly  upwards,  as  when  in  falling  a  person  clutches  at 
some  projecting  body,  or  from  forcible  depression  of  the  shoulder  in 
a  fall  whilst  the  head  is  driven  towards  the  opposite  side,  the  nerve 
roots  being  thereby  wrenched  from  their  attachments,  or  the  nerve 
trunks  compressed  by  the  clavicle  against  the  first  rib.  A  fracture  of 
the  clavicle  by  direct  violence  may  result  in  injury  of  the  plexus,  as 
also  a  dislocation  of  the  head  of  the  humerus  into  the  axilla.  The 
symptoms  vary  necessarily  with  the  degree  and  situation  of  the  lesion 
from  complete  loss  of  power  of  the  arm,  which  lies  by  the  side  flaccid 
and  anaesthetic  when  the  whole  plexus  is  torn  through  or  wrenched 
away  from  its  attachment  to  the  spinal  cord,  to  loss  of  power  of  one  or 
two  muscles,  as  when  a  blow  over  the  fifth  and  sixth  vertebrae  leads 
to  paralysis  of  the  serratus  magnus  and  rhomboids,  and  to  the  conse- 
quent development  of  a  '  winged  scapula.' 

Special  attention  must  be  drawn  to  the  paralysis  described  by  Erb 
and  Duchenne,  involving  the  muscles  derived  from  the  fifth  cervical 
root,  and  sometimes  the  sixth  in  part — viz.,  the  deltoid,  biceps, 
brachialis  anticus,  and  supmator  longus  and  brevis,  together  with 
anaesthesia  of  the  region  supplied  with  sensation  by  the  fifth  root. 
This  variety  is  usually  due  to  falls  on  the  shoulder  from  a  height — ■ 
e.g.,  from  a  high  dog-cart;  but  also  appears  in  infants  as  a  birth 
paralysis,  due  to  excessive  lateral  displacement  of  the  head  during 
delivery,  or  to  injudicious  traction  with  forceps.  The  arm  is  ad- 
ducted  and  rotated  in  at  the  shoulder,  and  the  forearm  is  extended 
and  pronated. 

Treatment  necessarily  varies  with  the  situation  and  probable  degree 
of  the  injury.  Obvious  causes  of  pressure,  such  as  the  depressed 
fragments  of  a  broken  clavicle  or  callus  derived  therefrom,  must  be 


390  A  MANUAL  OF  StJRGERf 

removed  ;  but  in  most  cases  one  has  to  rely  on  rest  to  the  arm  so  long 
as  the  immediate  pain  and  swelling  persist,  and  then  massage  and 
electricity  are  employed.  In  some  cases  of  the  so-called  birth  palsy, 
operation  has  been  undertaken  at  about  the  age  of  twelve  months, 
the  roots  of  the  injured  nerves  having  been  exposed,  the  cicatrix 
removed,  and  secondary  nerve  suture  performed  with  advantage. 

Neuritis  and  neuralgia  of  the  brachial  plexus  occur,  and  are  treated 
along  the  usual  lines.  Should  the  neuralgia  persist  and  prove  un- 
controllable, or  if  clonic  spasm  of  the  muscles  of  the  arm  and  shoulder 
develop,  stretching  of  the  brachial  plexus  may  be  required. 

Operation. — The  patient  lies  on  his  back,  with  the  head  directed  to  the  opposite 
side,  and  the  arm  well  drawn  down  ;  a  cushion  is  inserted  under  the  shoulder  to 
steady  it.  An  incision  is  made  above  the  centre  of  the  clavicle,  3  or  4  inches  in 
length,  parallel  to  the  anterior  border  of  the  trapezius.  The  platysma  and  deep 
fascia  are  divided,  and  the  wound  well  opened  up  by  retractors.  The  posterior 
belly  of  the  omo-hyoid  is  thus  exposed,  and  the  posterior  border  of  the  scalenus 
anticus  defined.  The  cords  of  the  plexus  are  found  emerging  between  the  latter 
muscle  and  the  medius  ;  they  are  carefully  isolated  by  division  of  the  sheath 
covering  them,  and  pulled  upon  by  the  finger  or  an  aneurism  needle  passed  under 
them.  Special  care  must  be  taken  of  the  lowest  cord  of  the  plexus,  which  passes 
behind  the  subclavian  artery.  The  nerves  are  stretched  both  centripetally  and 
centrifugally.  Excellent  results  have  followed  this  operation,  although  in  a  few 
cases  the  necessary  cicatrization  which  followed  led  to  a  recurrence  of  the 
symptoms. 

The  Circumflex  Nerve  is  liable  to  injury  from  its  exposed  position, 
winding  round  the  outer  side  of  the  neck  of  the  humerus  about  a 
finger's  breadth  above  the  middle  of  the  deltoid.  Blows  upon  the 
shoulder  may  in  this  way  cause  paralysis  ;  it  is  sometimes  torn  or  com- 
pressed in  fractures  of  the  surgical  neck  of  the  humerus,  or  in  disloca- 
tion of  the  shoulder,  or  it  may  be  impacted  in  the  callus  arising  from 
the  former  injury.  Paralysis  of  the  deltoid  and  teres  minor  follows, 
evidenced  by  inability  to  raise  the  arm  from  the  side,  whilst  the 
wasting  of  the  former  muscle  causes  undue  prominence  of  the  acromion. 
There  may  be  temporary  anaesthesia  over  the  posterier  fold  of  the 
axilla,  but  this  does  not  last  long.  No  operative  treatment  has  been 
adopted,  although  we  see  no  reason  why  it  should  not  be  attempted  in 
suitable  cases. 

The  Musculo-Spiral  Nerve  is  not  unfrequently  damaged  in  fractures 
and  dislocations  of  the  upper  extremity  of  the  humerus,  but  is  chiefly 
exposed  to  injury  in  the  musculo-spiral  groove,  where  it  lies  close  to 
the  bone.  It  is  implicated  with  or  without  other  nerves  in  crutch 
palsy,  or  by  lying  asleep  with  the  arm  across  the  edge  of  a  chair  or 
table,  as  so  frequently  occurs  in  drunken  people  ('  Saturday-night 
paralysis  ').  It  is  not  unknown  after  operations  when  the  outstretched 
arm  has  rested  on  the  edge  of  the  table,  or  when  the  Trendelenburg 
position  has  been  adopted  and  the  arms  have  been  kept  above  the 
patient's  head,  the  upper  end  of  the  humerus  pressing  against  the 
brachial  plexus.  In  this  position  the  arms  should  not  be  raised  to 
more  than  a  right  angle  with  the  trunk,  or  may  be  folded  across  the 
chest.  The  resulting  paralytic  symptoms  are  not  confined  to  the 
musculo-spiral  nerve. 


APFECTIONS  OF  NERVES 


391 


Total  division  of  the  nerve  causes  the  following  symptoms  : 

A.  Anaesthesia.     If  the  nerve  is  divided  in  the  upper  third  of  the 

arm — i.e.,  above  the  origin  of  its  external  cutaneous 
branch — there  is  loss  of  both  epicritic  and  protopathic 
sensation  over  the  radial  half  of  the  dorsum  of  the  hand, 
of  the  epicritic  a  little  more  than  of  the  protopathic. 
Section  of  the  radial  nerve  in  the  upper  third  of  the 
fore-arm  causes  no  loss  of  sensation,  which  is  supplied  to 
the  back  of  the  hand  by  the  external  cutaneous  of  the 
brachial  plexus ;  but  section"  in  the  lower  third  causes  a 
limited  loss  of  epicritic  sense  over  the  back  of  the  thumb. 

B.  Paralysis  of  the  following  groups  of  muscles : 

(i.)  Of  the  extensor  of  the  fore-arm  (triceps) ;  hence  the  fore-arm 

can  only  be  extended  by  its  own  weight. 
(ii.)  Of  the  long  and  short  supinators ;  hence  the  hand  is  pronated, 

the  only  supinator  remaining  being  the  biceps. 


Fig.  127. — Wrist-drop  from  Paralysis  of  the  Musculo-Spiral  Nerve. 

(TiLLMANNS.) 

(iii.)  Of  the  radial  and  ulnar  extensors  of  the  wrist ;  hence  wrist- 
drop (Fig.  127),  a  condition  also  present  in  certain  lesions 
of  toxic  or  central  origin,  e.g.,  lead  palsy. 

(iv.)  Of  the  extensors  of  the  fingers  and  thumb,  which  either 
hang  limp  and  motionless,  or  may  be  bent  up  into  the 
palm  from  the  unopposed  action  of  the  flexor  muscles. 
If,  however,  the  wrist  and  proximal  phalanges  are  sup- 
ported and  extended,  the  terminal  phalanges  can  be 
straightened  by  the  action  of  the  interossei  and  lumbricales. 
Treatment  consists  in  massage  and  electricity  applied  to  the  muscles, 
but  in  some  cases  an  operation  is  necessary. 

Operation. — The  musculo-spiral  nerve  can  be  exposed  on  the  outer  side  of  the 
arm  after  it  has  traversed  the  external  intermuscular  septum,  where  it  Has 
between  the  brachiaHs  anticus  and  supinator  longus.  To  define  this  intersection 
the  fore-arm  is  semi-flexed  and  pronated,  and  an  incision  made  extending  from 
the  centre  of  the  crease  of  the  elbow  upwards  and  outwards  along  a  line  made 
by  prolonging  upwards  the  radial  border  of  the  fore-arm,  which  in  this  position 
corresponds  with  the  supinator  longus  muscle.  The  interspace  is  opened  up, 
and  the  nerve  found  together  with  the  termination  of  the  superior  profunda 
artery.  From  this  point  the  nerve  may  be  traced  upwards,  if  necessary,  by 
dividing  the  intermuscular  septum,  and  retracting  or  dividing  the  triceps. 

To  expose  the  upper  part  of  the  nerve  as  it  enters  the  groove,  the  arm  is  placed 


392  A  MANUAL  OF  SURGERY 

over  the  body,  and  the  posterior  border  of  the  deltoid  defined.  An  oblique  incision 
is  made  a  finger's  breadth  behind  this,  and  the  intersection  between  the  long  and 
outer  heads  of  the  triceps  found.  By  opening  up  this  space  the  finger  can  be 
passed  down  to  the  bone,  and  the  nerve,  together  with  the  superior  profunda 
artery,  readily  exposed. 

Where  the  nerve  is  impacted  in  the  callus  arising  from  a  fracture  of  _  the 
middle  of  the  shaft  of  the  humerus,  it  is  often  best  to  expose  it  by  a  median 
incision  down  the  back  of  the  arm,  splitting  the  triceps,  the  centre  of  the 
wound  being  opposite  the  insertion  of  the  deltoid. 

The  Median  Nerve  may  be  damaged  in  fractures  and  dislocations 
of  the  humerus,  but  is  most  frequently  injured  just  above  the  wrist 
by  glass  wounds,  due  either  to  bursting  of  bottles,  etc.,  or  to  thrusting 
the  hand  and  arm  through  a  window.  Paralysis  necessarily  results  in 
these  cases,  with  the  following  symptoms : 
If  divided  just  above  the  wrist : 

A.  Anaesthesia.  Loss  of  epicritic  sensation  over  the  palmar 
aspect  of  the  radial  side  of  the  hand,  over  the  front  of  the 
thumb,  index,  middle,  and  half  the  ring  fingers,  and  over 
varying  portions  of  the  dorsum  of  the  same  (Fig.  128); 


Fig.  128. — Division  of  Median  Nerve  above  the  Wrist. 
(After  Sherren.) 

The  shaded  parts  indicates  the  area  over  which  epicritic  sensation  is  lost. 

loss  of  protopathic  sensation  including  analgesia  to  pin- 
pricks over  a  much  more  limited  portion,  varying  con- 
siderably in  different  cases  with  the  area  of  distribution 
of  the  terminal  branches  of  the  external  cutaneous  and 
ulnar  nerves. 

B.  (i.)  Paralysis  of  the  outer  group  of  the  short  muscles  of  the 
thumb  (i.e.,  abductor,  opponens,  and  outer  half  of  the 
flexor  brevis  pollicis),  so  that  the  thenar  eminence  wastes, 
and  the  movement  of  '  opposition  '  is  impaired,  the  thumb 
remaining  extended  by  the  side  of  the  fingers  (Duchenne's 
'  ape-hand '). 
(ii.)  Paralysis  of  the  outer  two  lumbrical  muscles,  causing  loss  of 
power  of  flexion  at  the  metacarpo-phalangeal  joints  of  the 
index  and  middle  fingers. 

The  great  impairment  of  mobility  in  the  hand  and  fingers  so  often 
seen  in  these  cases  depends  not  so  much  on  paralysis  of  muscles  as  on 


AFFECTIONS  OF  NERVES 


393 


the  fact  that  in  the  majority  of  them  the  synovial  sheaths  of  the  wrist 
are  also  laid  open  and  involved  in  septic  inflammation,  which  leads  to 
the  formation  of  diffuse  adhesions.  Hence  the  progress  is  often 
unsatisfactory,  even  when  the  nerve  has  been  skilfully  sutured. 

//  divided  at  the  bend  of  the  elbow  or  in  the  arm,  to  the  above-described 
symptoms  are  added : 

(i.)  Loss  of  pronation  from  paralysis  of  the  two  pronators. 
(ii.)  Paralysis  of  the  flexor  carpi  radialis,  causing  defective  wrist 

flexion  on  the  radial  side  and  impaired  radial  abduction, 
(iii.)  Paralysis  of  the  flexor  longus  poUicis,  of  the  flexor  sublimis, 
and  the  outer  half  of  the  flexor  profundus  digitorum,  leading 
to  loss  of  power  in  the  hand-grasp,  especially  on  the  radial 
side,  and  perhaps  hyper-extension  of  the  wrist, 
(iv.)   Paralysis  of  the  palmaris  longus. 

Operations. — When  the  nerve  has  been  divided,  primary  or  secondary  nerve 
suture  should  always  be  undertaken.  In  the  latter  case  incisions  are  made 
through  the  old  scars,  which  may  be  removed  with  advantage,  the  ends  of  the 
nerve  clearly  defined,  and  the  bulb  removed.     Suture  is  often  very  difficult  from 


Fig.   i2g.  Fig.  130. 

Anesthesia  resulting  from  Division  of  Ulnar  Nerve.    (After  Sherren.) 

In  Fig.  129  the  nerve  was  divided  above  the  origin  of  the  dorsal  branch  ; 
in  Fig.  130  below  that  branch  close  to  the  wrist.  The  continuous  dark  line 
indicates  the  limits  of  the  loss  of  epicritic  sensation  ;  the  shaded  area  shows 
the  loss  of  protopathic  sensation. 

lack  of  material,  and  to  assist  in  the  apposition  of  the  segments  the  hand  is  flexed 
to  a  right  angle,  and  also  the  elbow,  and  maintained  in  that  position  by  a  poro- 
plastic  or  plaster  of  Paris  splint. 

In  order  to  stretch  the  nerve,  it  may  be  exposed  in  the  arm  by  an  incision 
similar  to  that  for  ligature  of  the  brachial  artery,  or  at  the  wrist  by  an  incision 
placed  to  the  ulnar  side  of  the  flexor  carpi  radialis  tendon,  between  that  structure 
and  the  palmaris  longus  or  flexor  sublimis  tendons. 

The  Ulnar  Nerve  is  exposed  to  injury  at  the  wrist,  as  also  in  the 
hollow  between  the  olecranon  and  the  inner  condyle  of  the  humerus, 
and  paralysis  may  be  caused  by  wounds,  fractures,  blows,  implication 
in  callus,  etc.     The  symptoms  are  very  characteristic. 
//  divided  at  the  elbow  : 

A.  Analgesia  or  loss  of  protopathic  sensation  of  the  little  finger 
and  ulnar  border  of  the  pain*,  back  and  front,  seldom 
of  the   ring   finger ;    anaesthesia  to  light  touch   (loss  of 


394 


B. 


(iv. 


A  MANUAL  OF  SURGERY 

epicritic  sensation)  of  the  ulnar  side  of  the  front  of  the 
wrist  and  palm,  of  the  back  of  the  hand,  and  of  the  little 
and  half  the  ring  fingers,  back  and  front  (Fig.  129). 
Paralysis  of  the  flexor  carpi  ulnaris,  causing  weakness  in 

flexion  and  in  ulnar  adduction  of  the  wrist. 
Paralysis  of  the  inner  half  of  the  flexor  profundus,  with  weak- 
ened hand-grasp,  especially  in  the  ring  and  little  fingers, 
(iii.)   Paralysis    of    the    two    inner 
lumbricales  and   of   all   the 
interossei ;  hence,  loss  of  ad- 
duction and  abduction  of  the 
fingers,  with  flexion  of  the 
two  last  phalanges  in  each 
finger  and  hyper  -  extension 
at  the  metacarpo- phalangeal 
joint  (main-en- griffe)  or  claw- 
hand  (Fig.  131).     The  inter- 
osseous spaces  also  become 
very  evident  from  atrophy  of 
these  muscles. 
Paralysis  of  the  short  muscles 
of   the   little   finger,   of   the 
inner  group  of  short  thumb 
muscles    (adductor    trans- 
versus,    adductor    obliquus, 
and   deep  portion  of   flexor 
brevis),  and  of  the  palmaris 
brevis. 
If    divided   just    above    the    wrist,    the 
Byrom  anaesthesia    only   involves    the    palmar 
aspect   of   the   hand   and  back   of   the 
terminal   phalanges    (Fig.    130),   whilst 
the  paralysis  merely  affects  the  short  palmar  muscles.     Additional 
impairment  of  movement  may,  however,  arise  from  septic  inflamma- 
tion of  the  long  tendons  and  their  sheaths. 

Treatment. — If  divided,  the  nerve  must  be  dealt  with  (according  to 
the  rules  already  given)  at  the  injured  spot. 

To  expose  the  nerve  for  the  purpose  of  stretching  for  neuralgia,  or  suturing,  the 
following  methods  may  be  adopted  :  {a)  In  the  upper  arm  an  incision  is  made 
similar  to  that  for  tying  the  brachial  artery,  but  half  an  inch  behind  it.  (h)  At  the 
elbow,  cut  down  just  behind  the  internal  condyle,  and  find  the  nerve  behind  the 
internal  intermuscular  septum  with  the  inferior  profunda  artery,  {c)  Just  above 
the  wrist  it  lies  to  the  radial  side  of  the  flexor  carpi  ulnaris  between  the 
tendon  and  the  ulnar  vessels ;  the  skin  and  deep  fascia  alone  need  division. 

The  Intercostal  Nerves  are  frequently  the  seat  of  severe  neur- 
algia, either  from  a  chronic  neuritis,  probably  of  toxic  origin,  from 
compression  by  tumours  or  inflammatory  lesions  of  the  ribs,  or  from 
injury  or  pressure  directed  to  the  nerve-roots  as  they  emerge  from 
the    spine,    as    in    spinal    caries    (girdle-pain).      Herpes    zoster    or 


Fig.   131.— Claw-hand  (Main- 
en  -  Griffe)     FROM     Ulnar 
Paralysis.     (After 
Bramwell.) 


AFFECTIONS  OF  NERVES  395 

shingles    is    sometimes    associated    with    such    pain,    and    may    be 
followed  by  some  amount  of  anaesthesia. 

Sciatica,  or  neuralgia  of  the  great  sciatic  nerve,  is  a  most  painful 
affection,  and  often  exceedingly  intractable.  It  may  arise  from  the 
following  Causes :  (a)  Inflammation  of  the  neurilemma  (acute  or 
chronic),  the  result  of  cold,  injury,  gout,  rheumatism,  syphilis,  and 
many  toxic  agents ;  (b)  pressure  upon  the  extrapelvic  portion  of  the 
nerve,  as  by  aneurisms,  tumours,  or  old-standing  dislocations  of  the 
head  of  the  femur  on  the  dorsum  ilii ;  (c)  similar  pressure  upon  the 
nerve  in  the  pelvis,  or  as  it  emerges  through  the  sacro-sciatic  notch,  as 
from  sarcoma  or  osteoma  of  the  pelvic  bones,  rectal  or  uterine  cancer, 
a  pregnant  uterus,  or  uterine  fibroids ;  (d)  pressure  upon  the  nerve- 
roots  in  the  spinal  canal,  as  from  caries  or  sarcoma ;  (e)  chronic 
diseases  of  the  spinal  cord,  such  as  tabes. 

The  Symptoms  are  very  evident,  the  pain  shooting  down  the  back 
of  the  thigh  and  often  referred  to  the  toes.  It  is  of  a  paroxysmal 
nature,  and  may  be  brought  on  by  pressure  over  almost  any  part  of 
the  nerve  or  by  movements  of  the  thigh,  and  heiice  the  patient's  gait 
is  stiff  and  shambling.  Tenderness  in  the  line  of  the  nerve  is  felt 
when  the  cause  is  a  peripheral  neuritis,  and  the  trunk  may  sometimes 
be  detected  on  palpation  as  a  thickened  cord.  The  limb  is  often  kept 
slightly  bent,  but  complete  flexion  of  the  thigh  on  the  pelvis  is  an 
impossibility ;  and  if,  when  the  patient  is  standing  against  a  wall,  the 
limb  can  be  raised  to  a  right  angle  with  the  knee  extended,  it  is 
certain  that  sciatica  is  not  present.  Careful  examination  of  the 
patient's  pelvis  must  be  made  before  determining  that  a  case  is 
'  merely  sciatica,'  especially  if  the  pain  has  lasted  any  time. 

The  Treatment  necessarily  varies  with  the  cause.  If  due  to  neuritis 
or  perineuritis,  general  anti-syphilitic  or  anti-rheumatic  measures  may 
be  adopted,  and  blisters  or  sedative  remedies  in  the  more  acute  cases 
applied  to  the  back  of  the  thigh.  Hypodermic  injections  of  morphia 
and  atropine  may  also  be  useful ;  but  if  all  the  usual  anti-neuralgic 
remedies  have  been  exhausted  without  benefit,  stretching  of  the  nerve 
may  be  employed. 

Stretching  of  the  sciatic  nerve  may  be  required  for :  (i.)  neuralgia  of 
an  intractable  type ;  (ii.)  paralysis  or  spasm  of  muscles  supplied  by 
it,  owing  to  adhesions  contracted  between  it  and  surrounding  parts, 
the  result  of  injury,  cellulitis,  or  perineuritis ;  (iii.)  in  paralysis  or 
spasm  due  to  some  forms  of  tabes.  Nerve-stretching  may  be  ac- 
complished without  operation  by  flexing  the  thigh  upon  the 
abdomen  and  then  extending  the  knee ;  in  cases  of  sciatica  an 
anaesthetic  will  be  required  for  this,  but  it  may  be  attempted  before 
undertaking  operative  procedures.  The  nerve  will  also  require  to 
be  exposed  in  order  to  suture  it  after  accidental  division. 

The  nerve  is  best  .exposed  for  stretching  at  the  point  where  it  emerges  from 
under  cover  of  the  gluteus  maximus,  midway  between  the  tuber  ischii  and  the 
great  trochanter.  The  patient  hes  in  the  prone  position  with  the  limb  sUghtly 
flexed,  and  a  4  or  5  inch  incision  is  made  vertically  downwards  from  the  gluteal 
fold  in  the  middle  line  of  the  thigh.     The  lower  border  of  the  gluteus  maximus 


396  A  MANUAL  OF  SURGERY 

is  first  exposed,  and  its  fibres  are  seen  running  downwards  and  outwards.  The 
hamstring  muscles  emerging  from  under  it  are  drawn  inwards,  and  the  nerve  is 
found  ensheathed  in  loose  connective  tissue  ;  it  is  stretched,  by  a  finger  hooked 
under  it,  both  peripherally  and  proximally. 

The  Anterior  Crural  Nerve  may  be  paralyzed  as  a  result  of  injury 
or  pressure,  and  may  be  the  seat  of  neuralgia  or  spasm.  Its  division 
causes  paralysis  of  the  quadriceps  extensor,  pectineus,  and  sartorius, 
and  the  most  marked  effect  will  be  secondary  flexion  of  the  knee-joint 
from  the  unopposed  action  of  the  hamstrings ;  anaesthesia  extends 
over  the  front  of  the  thigh  and  along  the  inner  side  of  the  leg  and  foot 
as  far  as  the  ball  of  the  great  toe.  The  nerve  may  be  exposed  on  the 
outer  side  of  the  femoral  vessels,  just  below  Poupart's  ligament,  by  a 
vertical  incision  half  an  inch  outside  the  line  of  the  artery. 

The  External  Popliteal  Nerve  may  be  divided  during  a  subcutaneous 
tenotomy  of  the  biceps,  to  which  it  lies  immediately  internal ;  or 
compressed,  as  it  winds  round  the  neck  of  the  fibula,  by  strapping, 
bandages,  or  splints  ;  or  it  may  be  injured  in  fractures  of  the  neck 
of  the  fibula.  Total  division  causes  anaesthesia  of  the  dorsum  of 
the  foot,  and  of  a  varying  portion  of  the  front  and  outer  side  of  the 
leg,  together  with  paralysis  of  the  extensor  and  peroneal  groups  of 
muscles ;  and  from  the  contraction  of  the  unbalanced  opposing  groups, 
the  paralytic  form  of  talipes  equino-varus  results.  The  nerve  may  be 
exposed  by  making  an  incision  i^  inches  long  to  the  inner  side  of  the 
biceps  tendon,  terminating  at  the  neck  of  the  fibula.  The  knee  is 
then  flexed,  and  the  nerve  is  readily  found  embedded  in  the  loose 
cellular  tissue  of  the  popliteal  space. 

The  Internal  Popliteal  Nerve  is  much  less  exposed  to  injury  owing 
to  its  more  sheltered  position.  Division  results  in  loss  of  epicritic 
and  protopathic  sensation  over  the  sole  of  the  foot,  and  of  epicritic 
sensation  for  the  plantar  surface  of  all  the  toes  and  for  the  dorsal 
aspect  of  the  outer  four ;  also  in  paralysis  of  the  calf  muscles, 
flexors  of  the  foot  and  toes,  and  of  the  short  muscles  of  the  sole. 
Paralytic  talipes  calcaneo- valgus  is  very  likely  to  ensue.  The  nerve 
is  laid  bare  by  a  vertical  incision  in  the  middle  of  the  popliteal  space, 
which  should  avoid  the  short  saphena  vein..  After  division  of  the 
deep  fascia,  the  nerve  is  the  most  superficial  structure. 

If  the  Tibial  Nerves  are  divided,  the  resulting  effects  are  more 
limited  ;  thus,  paralysis  of  the  extensors  of  the  foot  and  paralytic 
talipes  equinus  result  from  division  of  the  anterior  tibial ;  and  paralysis 
of  the  short  and  long  flexors  of  the  foot  and  of  the  interossei,  with 
resulting  talipes  cakaneo- valgus,  follow  lesions  of  the  posterior  tibial. 
The  nerves  may  be  exposed  in  the  same  way  as  the  accompanying 
arteries  (p.  341). 

The  Sympathetic  Nerve-trunk  in  the  neck  is  occasionally  com- 
pressed by  aneurisms  or  tumours.  If  merely  irritated,  dilatation  of 
the  pupil  on  the  same  side  and  unilateral  sweating  of  the  head  and 
face  are  produced ;  but,  if  divided,  the  pupil  is  contracted  from  un- 
balanced action  of  the  third  nerve.  It  has  also  been  completely 
excised  on  both  sides  in  the  treatment  of  Graves'  disease  and  for 
glaucoma,  and  the  operation  appears  to  be  of  some  value. 


CHAPTER  XVI. 

SURGICAL  DISEASES  OF  THE  SKIN  AND  OF  THE 
CUTANEOUS  APPENDAGES. 

A  Boil  or  Furuncle  is  a  limited  form  of  infective  gangrene  involving 
merely  a  small  portion  of  skin  and  subcutaneous  tissue,  usually  round 
a  hair  follicle.  Experimentally,  a  plentiful  crop  of  boils  can  be  pro- 
duced by  rubbing  a  culture  of  staphylococci  into  the  skin,  and  clini- 
cally it  is  supposed  that  a  similar  infection  through  the  hair  follicles 
is  the  most  common  cause  of  this  condition.  The  secondary  boils 
around  a  primary  one  are  without  doubt  due  to  the  friction  upon  the 
healthy  integument  of  dressings,  covered  with  pus  and  microbes. 

People  with  coarse  skins  and  a  tendency  to  comedones  are  specially 
liable  to  the  occurrence  of  boils.  A  gangrenous  inflammation  ensues 
after  infection,  resulting  in  the  death  of  the  hair  follicle,  or  of  the 
sweat  or  sebaceous  gland  involved,  and  of  the  surrounding  connective 
tissue,  and  the  slough  thus  formed  is  cast  off  by  a  process  of  suppura- 
tion. A  matured  or  ripe  boil,  therefore,  consists  of  a  central  slough 
or  core,  a  zone  of  pus  around  it,  and  external  to  this  granulation  tissue 
merging  into  healthy  skin  and  connective  tissue.  Although  infection 
from  without  is  the  local  exciting  cause,  some  depression  of  the  vital 
powers  is  frequently  present,  which  may  lead  to  recurrence. 

Signs. — A  boil  commences  as  a  small  red  irritable  pimple,  from 
which  a  hair  may  often  be  seen  to  protrude ;  it  increases  gradually 
in  size,  becoming  more  and  more  painful,  until  it  forms  a  conical 
tumour,  deep  red  in  colour  and  exquisitely  tender.  A  small  whitish 
spot  appears  in  the  centre,  and  around  this  so-called  core  yellow  pus 
can  be  seen.  Finally  it  bursts,  discharging  the  pus,  and  subsequently 
the  core  or  slough  comes  away.  The  process  is  then  at  an  end,  and 
the  wound  rapidly  heals  by  granulation.  Occasionally  the  inflamma- 
tion extends  more  deeply  into  the  subcutaneous  tissues,  constituting 
a  '.  carbuncular  boil.'  Lymphangitis  sometimes  follows,  and  the 
neighbouring  lymphatic  glands  may  become  sympathetically  enlarged 
and  painful,  but  rarely  suppurate.  A  boil  sometimes  subsides  without 
suppuration,  leaving  the  parts  thickened  and  infiltrated,  the  condition 
then  being  known  as  a  '  blind  boil.' 

Treatment. — Many  boils  may  be  left  to  burst  naturally,  though 
possibly  the  process  may  be  checked  by  the  employment  of  Bier's 
suction-glass,  or   by   surrounding   them   with   a   piece   of   ordinary 

397 


398  A  MANUAL  OF  SURGERY 

adhesive  plaster,  with  a  hole  over  the  apex  of  the  swelling.  Poultices 
are  generally  applied,  and  the  boil  is  incised  when  mature.  The 
skin  around  should  be  thoroughly  purified,  and  the  pus  received  on 
portions  of  wool  soaked  in  carbolic  lotion  (i  in  20),  and  the  cavity 
lightly  swabbed  out  with  pure  carbolic  acid.  A  small  collodion 
dressing  is  then  applied.  Constitutionally  tonics,  such  as  iron  and 
quinine,  are  usually  required,  except  in  plethorit  indi^'iduals,  in  whom 
a  spare  diet  and  abstinence  from  stimulants  may  be  recommended. 
A  change  of  air  to  a  bracing  seaside  place  is  often  advisable,  especially 
when  a  succession  of  boils  iias  appeared.  In  the  more  persistent 
cases  a  staphylococcal  vaccine  may  be  employed  with  advantage,  and 
the  boils  will  probably  be  quickly  cured  or  aborted  (p.  28). 

A  Carbuncle  is  a  more  extensive  infective  gangrene  of  the  sub; 
cutaneous  tissues,  due  to  a  local  invasion  with  pyogenic  microbes, 
the  commonest  being  the  Staphylococcus  pyogenes  aureus.  It  occurs  in 
individuals  run  down  by  any  general  debilitating  condition,  such  as 
albuminuria  or  diabetes,  in  whom  the  germicidal  powers  of  the  tissues 
are  much  depreciated ;  it  is  also  occasionally  met  with  as  a  sequela 
of  acute  fevers.  The  exciting  cause  may  be  some  blow  or  squeeze, 
resulting  in  extravasation  of  blood  or  some  local  diminution  of 
vitality ;  into  this  area  cocci  are  implanted  either  by  auto-infection, 
or  more  usually  through  the  sweat-glands  or  hair  follicles,  or  through 
some  slight  superficial  abrasion. 

Signs. — A  carbuncle  commences  as  a  hard,  painful  infiltration  of 
the  subcutaneous  tissues,  the  skin  over  which  becomes  red  and  dusky 
The  swelling  gradually  increases  in  size  in  all  directions,  until  a 
diameter  of  many  inches  may  be  reached.  As  it  extends  peripherally, 
the  central  parts,  which  were  formerly  brawny,  become  soft  and 
boggy,  and  the  overlying  skin  shows  evidences  of  yielding  to  the 
pressure  within.  Vesicles  form  on  the  surface,  and  finally  pustules  ; 
these  in  turn  burst,  and  allow  a  tardy  exit  to  the  ashy-gray  sloughs 
and  purulent  discharge  accumulated  below.  Fresh  openings  gradually 
develop,  leading  to  a  cribriform  condition  of  the  cutis,  due  probably 
to  the  passage  of  pus  along  the  lines  of  least  resistance,  viz.,  the 
perforations  of  the  cutis  at  the  sites  of  the  sebaceous  glands  and  hair 
follicles.  Some  of  these  apertures  enlarge  and  run  into  one  another, 
producing  a  central  irregular  crateriform  opening,  at  the  bottom  of 
which  lies  the  necrotic  tissue.  As  the  violence  of  the  inflammation 
subsides,  the  sloughs  gradually  separate,  leaving  a  clean  granulating 
wound.  Carbuncles  most  frequently  occur  on  the  back,  the  nape  of 
the  neck,  the  shoulders,  and  nates,  where  the  vitality  of  the  tissues  is 
never  very  active  ;  when  they  form  on  more  vascular  parts,  such  as 
the  face  and  lips,  the  consequences  may  be  even  more  serious,  since 
infective  thrombosis  of  the  large  veins  may  follow,  and  this  may 
quickly  spread  up  to  the  cavernous  sinus.  The  soft  and  spongy 
tissue  of  the  cheek  is  a  very  favourable  place  for  the  extension  of 
the  necrotic  process,  and  there  may  be  a  wide  area  of  mischief  under 
an  apparently  insignificant  superficial  lesion.     A  carbuncle  is  usually 


SURGICAL  DISEASES  OF  THE  SKIN  39«, 

single,  and  may  be  accompanied  by  lymphangitis  and  a  painful 
enlargement  of  the  nearest  lymphatic  glands. 

There  is  often  considerable  constitutional  disturbance  of  an  asthenic 
type,  although  the  temperature  is  not  necessarily  much  raised.  A 
temporary  glycosuria  is  sometimes  present,  and  disappears  as  the 
condition  improves,  but  occasionally  the  gravest  symptoms  of  blood- 
poisoning  (pyaemia  or  septicaemia)  may  supervene. 

The  Prognosis  of  a  carbuncle  mainly  depends  upon  the  condition 
of  the  internal  organs.  If  the  patient  is  a  confirmed  sufferer  from 
diabetes  or  albuminuria,  there  is  always  considerable  risk  of  his 
sinking  from  exhaustion.  The  vascularity  of  the  parts  also  influences 
the  result,  as  although  there  is  more  reparative  power  about  a  vascular 
region  like  the  face,  yet  the  implication  of  large  veins  may  lead  to 
embolic  pyaemia. 

Treatment. — The  most  thorough  and  satisfactory  is  to  lay  the  car- 
buncle freely  open  under  an  anaesthetic,  and  scrape  with  a  sharp  spoon 
or  cut  away  all  sloughs  until  healthy  tissue  is  reached,  and  then  to 
disinfect  the  cavity  thoroughly  with  pure  carbolic  acid  or  peroxide  of 
hydrogen  (lo  volumes).  The  hollow  thus  formed  is  packed  with  gauze 
soaked  in  an  iodoform  emulsion  (lo  per  cent.),  and  allowed  to  heal 
by  granulation.  Another  less  radical  proceeding  is  to  make  a  free 
crucial  incision,  and  allow  the  sloughs  to  separate  naturally,  assisting 
matters  by  antiseptic  fomentations  or  Bier's  suction-glass.  Good 
food,  iron,  quinine,  and  alcohol  according  to  judgment,  must  be 
administered,  whilst  appropriate  medicine  (e.g.,  codeia  or  opium) 
and  limitation  of  diet  are  necessary  in  diabetic  patients. 

In  the  early  stages  Bier's  treatment  by  induced  hyperaemia  may  be 
successful  in  preventing  suppuration,  but  where  the  organisms  are  at 
all  virulent  or  the  focus  large,  it  will  probably  fail.  Vaccines  will  be 
of  little  use  apart  from  operation. 

A  Com  (clavus)  is  a  localized  outgrowth  of  the  epidermic  layer  of 
the  skin,  together  with  a  central  ingrowth  of  a  hard,  horny  plug, 
which  compresses  and  causes  atrophy  of  the  underlying  papillae,  con- 
stituting a  cup-shaped  hollow,  whilst  the  surrounding  papillae  are 
hypertrophied.  It  is  the  presence  of  this  central  plug  that  constitutes 
the  difference  between  a  true  corn  and  a  simple  callosity  or  diffuse 
overgrowth  of  the  epidermis.  Any  abnormal  pressure  is  capable  of 
producing  either  condition,  granting  that  it  is  not  sufl&ciently  severe 
or  intense  to  lead  to  ulceration ;  but  it  is  rare  to  find  corns  except  on 
the  feet,  and  the  chief  cause  is  badly-fitting  boots.  Two  kinds  of 
corns  are  described,  viz.,  the  hard  and  the  soft. 

The  hard  corn  usually  occurs  on  the  little  toe,  or  over  the  head  of 
the  metatarsal  bone  of  the  great  toe,  or  over  the  heads  of  the  first 
phalanges  of  the  other  toes,  especially  if  there  is  any  tendency  to 
hammer-toe.  They  form  more  or  less  conical  swellings,  with  a  dark, 
dry,  central  plug,  and  are  often  very  painful,  especially  when  rain  is 
threatening.  Suppuration  sometimes  occurs  beneath  a  corn,  and  the 
pain  then  becomes  acute.  If  it  is  not  attended  to  early,  the  pus  may 
buirow  and  involve  deeper  parts,  causing  necrosis  or  a,  destructive 


400 


A  MANUAL  OF  SURGERY 


arthritis,  and  possibly  necessitating  amputation.  Treatment  consists 
in  paring  the  corn,  after  softening  with  hot  water  or  treating  with 
salicyhc  acid  plaster  (lo  or  20  per  cent.),  or  painting  with  a  solution 
of  salicylic  acid  in  collodion.*  A  circular  ring  of  felt  plaster  may 
subsequently  be  worn,  but  attention  must  be  directed  to  the  boots, 
and  the  cause  of  the  trouble  removed.  Occasionally,  where  the  toe  is 
deformed,  it  is  necessary  to  perform  amputation. 

A  soft  corn  occurs  between  the  toes,  and  owing  to  the  absorption 
of  sweat  the  surface  looks  white  and  sodden  ;  it  is  often  extremely 
painful.  Treatment  consists  in  removing  the  thickened  cuticle  after 
the  use  of  salicylic  acid.  The  parts  are  very  carefully  cleansed  night 
and   morning,   and    spirit   of   camphor  painted  on  at  night,  whilst 

cotton -wool    is   worn   between   the 
toes  during  the  day. 

Perforating    Ulcer    of    the    Foot 

forms  on  some  part  of  the  sole  and 
progresses  deeply  so  as  to  involve 
sooner  or  later  the  bones  and  joints. 
It  is  usually  due  to  two  main  factors, 
viz.,  ancssthesia  of  the  sole,  and  more 
or  less  persistent  traumatism,  such 
as  arises  from  wearing  a  tight  boot 
or  from  the  presence  of  a  nail,  which 
is  not  noticed  owing  to  the  concur- 
rent anaesthesia.  It  is  therefore 
likely  to  be  met  with  :  (i)  In  certain 
central  nervous  diseases — e.g.,  tabes 
dorsalis,  syringomyelia,  spina  bifida, 
etc. ;  (2)  in  diseases  such  as  diabetes, 
syphilis,  alcoholism,  etc.,  which  lead 
to  peripheral  neuritis  ;  and  (3)  as  a 
sequence  of  traumatic  lesions  of  the 
nerves  affecting  any  portion  of  their 
course  from  the  spinal  cord  down- 
wards. (4)  Perforating  ulcer  is  occa- 
sionally due  to  pure  plantar  lesions, 
apart  from  any  nervous  influence,  e.g.,  a  suppurating  wart  or  corn, 
or  even  a  chronic  epithelioma.  The  skin  under  the  head  of  the  first 
metatarsal  is  the  part  most  frequently  affected,  but  any  spot  to  which 
undue  pressure  is  directed  may  become  involved,  and  not  uncommonly 

*  The  following  is  a  useful  formula  : 

^.     Acidi  salicylici,  gr.  xv. 

Ext.  cannabis  ind.,  gr.  yiii. 
Sp.  vini  rect. ,  ttixv. 
i^theris,  nixl. 
Collodion  flexile,  iiilxxv. 
M.  Ft.  pigm. 
Sig.  ;  To  be  painted  on  with  a  brush  three  times  a  day  for 
a  week. — R.Crocker. 


Fig.  132. — Perforating  Ulcer  of 
Great  Toe,  penetrating  to 
Bones  and  causing  Necrosis. 

The  scar  of  an  old  healed  ulcer  of 
similar  type  is  seen  on  the  outer 
side  of  the  foot. 


SVRCICAL  DISEASES  OF  THE  SKiM  4°! 

several  such  sores  may  be  seen  on  the  same  foot.  A  corn  or  callosity 
first  forms,  and  under  this  a  bursa,  in  which  suppuration  takes  place, 
the  pus  travelling  not  only  to  the  surface,  but  also  deeply,  so  as  to 
involve  bones  and  joints.  A  typical  perforating  ulcer  presents  the 
appearance  of  a  sinus  passing  down  to  the  deeper  parts  of  the  foot, 
and  even  extending  through  to  the  dorsum ;  the  orifice  is  surroLinded 
by  heaped-up  and  thickened  cuticle  (Fig.  132).  There  is  sometimes 
but  little  discharge  and  often  no  pain,  but  when  bones  or  joints  are 
affected,  free  suppuration  may  occur.  If  allowed  to  progress  without 
treatment,  the  bones  and  joints  of  the  foot  may  be  destroyed  ex- 
tensively, or  may  be  welded  together  into  a  solid  painful  mass,  in 
either  case  necessitating  amputation.  A  cure  can  sometimes  be 
determined  by  removing  the  thickened  mass  of  cuticle  and  purifying 
or  excising  the  sinus ;  the  cavity  thereby  formed  is  packed  with 
gauze  and  allowed  to  heal  by  granulation.  Should  this  fail,  or  if 
bones  or  joints  are  involved,  amputation  will  be  required. 

A  Wart  {verntca)  is  a  papillary  overgrowth  of  the  skin,  which  may 
manifest  itself  in  many  different  appearances.  The  common  wart  is 
a  horny  projection  about  the  size  of  a  split  pea,  usually  seen  on  the 
hands  of  young  people ;  its  surface  may  be  smooth  or  irregularly 
filiform,  and  its  colour  varies  with  the  amount  of  dirt  ingrained  on 
the  surface.  When  smooth-topped,  they  are  sometimes  extremely 
numerous,  and  may  be  a  little  difficult  to  distinguish  from  lichen 
planus.  In  parts  where  there  is  a  certain  amount  of  moisture  warts 
become  soft  in  character,  and  form  large  vascular  masses — e.g., 
venereal  warts.  The  best  method  of  treating  ordinary  warts  is  to 
paint  them  with  glacial  acetic  acid,  or  some  other  caustic,  every  two 
or  three  days,  after  softening  and  removing  the  horny  crust  with 
salicylic  acid. 

Verruca  Necrogenica  (see  p.  246). 

A  CMlblain  {pernio)  is  an  inflammatory  Jtiyperaemia,  usually  involv- 
ing the  fingers,  toes,  or  ears,  and  determined  by  exposure  to  cold. 
It  is  generally  seen  in  young  people  with  defective  circulation,  whose 
fingers  and  toes  easily  go  dead.  After  the  period  of  anaemia  and 
pallor,  the  part  begins  to  itch  or  burn,  and  becomes  red,  swollen  and 
shiny.  Exudation  occurs  into  and  beneath  the  skin,  and  in  bad 
cases  a  blister  with  blood-stained  contents  forms ;  when  this  bursts 
troublesome  ulceration  ensues.  To  prevent  the  formation  of  chilblains 
the  patient's  circulation  must  be  improved,  and  exposed  parts  kept 
warm.  In  the  earlier  stages  calcium  lactate  in  lo-grain  doses  may 
be  administered,  and  the  parts  painted  with  iodine  or  exposed  two  or 
three  times  to  the  X  rays.  When  the  chilblain  breaks,  simple 
antiseptic  precautions  must  be  taken,  and  the  part  dressed  daily ;  a 
portion  of  lint  soaked  in  Peruvian  balsam  is  sometimes  found  useful. 

Tuberculous  Affections  of  the  Skin. — Lupus  Vulgaris  is  a  chronic 
inflammation  of  the  skin  of  tuberculous  origin.     It  is  met  with  in 

26 


402  A  MANUAL  GF  SURGERY 

children  and  young  adults,  rarely  commencing  after  the  age  of  thirty. 
Its  most  common  situation  is  the  face,  usually  starting  on  the  nose 
or  cheek.  It  is  rare  on  the  scalp,  but  tairly  frequent  on  the  trunk 
and  extremities.  The  mucous  membrane  of  the  nose  and  mouth ,  is 
also  attacked,  but  usually  by  extension  from  the  skin.  It  is  not  often 
symmetrical,  except  when  commencing  on  the  nose. 

Clinical  Features. — The  earliest  manifestation  of  lupus  consists  in 
the  formation  of  one  or  more  shot-like  nodules  in  the  deeper  layers 
of  the  skin,  which  are  surrounded  by  a  zone  of  hyperaemia  and  infil- 
tration. These  nodules  are  not  particularly  hard  to  the  touch,  but 
when  of  any  size  can  be  demonstrated  to  be  of  a  brownish-orange 
tint,  especially  if  they  are  devascularized  by  the  pressure  of  a  glass 
slide,  and  then  the  colour  somewhat  resembles  that  of  apple-jelly. 
Gradually  the   process   extends,    and   usually  more   rapidly   in   one 


PiQ_  ioo.—Non-Ulcerating  Lupus  of  Cheek.     (From  a   Photograph.) 


Special  direction,  following  the  course  of  the  vessels.  At  the  same  time 
the  integument  becomes  infiltrated  and  transformed  into  granulation 
or  cicatricial  tissue,  covered  by  a  layer  or  two  of  epithelium  (Fig.  133), 
and  owing  either  to  degeneration  of  the  tuberculous  nodules,  or  to  a 
lack  of  vitality,  arising  from  compression  of  the  vessels  by  the  con- 
traction of  this  new  formation,  ulceration  is  very  liable  to  follow.  In 
the  extremities  the  lupoid  growth  not  unfrequently  takes  on  a  warty 
.aspect,  somewhat  similar  to  the  '  anatomical  wart '  occasionally  seen 
on  the  knuckles  of  post-mortem  porters  (p.  246). 

A  Lupoid  Ulcer  usually  spreads  at  one  margin  as  it  heals  at  the 
other,  and  hence  under  typical  circumstances  is  more  or  less  cres- 
centic  in  shape.     The  surface  is  covered  with  granulations,  often  of 


SURGICAL  DISEASES  OF  THE  SKIN 


403 


a  protuberant  nature.  The  ed^es  are  raised  and  infiltrated,  and 
scattered  lupoid  tubercles  are  readily  distinguishable,  extending  into 
the  healthy  tissues,  which  are  usually  red  and  congested.  A  consider- 
able amount  of  sero-pus  is  often  secreted,  and  this  by  drying  forms 
thick  scabs.  Any  cicatrix  which  results  from  natural  processes  of 
cure  is  thin  and  vascular,  easily  breaking  down  from  slight  irritation. 
The  process  extends  gradually,  with  or  without  intermissions,  from 
the  seat  of  its  first  appearance,  being,  as  a  rule,  distinctly  limited  to 
the'  cutaneous  tissues  ;  but  when  it  attacks  the  nose,  the  cartilages 
are  often  involved  and  destroyed,  whilst  if  it  involves  the  palate  or 
septum  nasi,  perforation  is  very  likely  to  ensue.  The  disease  is 
practically  painless,  and  does  not  at  first  affect  the  general  health. 
Neighbouring  lymphatic  glands  may  become  inflamed,  and  in  some 


Fig.  134 — Spreading  Margin  of  a  Patch  of  Lupus.     (Ziegler.) 
a.  Normal  epidermis ;  &,  normal  corium  with  sweat-gland  {i)  ;  c,  focus  of  lupoid 
tissue  ;  d,  vascular  nodule  surrounded  by  diffuse  cellular  infiltration ;   e,  non- 
vascular nodule  ;  /,  strings  of  cells  in  course  of  lymphatics ;  g,  lupoid  ulcer  ■ 
h,  proliferating  epithelium. 

few  instances  are  the  seat  of  a  tuberculous  deposit.  Even  if  left  to 
itself,  it  tends  sooner  or  later  to  come  to  an  end,  the  ulcerated  parts 
cicatrizing,  but  leaving  indelible  traces  of  its  ravages  in  the  shape  of 
obvious  scars,  with  often  considerable  loss  of  substance.  Occasionally 
it  persists,  in  spite  of  treatment,  and  then  an  epithelioma  may  in 
time  develop  on  the  site  of  the  mischief,  running  a  rapid  course 
owing  to  the  vascularity  of  the  part. 

Pathological  Anatomy.^The  characteristic  microscopical  feature 
of  lupus  lies  in  the  formation  of  nodules  around  the  smaller  vessels 
of  the  skin  (Fig.  134),  consisting  chiefly  of  a  mass  of  round  cells, 
within  which  may  perhaps  be  observed  a  giant  cell  and  endothelioid 
cells,  arranged  in  the  same  v/ay  as  in  tubercle.  The  structures  around 
are  infiltrated  and  hyperaemic ;  as  the  disease  progresses,  the  original 


4C4  A  MANUAL  OF  SURGERY 

tissue  of  the  part  disappears,  and  is  replaced  by  granulation  of 
fibro-cicatricial  tissue.  The  bacilli  are  by  no  means  readily  found, 
and  are  always  few  in  number. 

The  Diagnosis  of  lupus  from  syphilitic  and  other  destructive  affec- 
tions of  the  skin  turns  on  the  presence  of  outlying  nodules  beyond  the 
spreading  edge  of  the  lesion,  together  with  the  apple-jelly-like  granula- 
tions, and  the  thin,  congested  character  of  any  cicatricial  tissue  present, 
whilst  the  slow,  though  continuous,  progress,  and  the  tendency  to  heal 
at  one  part  as  it  spreads  at  another,  are  also  suggestive  of  its  presence. 
The  age  and  constitution  of  the  individual,  and  the  persistence  of  the 
disease  in  spite  of  treatment,  must  also  be  taken  into  account. 

The  Treatment  of  lupus  has  been  greatly  modified  of  recent  years, 
owing  to  the  discovery  of  the  remedial  properties  of  Finsen  light, 
X  rays,  and  other  agents.  Of  course  where  practicable,  excision  of 
the  whole  area  of  disease  is  the  quickest  and  safest  cure  ;  but  it  is 
seldom  available. 

The  Finsen-light  cure  consists  in  exposing  the  lupoid  tissue  to  con- 
centrated electric-  or  sun-light,  which  is  focussed  on  the  skin  through 
an  inverted  telescope,  and  finally  passes  through  a  rock-crystal 
chamber  full  of  cold  running  water,  so  as  to  eliminate  the  heat  rays. 
It  is  important  that  the  water-chamber  should  be  pressed  firmly 
against  the  skin  so  as  to  devascularize  it  during  the  application. 
Each  sitting  lasts  for  one  and  a  quarter  hours,  and  an  attendant  whose 
eyes  are  shielded  by  dark  glasses  controls  the  crystal  water- chamber, 
keeping  it  firmly  against  the  skin,  and  slightly  shifting  it  from  time  to 
time  so  that  an  area  about  as  large  as  a  shilling  shall  be  acted  upon 
at  each  seance.  Slight  inflammatory  phenomena  follow,  and  a  local 
leucocytosis  supervenes,  as  a  result  of  which  the  disease  disappears, 
and  a  soft  supple  scar  is  produced,  which  is  very  little  obvious. 
It  has  been  found  of  most  value  where  ulceration  is  absent  and  the 
patch  not  of  great  size. 

X-ray  treatment  is  also  valuable.  The  same  precautions  as  to  pro- 
tecting healthy  parts  must  be  observed  as  in  treating  cancer  (p.  219). 
The  best  results  have  been  obtained  by  using  a  tube  of  comparatively 
low  vacuum,  and  by  working  for  a  definite  inflammatory  reaction, 
and  then  stopping  till  this  has  disappeared.  The  length  of  the 
treatment  necessarily  varies,  but,  as  a  rule,  three  to  six  exposures 
a  week  of  not  more  than  ten  minutes  each  will  suffice.  The  X  rays 
appear  to  act  best  on  the  ulcerative  and  fungating  forms  of  lupus, 
which  clear  up  and  heal ;  but  the  cure  is  only  up  to  a  point,  as  the 
scars  are  frequently  found  to  contain  small  nodules  over  which  the 
rays  have  no  further  influence.  For  these  the  Finsen  light  may  be 
employed  beneficially ;  but  in  the  absence  of  this  agent  they  should 
be  dealt  with  by  scraping  with  a  lupus  spoon,  and  subsequently 
applying  solid  nitrate  of  silver,  acid  nitrate  of  mercury  on  a  match 
end,  chloride  of  zinc  as  a  paste,  or  even  the  actual  cautery. 

In  some  bad  cases  with  much  ulceration  and  when  there  is  a  super- 
abundance of  granulations  it  may  be  wise  to  remove  these  with  a  sharp 
spoon  as  a  preliminary  measure,  and  then  hand  the  patient  over  to 


SURGICAL  DISEASES  OF  THE  SKIN  405 

the  radiographer.  The  surgeon  must  remember,  however,  that  he  is 
not  operating  to  cure  the  disease,  but  merely  to  lay  bare  the  deeper 
tissues  in  order  that  the  rays  may  reach  them  more  effectively.  He 
must  not  include  in  the  scope  of  his  operation  healthy  tissues. 

Tuberculin  probably  renders  the  disease  more  amenable  to  local 
measures,  and  prevents  recurrence  after  its  destruction,  but  by  itself 
seldom  cures.  The  patient's  health  also  must  be  attended  to,  and  a 
course  of  suitable  tonics  administered.  An  open-air  life,  as  nearly 
assimilated  to  the  sanatorium  type  as  possible,  is  also  desirable. 

Lupus  Erythematosus  is  a  disease  the  nature  of  which  is  not  yet 
satisfactorily  determined.  The  appearance  of  the  affection  is  tolerably 
characteristic ;  it  is  usually  situated  on  the  face,  and  in  the  most 
typical  cases  symmetrical  patches  are  formed  over  the  root  of  the 
nose  and  cheeks,  corresponding  in  appearance  to  a  butterfly  with 
outspread  wings.  The  condition  frequently  invades  the  forehead, 
ears,  and  scalp,  and  occasionally  appears  on  the  trunk,  being  then 
unilateral.  It  appears  as  a  smooth  hyperaemic  surface,  covered  with 
a  branny  desquamation  ;  the  scales  consist  of  inspissated  sebum,  and 
are  continuous  with  deep  plugs,  which  can  be  traced  into  the  mouths 
of  enlarged  sebaceous  follicles.  As  the  disease  spreads  peripherally, 
the  older  and  central  portions  are  transformed  into  cicatricial  tissue 
of  a  pale,  thin  and  "white  type,  in  marked  contrast  to  the  hyperaemic 
condition  of  the  advancing  margin.  It  is  usually  seen  in  adults,  and 
more  frequently  in  women  than  men.  Progress  is  exceedingly  slow, 
and  ulceration  uncommon,  except  when  the  ears  or  scalp  are  involved ; 
in  the  latter  region  the  hair  is  often  lost.  Epithelioma  has  also  been 
known  to  follow  this  affection. 

The  Treatment  consists  in  attention  to  the  general  health,  together 
with  the  local  application  of  weak  tarry  and  mercurial  preparations. 
The  X  rays  and  Finsen  light  act  rapidly,  but  must  be  used  with 
caution,  since  the  inflammatory  disturbance  caused  by  them  is  con- 
siderable. 

The  so-called  Tuberculous  Ulcers  differ  from  the  lupoid  in  the  fact 
that  they  always  result  from  the  breaking  down  of  a  subcutaneous 
focus,  and  hence  may  be  connected  with  diseases  of  bones,  joints, 
lymphatic  glands,  or  simply  of  the  connective  tissues.  Their  characters 
and  treatment  have  been  already  indicated  (p.  173). 

Other  cutaneous  manifestations  of  tubercle  are  recognised,  but  need 
scarcely  be  mentioned  here. 

Affections  of  the  Nails. 

Onychia  is  almost  always  due  to  the  infection  with  pyogenic  or 
other  organisms  of  the  matrix,  starting  at  the  side  or  base  of  the  nail 
under  the  semilunar  fold.     Two  varieties  are  described : 

I .  Onychia  Purulenta  [Pen-onychia,  or  Ungual  Whitlow)  is  an  affection 
of  the  matrix  commonly  seen  in  surgeons  and  nurses,  in  which  suppura- 
tion occurs  beneath  the  nail,  which  is  thereby  loosened  ;  the  individual 
attacked  is  generally  out  of  health.     The  condition  usually  starts  on 


4o6  A  MANUAL  OF  SURGERY 

one  side,  and  gradually  extends  round  the  semilunar  fold  and  beneath 
the  nail,  until  the  whole  matrix  may  be  affected.  When  the  loosened 
nail  is  cut  away,  it  is  found  that  the  diseased  portion  of  the  matrix  is 
converted  into  granulation  tissue.  The  process  is  extremely  painful 
and  somewhat  tedious.  The  only  hope  of  checking  its  progres=  lies 
in  removing  with  fine  scissors,  possibly  under  an  anaesthetic,  all  the 
loosened  portion  of  the  nail,  and  then  touching  the  exposed  granula- 
tions with  nitrate  of  silver,  whilst  the  most  comforting  applications 
are  without  doubt  linseed-meal  poultices,  possibly  made  with  hot 
carbolic  lotion  (i  in  40),  and  frequently  repeated.  At  the  same  time 
the  general  health  must  be  attended  to. 

2.  Onychia  Maligna  is  the  term  applied  to  a  somewhat  similar 
condition  met  with  in  badly-nourished  children,  who  are  perhaps 
syphilitic.  The  whole  matrix  is  transformed  into  granulation  tissue, 
whilst  the  digit  becomes  swollen  and  club-shaped.  Treatment  consists 
in  avulsion  of  the  nail  from  its  bed,  and  the  application  of  antiseptic 
fomentations  or  poultices,  together  with  iodoform. 

Ingrowing  Toenail  is  an  ulcerative  condition  of  the  soft  parts  curling 
over  the  side  of  one  of  the  toenails  (usually  that  of  the  great  toe),  and 
due  either  to  the  pressure  of  pointed  or  badly-fitting  boots,  or  to  neglect 
in  trimming  the  nails.  The  fold  of  skin  is  thus  pressed  by  the  boot 
over  and  against  the  nail  when  the  patient  walks,  and  in  order  to 
diminish  the  pain  and  irritation  caused  thereby,  he  often  cuts  away 
the  projecting  angle  of  the  nail,  but  leaves  a  deep  corner  which  still 
further  irritates  the  soft  parts.  Ulceration  ensues,  accompanied  by 
an  offensive  discharge  and  so  much  pain  as  to  prevent  the  patient 
from  walking.  The  matrix  of  the  nail  may  also  become  inflamed, 
and  onychia  result.  In  the  earliest  stages,  further  progress  can  often 
be  prevented  by  careful  attention  to  the  nails,  by  the  use  of  square- 
toed  boots  fitting  easily,  and  by  introducing  small  piugs  of  aseptic 
wool  to  press  back  the  overhanging  fold  of  skin.  When  ulceration  is 
actually  present,  the  best  treatment  is  the  removal  of  the  affected 
half  of  the  nail,  giving  special  attention  to  the  extraction  of  the  project- 
ing angle.  If  there  is  much  discharge,  it  is  also  wise  to  cut  away 
the  overhanging  fold  of  skin  with  scissors,  and  scrape  away  any 
granulations  present.  The  parts  are  then  dressed  antiseptically,  and 
in  a  few  days  the  patient  is  able  to  walk  about.  Where  there  is  no 
ulceration,  a  cure  can  sometimes  be  effected 
by  excising  an  oval  portion  of  skin  from  the 
side  of  the  toe  and  close  to  the  nail.  The 
edges  of  the  incision  are  drawn  together  by 
horsehair,  and  thus  the  overgrowing  fold  of 
skin  is  drawn  away  from  the  nail  (Fig.  135). 
Fig.  135.— Operation  for  q^j^g  ^g^-j^  Onychogryphosis  is  applied  to  a 
Ingrowing  Toenail.        ,  ,        1  •  j-.-  r    J_^  -f         1  •   1 

hypertrophic    condition  or    the  nails,  which 

become  distorted  and  bent,  or  twisted  up,  perhaps  simulating  a 
ram's  horn.  It  is  usually  limited  to  the  great  toes  of  elderly  people, 
and  is  due  to  neglect.  The  nails  are  very  rough,  and  often  covered 
with  grooves  or  ridges,  whilst  beneath  them  is  an  accumulation  of 
soft,  offensive  epithelium.     The  only  treatment  is  removal. 


SURGICAL  DISEASES  OF  THE  SKIN  407 

Affections  of  the  Sebaceous  G-lands. 

Sebaceous  Cysts  occur  on  any  part  of  the  surface  of  the  body,  but 
especially  the  scalp,  and  are  due  to  obstruction  of  the  duct  of  a  seba- 
ceous gland.     They  are  rounded  swellings,  firm  and  elastic  to  the 
touch,  moveable  on  the  deeper  structures,  and  always  attached  at  one 
spot  to  the  skin.     On  careful  examination,  the  obstructed  mouth  of  a 
sebaceous  follicle  can  usually  be  seen,  and  possibly  some  of  the  con- 
tents of   the  sac  squeezed  through  this  opening.     The  cyst  wall  is 
formed  by  several  layers  of  epithelium,  surrounded  by  dense  fibro- 
cicatricial  tissue,  and  if  exposed  to  irritation  or  pressure,  as  when 
situated  on  the  back  or  shoulder,  and  rubbed  by  the  braces,  becomes 
very  firmly  adherent  to  the  surrounding  parts.    The  material  contained 
within  is  of  a  cheesy,  pultaceous  consistency,  with  a  peculiar  stale 
odour,  yellowish-white  in  colour,  and  under  the  microscope  is  seen  to 
be  composed  of  fatty  and  granular  debris,  epithelial  cells,  and  choles- 
terine.     Left  to  themselves,  the  cysts  may  attain  considerable  dimen- 
sions, whilst  the  walls  and  contents   sometimes   become   calcified. 
Occasionally  the  exudation  oozes  through  the  duct,  and  dries  on  the 
surface,  with  just  sufficient  cohesion  to  prevent  it  from  falling  off ; 
layer  after  layer  of  this  desiccated  material  is  deposited  from  below, 
finally  giving  rise  to  what  is  known  as  a  Sebaceous  Horn.     These 
become  dark  in  colour  from  admixture  with  dirt,  and  are  always  more 
or  less  fibrillated  in  texture ;  the  base,  to  which  they  are  firmly  adherent, 
is  infiltrated  and  hyperaemic.      Sebaceous  cysts  sometimes  inflame 
and  suppurate ;  sooner  or  later  they  burst  or  are  opened,  and  then  the 
process  subsides.     They  are  occasionally  cured  in  this  way,  but  more 
frequently  the  cyst  fills  up  again,  and  the  same  series  of  phenomena 
are  repeated  after  an  interval.     Should  the  contents  only  escape  par- 
tially, the  remainder  is  liable  to  undergo  putrefactive  changes,  giving 
rise  to  an  offensive  ulcerated  surface  with  raised  edges,  which  may 
readily  be  mistaken  for  epithelioma.     It  is  sometimes  known  as  Cock's 
Peculiar  Tumotir.    True  malignant  disease  of  an  epitheliomatous  nature 
is  said  occasionally  to  supervene. 

Diagnosis. — From  a  dermoid  cyst  it  is  known  by  the  facts  that  the 
dermoid  is  congenital  in  origin,  that  it  is  limited  to  certain  localities, 
whilst  it  is  hardly  ever  directly  attached  to  the  skin.  From  a  fatty 
tumour  it  is  recognised  by  its  rounded  shape,  its  fixity  to  the  skin,  the 
absence  of  lobulation,  and  by  its  more  solid  character,  whilst  a 
lipoma  is  softer  and  more  moveable.  From  a  chronic  abscess  it  is  dis- 
tinguished by  the  dilated  orifice,  by  its  firmer  consistency,  and  by  the 
history,  but  it  is  sometimes  impossible  to  be  certain  before  incising  it. 

Treatment. — A  sebaceous  cyst  should  be  entirely  and  completely 
removed  if  giving  rise  to  any  disfigurement,  inconvenience,  or  pain. 
In  the  scalp  all  that  is  needed  is  to  transfix  the  tumour,  squeeze  out 
the  cheesy  contents,  and  then  the  cyst  wall  can  be  readily  removed 
by  grasping  it  with  dissecting  forceps  and  pulling  it  away.  In  other 
situations  the  cyst  wall  may  require  to  be  dissected  out ;  but  even 
then  it  is  advisable  to  open  it  by  transfixion,  and  to  deal  with  the  sac 


4o8  A   MANUAL  OF  SURGERY 

from  below  rather  than  from  above.     Horns  and  fungating  ulcer 
should  be  excised  with  the  surrounding  skin. 

Sometimes  a  true  sebaceous  adenoma  may  develop  in  connection  with 
these  cysts.  It  may  be  slowly-growing  and  of  a  firm,  solid  consistency; 
but  sometimes  it  is  much  more  vascular  and  grows  rapidly.  The  latter 
has  a  form  of  semi-malignancy  in  that  it  is  very  liable  to  recurrence, 
and  has  therefore  often  been  mistaken  for  a  sarcoma.  On  microscopic 
section  it  closely  resembles  a  rodent  ulcer,  but  its  clinical  history  is 
quite  distinct.  Its  most  frequent  situation  is  the  scalp,  and  it  requires 
to  be  removed  with  a  free  hand,  the  defect  in  the  scalp  being  made 
good  by  Thiersch-grafting. 

MoUuscum  Contagiosum. — This  affection  shows  itself  in  the  form 
of  a  number  of  firm  hemispherical  nodules,  a  little  larger  than  a  split 
pea,  usually  of  a  yellowish- white  colour,  and  very  definitely  umbilicated. 


Fig.   136. — Rodent  Ulcer  of  many  Years'  Standing.     (From  a 
Photograph.) 

The  depression  in  the  centre  may  be  occupied  by  dry  debris,  and  froni 
the  larger  ones  a  waxy  mass  can  be  expressed.  They  are  usually 
seen  on  the  face,  but  may  involve  any  part  of  the  surface  of  the  body. 
There  seems  no  doubt  as  to  their  contagious  properties,  this  being 
perhaps  best  seen  in  the  development  of  growths  of  this  nature  on  a 
mother's  breast,  secondary  to  those  on  the  face  of  her  baby,  but  the 
cause  of  the  contagion  is  by  no  means  certain.  Pathologically,  the 
tumours  consist  of  numerous  wedge-shaped  lobules  of  polygonal, 
nucleated,  epithelial  cells,  supported  by  a  fibrous  stroma.  The  cells 
towards  the  centre  undergo  a  waxy  or  hyaline  degeneration,  and  in 
them  are  seen  numerous  rounded  bodies,  which  have  been  supposed 
to  resemble  psorosperms.  Treatment  consists  in  cutting  or  pulling 
them  away,  or  in  cutting  them  across,  and  squeezing  the  contents  out 
from  the  well-defined  capsule. 

Rodent  Ulcer  is  a  special  variety  of  glandular  cancer,  commencing 


SURGICAL  DISEASES  OF  THE  SKIN 


409 


either  in  the  sebaceous  glands  or  in  the  basal  layer  of  the  rete 
Malpighii.  It  is  usually  met  with  in  elderly  patients,  though 
occasionally  observed  in  those  under  forty,  and  is  seen  with  special 
frequency  on  the  upper  two-thirds  of  the  face,  the  skin  below  the 
inner  and  outer  canthi  being  the  chief  seats  of  election.  It  commences 
as  a  papule  or  flat-topped  nodule  in  the  skin,  surrounded,  perhaps,  by 
an  area  of  hypersemia.  The  infiltration  extends  gradually  in  all 
directions,  but  the  ulceration  usually  keeps  pace  with  the  new 
growth.  The  ulcer  has  a  smooth  but  somewhat  depressed  surface,  is 
perhaps  covered  with  granulations,  and  bounded  by  a  slightly  raised, 
indurated,  rolled-over  edge  (Fig.  136).     In  most  cases  one  can  detect 


Fig.  137. — Rodent  Ulcer.     (Photomicrograph,  X30.) 


evidences  of  the  new  formation  beneath  the  skin  beyond  the  edge. 
If  kept  aseptic,  there  is  but  little  discharge,  and  imperfect  attempts 
at  cicatrization  are  often  observed,  the  scar,  however,  readily  breaking 
down  ;  but  when  septic,  the  surface  is  covered  with  sloughs,  and  an 
abundant  offensive  discharge  escapes.  The  condition  is  painless  ; 
neighbouring  lymphatics  aire  not  enlarged,  and  the  general  health 
does  not  suffer,  except  in  the  later  stages.  The  progress  of  the  case 
is  slow,  but  continuous,  and  although  it  spreads  for  a  time  superficially 
rather  than  deeply,  sooner  or  later  underlying  structures  become 
involved,  and  then  nothing  hinders  the  destructive  process,  even  the 
bones  of  the  skull  being  eroded,  and  the  dura  mater  exposed. 

Microscopically,  the  growth  consists  of  interlacing  columns  of 
epithelial  cells,  interspersed  Avith  fibro-cellular  tissue  (Fig.  137.).  The 
constituent  cells  are  small,  globular,  and  closely  packed,  never  of  the 
'  prickle-cell '  type,  and  rarely  show  signs  of  keratinization ;  hence, 
'  cell-nests '  are  uncommon,  although  they  are  sometimes  observed. 


4IO  A  MANUAL  OF  SURGERY 

The  cells  of  the  peripheral  layer,  however,  are  often  elongated,  and 
arranged  side  by  side  like  a  palisade.  The  deep  processes  spread 
laterally  rather  than  deeply  beneath  the  unaffected  skin,  the  papillae 
of  which  are  atrophied  ;  their  outline  is  clearly  defined,  and  frequently 
angular  on  section.  There  is  but  little  infiltration  of  round  calls 
around  the  epithelial  columns. 

The  Treatment  of  rodent  ulcer  has  been  considerably  modified  of 
late.  Formerly  the  method  of  choice  consisted  in  free  excision 
when  practicable,  a  margin  of  at  least  half  an  inch  being  allowed  all 
round,  and  the  defect  made  good  by  skin-grafting  or  by  some 
plastic  operation.  Where  such  could  not  be  undertaken,  the  ulcer 
was  thoroughly  scraped,  and  the  surface  treated  with  nitric  acid, 
chloride  of  zinc  paste,  or  some  other  caustic,  the  wound  being  allowed 
to  heal  by  granulation. 

The  discovery  of  the  therapeutic  value  of  the  X  rays  has  con- 
siderably diminished  the  number  of  cases  operated  on  for  this 
disease.  The  sore  or  nodule  is  exposed  to  the  influence  of  the  rays 
for  about  ten  minutes  daily,  and  a  reaction  of  variable  intensity 
follows,  which  results  in  many  cases  in  the  surface  of  the  sore 
cleaning  up  and  healing.  Recurrence  is  occasionally  observed,  but 
the  recurrent  nodules  cau  be  treated  in  the  same  way.  Of  course, 
surrounding  parts  have  to  be  carefully  protected. 

Radium  bromide  has  also  proved  serviceable  in  some  cases.  It 
is  best  applied  in  a  lead  capsule  with  a  mica  window,  and  5  or  10 
milligrammes  is  the  usual  quantity  employed.  This  capsule  is 
enclosed  in  a  piece  of  sterilized  gutta-percha  tissue  and  fixed  over 
the  diseased  area  with  strapping.  It  may  be  applied  for  a  short 
time  (five  or  ten  minutes)  daily,  but  acts  equally  well  if  applied  for 
half  an'  hour  once  a  week.  The  reaction  varies  considerably  with 
the  quality  of  the  radium,  but  sometimes  an  inflammatory  reaction  of 
some  intensity  follows.  Treatment  by  zinc  ions  (p.  47)  has  also  been 
found  useful,  especially  in  patients  who  can  only  come  for  treatment 
occasionally.  The  process  is  painful,  and  it  is  well  to  introduce 
cocaine  as  a  preliminary  by  moistening  the  positive  pad  with  a  solu- 
tion of  the  hydrochlorate.  The  rodent  ulcer  is  then  covered  with 
several  layers  of  lint  wet  with  a  2  per  cent,  solution  of  sulphate  or 
chloride  of  zinc,  and  the  positive  electrode  is  applied  over  this. 

Our  present  experience  seems  to  indicate  that  superficial  growths 
are  best  treated  by  X  rays,  whilst  the  deeper  ones  are  more  amenable 
to  the  action  of  radium  or  zinc  ions.  The  scar  left  after  treatment 
by  any  of  these  agents  is  of  a  most  satisfactory  type,  being  soft, 
supple,  and  often  not  at  all  obvious,  and  hence  this  treatment  is 
particularly  indicated  when  the  disease  affects  the  eyelids  or  front  of 
the  face.  In  other  places  it  m.ay  be  possible  to  remove  the  greater 
part  of  the  disease  with  the  knife,  and  the  rays  may  then  be  used  with 
advantage  to  the  raw  surface  before  grafting  is  undertaken.  When 
bone  or  cartilage  is  affected,  operation  is  the  only  hope,  as,  although 
improvement  follows  the  use  of  the  rays,  recurrence  is  almost 
invariably  the  rule. 


CHAPTER  XVII. 
AFFECTIONS   OF   MUSCLES,  TENDONS,  AND  BUKS^. 

Injuries  of  Muscles  and  Tendons. 

Contusion. — Muscles  are  bruised  as  a  result  of  blows  or  falls,  leading 
to  more  or  less  extravasation,  with  possibly  some  rupture  of  the 
fibres.  The  part  becomes  tender  and  swollen,  and  any  active  con- 
traction gives  rise  to  pain  ;  passive  movement,  however,  is  tolerated, 
if  the  injured  fibres  are  not  thereby  put  on  the  stretch.  Fomenta- 
tions and  rest  may  be  needed  for  a  few  days ;  but  regular  massage, 
and  perhaps  elastic  support,  are  subsequently  necessary. 

Sprains  and  Strains,  due  to  violent  efforts  or  falls,  result  in  the 
tearing  or  stretching  of  some  of  the  fibres.  Considerable  stiffness 
follows,  especially  in  rheumatic  and  gouty  patients.  Rest  and  either 
hot  or  cold  applications  may  be  used  at  first ;  but  elastic  pressure 
■  and  regular  massage  will  be  needed  later.  In  individuals  predisposed 
to  the  development  of  tuberculous  disease,  special  precautions  must 
be  taken  to  ensure  complete  recovery. 

Rupture  of  the  Sheath  of  a  muscle  is  an  accident  occasionally  met 
with,  especially  in  the  biceps  cubiti  or  rectus  femoris.  The  belly  of 
the  muscle,  when  contracted,  protrudes  through  the  opening  as  a 
hernia,  constituting  a  soft  semi-fluctuating  swelling.  In  treating 
this  condition  the  limb  must  be  kept  at  rest  in  such  a  position  as  to 
relax  the  muscular  fibres  and  allow  the  rent  in  the  fascial  sheath  to 
heal.  In  old-standing  cases  it  is  justifiable  to  cut  down  upon  and 
expose  the  opening  in  the  muscular  sheath,  the  edges  of  which  are 
sutured  together,  or  if  this  cannot  be  effected  a  sterilized  sheet  of  silver 
foil  may  be  stitched  over  the  defect. 

Displacement  of  Tendons  rarely  occurs,  except  in  parts  where 
these  structures  pass  through  osseo-fibrous  canals,  and  particularly 
in  those  where  the  line  of  action  is  thereby  changed.  During  some 
violent  effort  the  patient  feels  a  sudden  localized  pain,  followed  by  a 
certain  amount  of  limitation  of  mobility.  This  accident  is  popularly 
known  as  a  '  rick.'  In  superficial  parts  the  displaced  tendon  can 
sometimes  be  distinctly  felt  in  an  abnormal  position,  and  this  becomes 
more  evident  on  attempting  to  move  it.  Thus  the  long  tendon  of 
the  biceps  may  be  dislocated  from  the  bicipital  groove ;  and  various 

411 


412  A  MANUAL  OF  SURGERY 

tendons  about  the  wrist  or  ankle,  especially  that  of  the  peroneus 
longus,  may  similarly  suffer.  If  left  alone,  the  parts  settle  down 
more  or  less  comfortably,  but  some  permanent  weakness  may  persist ; 
recurrence  is  very  likely  to  ensue  if  movement  is  permitted  before 
the  newly-formed  connections  have  had  time  to  consolidate. 

Treatment  consists  in  fully  relaxing  the  muscles  and  replacing 
the  tendon,  if  possible,  by  manipulation.  The  parts  are  then  im- 
mobilized for  six  or  eight  weeks  by  a  plaster  of  Paris  splint  or 
strapping.  If  the  displacement  recurs,  it  is  sometimes  advisable  to 
expose  the  tendon,  and  stitch  it  back  into  position,  using  early 
passive  movement  to  prevent  the  formation  of  troublesome  adhesions. 
This  is  required  most  frequently  in  the  case  of  the  peroneus  longus 
tendon,  which  slips  forwards  from  its  groove  behind  the  external 
malleolus.  The  external  annular  ligament  is  thereby  ruptured,  and 
the  operation  consists  either  in  suturing  the  divided  segments,  or  in 
more  aggravated  cases  it  may  be  necessary  to  turn  down  a  flap  of 
periosteum  from  the  malleolus,  and  by  stitching  its  apex  to  the  outer 
side  of  the  os  calcis  secure  the  tendon  in  place. 

Rupture  of  Muscles  and  Tendons  is  by  no  means  uncommon,  resulting 
from  excessive  violence  of  a  sudden  and  unexpected  nature.  Most 
frequently  the  tendon  gives  way  at  its  union  with  the  muscular  belly ; 
less  often  the  belly  itself  yields,  whilst  occasionally  the  tendon  may 
snap,  or  the  point  of  bone  to  which  it  is  attached  may  be  torn  off. 

Signs. — The  patient  at  the  moment  of  the  accident  experiences  a 
sharp  and  severe  pain,  as  if  he  had  been  struck  with  a  whip ;  he  may 
also  feel  or  hear  a  snap.  Loss  of  function  follows,  together  with  a 
certain  amount  of  swelling  and  bruising,  which  is  more  evident  if  the 
muscular  fibres  have  been  torn  across  than  if  the  tendon  alone  has 
been  lacerated.  On  attempting  to  contract  the  affected  muscle,  the 
belly  rises  up  as  a  soft,  rounded,  semi -fluctuating  tumour,  drawn 
towards  the  uninjured  attachment,  if  the  union  between  the  tendon 
and  belly  has  given  way  ;  whilst  if  the  lesion  has  been  through  the 
muscular  substance,  the  divided  halves  of  the  belly  become  similarly 
prominent,  and  a  distinct  gap  or  sulcus  can  be  felt  between  them. 

Repair  is  established  in  the  usual  way  already  described  (p.  249) — 
viz.,  a  cellulo-plastic  effusion  is  first  poured  out,  taking  the  place  of 
the  blood-clot,  which  is  absorbed  ;  this  becomes  vascularized  into 
granulation  tissue,  and  finally  cicatricial  tissue  is  developed.  Where 
a  muscular  belly  is  involved  and  the  ends  are  much  separated,  a  long 
and  weak  bond  of  union  is  likely  to  form  ;  but  when  they  are  closely 
apposed,  the  cicatrix  is  short,  and  may  be  replaced  subsequently  by 
true  muscular  tissue.  When  a  tendon  has  been  divided  or  torn,  the 
connecting  medium  is  at  first  attached  to  the  sheath,  and  if  this 
adhesion  persists,  it  may  lead  to  pain  and  weakness.  It  is  an 
interesting  fact  to  note  how  rapidly  this  tissue  becomes  strong ;  a 
rabbit's  tendon  ten  days  after  division  requires  a  weight  of  56  lbs.  to 
break  it  (Paget). 

Treatment. — It  is  essential  to  relax  the  parts  fully  so  as  to  limit 
the  separation  of  the  divided  ends,  and  to  maintain  them  in  this 


AFPECTIONS  OP  MVSCLPS,  TENDOMS.  AND  BURSM 


413 


position  for  two  or  three  weeks.  Any  resulting  stiffness  is  combated 
by  passive  movements  and  massage,  whilst,  if  need  be,  adhesions  are 
broken  down  under  an  anaesthetic.  Tendons  accidentally  divided  in 
open  wounds  should  be  sutured  together  by  silk  or  catgut,  special 
antiseptic  precautions  being  adopted  to  prevent  suppuration  along 
the  tendon  sheaths.  Where  there  has  been  actual  loss  of  substance 
in  a  tendon,  one  may  be  split  longitudinally  in  such  a  way  as  to  leave 
a  thin  flap  attached  peripherally,  so  that  the  free  end  can  be 
turned  down  and  united  to  the  other  segment  (Fig.  138)  ;  or  similar 
flaps  may  be  provided  from  each  end  (Fig.  139) ;  or  it  is  possible  to 
remedy  the  defect  by  grafting  a  portion  of  tendon  from  another  region 
or  person,  or  from  an  animal,  between  the  two  ends.  Care  must  be 
exercised  to  prevent  opposing 
muscles  from  dragging  on  and 
stretching  the  new  bond  of 
union,  as  thereby  considerable 
functional  disability  may  result. 
Thus  a  young  man  had  his 
anterior  tibial  muscles  divided 
by  a  stab  with  a  knife ;  they 
were  carefully  sutured  together, 
but  during  convalescence  the 
foot  was  allowed  to  drop,  the 
result  being  that  the  muscles  and ' 
tendons  were  stretched,  and 
hence  the  most  vigorous  con- 
tractions had  no  effect  in  rais- 
ing the  toes,  which  dragged 
along  the  ground.  A  second 
operation  to  shorten  all  these 
structures  was  required. 

When  muscular  bellies  have 
been  divided,  it  is  not  difficult 
to  secure  them,  if  the  fibres 
have  been  severed  longitudinally  or  obliquely ;  but  when  the  section 
is  transverse,  there  is  a  great  tendency  for  the  stitches  to  cut  out. 
In  such  a  case  it  is  advisable  to  encircle  with  a  ligature  a  bundle  of 
muscular  fibres  on  either  side  of  the  incision,  and  then  tie  the  two 
threads  together.  This  must  be  done  at  several  spots  in  the  cross- 
section. 

The  long  tendon  of  the  biceps  is  not  unfrequently  torn  from  the 
muscular  belly,  which,  on  attempting  to  bend  the  arm,  is  drawn 
down  towards  the  elbow,  constituting  a  soft  tumour,  somewhat 
resembling  a  lipoma.  No  special  treatment  is  needed  beyond  keep- 
ing the  fore-arm  flexed  for  a  time.  If  the  tendo  Achillis  is  ruptured, 
union  may  be  attained  by  keeping  the  knee  bent  and  the  heel  raised, 
as  by  securing  a  strap  to  the  back  of  a  slipper  below,  and  to  a  dog- 
collar  or  suitable  strap  passed  round  the  knee  above.  A  better  result, 
however,  would  follow  an  aseptic  incision  and  suture.     Similarly,  if 


Fig.  139. 

OF   Union    of    Tendon    after 
Loss  OF  Tissue. 

In  Fig.  138  the  flap  is  taken  from  one  end 
only  ;  in  Fig.  139  from  both  ends. 


414  A  MANUAL  OF  SURGERY 

the  ligamentiim  patellm  is  torn  across,  suture  through  an  open  wound 
gives  the  best  result.  The  inner  head  of  the  gastrocnemius  is  sometimes 
torn  in  wrenches  or  shps,  as  at  lawn  tennis,  and  theplantaris  is  similarly 
affected.  Cooling  lotions  are  applied  for  a  few  days,  and  the  parts - 
are  kept  at  rest  until  the  tenderness  and  swelling  have  in  a  measure 
subsided,  and  then  regular  massage  is  undertaken.  The  adductor 
longus  may  be  lacerated  in  violent  attempts  to  maintain  a  seat  on 
horseback,  and  constitutes  one  form  of  rider's  sprain  ;  it  is  treated 
by  rest  and  the  application  of  a  firm  spica  bandage,  but  in  bad  cases 
operation  may  be  required. 

The  long  tendons  of  the  fingers  are  not  unfrequently  divided  acci- 
dentally, and  unless  they  are  effectively  sutured  considerable 
impairment  of  function  will  result,  the  finger  remaining  in  a  position 
of  flexion  or  hyper-extension,  according  to  whether  the  extensors  or 
flexors  are  involved.  Operation  to  secure  the  divided  ends  should 
be  undertaken  at  the  earliest  possible  moment,  but  not  until  suitable 
aseptic  conditions  are  present.  Owing  to  the  existence  of  a  sheath 
the  flexor  tendons  retract  considerably,  and  a  longitudinal,  incision  in 
the  middle  line  of  the  finger  may  be  required  to  expose  the  proximal 
end;  the  extensor  tendon  has  no  sheath  (in  the  finger),  and  hence 
retraction  is  less  marked.  Attempts  must  be  made  to  close  the  flexor 
sheath  by  suture,  so  as  to  limit  the  chances  of  the  formation  of 
adhesions.  The  finger  must  subsequently  be  kept  on  a  splint,  and 
active  movements  are  not  permitted  for  a  fortnight. 

It  is  sometimes  important  to  differentiate  between  a  divided  tendon  with 
retraction  -of  the  segments,  an  adherent  tendon,  and  one  which  has  been 
destroyed  by  sloughing.  Particularly  is  this  the  case  in  connection  with  the 
flexors  of  the  fingers.  Division  of  a  tendon  involves  loss  of  active  movement 
alone ;  the  finger  can  be  moved  passively,  but  immediately  springs  back  into  the 
old  position.  Adhesion  of  a  tendon  to  its  sheath  or  in  the  palm,  involves  more  or 
less  flexion  of  the  finger  and  stiffness  ;  attempts  to  straighten  it  are  painful,  and 
cause  the  tendons  above  the  wrist  to  be  dragged  on.  Sloughing  of  the 
flexor  tendon  results  in  flexion  from  contraction  of  scar-tissue,  together  with 
wasting  and  impairment  of  nutrition  of  the  finger.  Attempts  at  extension  produce 
no  result  either  on  the  finger  or  on  the  tendons  above  the  wrist.  Sloughing  of 
the  extensor  tendon  also  results  in  the  finger  becoming  bent  from  unbalanced 
action  of  the  flexors. 

The  persistence  of  any  of  these  conditions  is  followed  by  changes  in  the  inter- 
phalangeal  joints  and  their  ligaments  which  may  invalidate  the  success  of  subse- 
quent operations.  Under  such  circumstances  it  may  be  necessary  to  include  a 
resection  of  the  joint  at  the  same  time  as  the  tendons  are  reunited.  Where  there 
is  much  loss  of  substance,  tendon-grafting  may  be  required,  or  the  finger  may  be 
shortened  by  suitable  excision  of  bone. 

Diseases  of  Muscles. 

Inflammation  of  Muscles  (Myositis)  may  arise  from  a  variety  of 
circumstances,  but  the  chief  results  are  alike,  whatever  the  cause, 
viz.,  a  more  or  less  painful  infiltration  of  the  muscle,  with  increased 
discomfort  on  attempting  movement.  The  part  feels  hard  and  rigid, 
and  may  be  tender  to  the  touch.     If  suppuration  ensues,  the  ordinary 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURS^  4I5 

signs  of  an  abscess  subsequently  make  themselves  evident.  A 
certain  amount  of  contractile  tissue  is  thereby  destroyed,  and  the 
cicatricial  changes  induced  will  possibly  lead  to  deformity. 

Varieties. — i.  Simple  Traumatic  Myositis  results  from  contusion  or 
laceration  of  the  fibres,  and  is  merely  a  plastic  inflammation,  with 
or  without  haemorrhage,  running  on  to  resolution,  with  perhaps  a 
little  fibroid  thickening  of  the  part.  It  is  liable  in  some  cases  to 
become  chronic,  the  muscle  substance  becoming  shortened  and  re- 
placed by  fibrous  tissue  (Af.  fibrosa),  and  this  fibrosis  may  extend 
beyond  the  limits  of  the  original  lesion.  The  induration  of  the 
sterno-mastoid  muscle  met  with  in  children  is  of  this  type,  and  may 
lead  to  torticollis. 

2.  Rheumatic  Myositis  usually  results  from  exposure  to  cold — e.g., 
wry-neck  from  sitting  in  a  draught.  It  is  treated  by  fomentations 
and  ordinary  saline  anti-rheumatic  remedies,  whilst  later  on  friction 
with  stimulating  embrocations  is  needed.  Radiant-heat  baths  and 
the  introduction  of  iodine  by  ionic  medication  (p.  47)  will  also  prove 
of  great  service. 

3.  Acute  Suppurative  Myositis  is  the  outcome  of  infection  with 
pyogenic  organisms,  either  from  without,  as  after  operation  wounds, 
penetrating  injuries,  gangrene,  etc.,  the  pus  in  such  cases  spreading 
widely  up  and  down  the  muscular  planes  ;  or  from  within  the  body, 
as  in  pysemia ;  or  by  extension  from  neighbouring  suppurative  foci, 
as  from  subperiosteal  abscesses  ;  it  may  also  arise  after  a  contusion 
or  sprain  by  auto-infection.  Great  cicatricial  deformity  is  likely  to 
follow. 

4.  Chronic  Tuberculous  Myositis,  with  the  formation  of  a  chronic 
abscess,  is  not  an  uncommon  secondary  consequence  of  a  similar 
affection  of  neighbouring  bones  or  joints — e.g.,  a  psoas  abscess. 

5.  Syphilitic  Disease  is  usually  met  with  in  the  tertiary  period,  and 
takes  the  form  either  of  a  diffuse  sclerosis  or  of  a  localized  gumma. 
Any  muscle  may  be  affected,  but  perhaps  the  tongue  and  sterno- 
mastoid  are  those  most  frequently  involved.  Care  is  needed  in 
making  a  diagnosis,  since  these  conditions  resemble  tumours  in  their 
method  of  onset ;  but  the  presence  of  a  syphilitic  history,  the  slow 
growth,  the  hardness,  with  subsequent  central  softening,  and  the, 
rapid  disappearance  after  the  administration  of  iodide  of  potassium, 
should  suffice  to  determine  their  nature. 

Occasionally  gummata  appear  in  muscles  in  the  shape  of  small 
hard  and  shotty  nodules,  usually  arranged  more  or  less  longitudi- 
nally, which  are  painless  and  apparently  attached  to  the  fascial  sheath. 
They  react  readily  to  iodide  of  potassium. 

6.  Parasitic  Myositis,  arising  from  the  presence  either  of  the  Trichina 
spiralis  or  of  hydatids,  need  not  be  described  here. 

7.  Myositis  Ossificans  is  a  rare  disease,  in  which  various  muscles, 
especially  those  of  the  back,  are  transformed  into  bony  plates  or  rods, 
so  as  to  lead  to  extensive  ankylosis.  The  process  seems  to  be  one 
of  ossification  of  the  connective  tissue  associated  with  atrophy  of 
the  muscular  fibres,  and  is  sometimes  extremely  painful.     It  is  most 


4i6  •        A  MANUAL  OF  SURGERV 

commonly  seen  in  young  males,  and  is  possibly  rheumatic  in  origin. 
In  a  boy  under  observation  the  arms  were  immobilized  by'  ossifica- 
tion of  the  latissimus  dorsi  muscles  on  either  side,  whilst  the  pectoralis 
major  was  also  ossified  on  the  right  side.  The  erector  spinae  was- 
involved,  the  back  being  thus  rendered  rigid,  and  the  right  trapezius 
was  undergoing  the  same  change.  This  disease  is  not  unusually 
associated  with  a  congenital  deformity  of  the  great  toes  in  which  the 
proximal  phalanx  is  absent  or  stunted.  No  treatment  has  proved  of 
any  value. 

Quite  distinct  in  nature  is  the  Traumatic  M.  Ossificans,  to  which 
attention  has  been  drawn  of  recent  years,  owing  to  the  extensive 
use  of  X  rays  in  diagnosis.  Two  varieties  are  described  :  (i.)  The 
new  formation  results  from  persistent  and  repeated  irritation  of 
muscles  or  tendons,  and  usually  starts  from  the  periosteal  attach- 
ment. The  '  riders'  bone '  developed  in  the  tendon  of  the  adductor 
longus  is  of  this  description,  (ii.)  Less  commonly  the  affection 
follows  a  severe  injury  to  a  muscle  and  is  often  secondary  to  a 
fracture  or  dislocation.  Extensive  haemorrhage  follows,  leading  to 
the  formation  of  much  fibrous  tissue,  and  in  about  three  to  four 
weeks  the  presence  of  bone  can  be  recognised.  Some  painful 
limitation  of  movement  may  ensue,  but  if  possible  the  condition  is 
left  alone,  unless  the  disability  is  great,  and  then  removal  must  be 
undertaken.  The  muscles  in  which  this  type  of  inflammation  has 
been  most  commonly  observed  are  the  quadriceps  femoris  and  the 
brachialis  anticus. 

Tumours  of  Muscles  are  not  very  common.  Primary  growths 
consist  of  angioma,  lipoma,  fibroma,  chondroma,  myxoma,  or  sarcoma, 
and  of  these  the  majority  start  in  the  fibrous  sheaths  or  the  inter- 
fibrillar  connective  tissue.  Secondary  deposits  of  both  carcinoma 
and  sarcoma  occur,  but  there  is  nothing  special  to  be  noted  about 
them.  Treatment  must  be  determined  on  ordinary  surgical  principles. 
If  sarcomatous,  the  whole  thickness  of  the  muscle  should,  if  possible, 
be  excised  for  some  distance  from  the  growth,  since  the  lymphatics 
run  in  the  direction  of  the  fibres,  but  the  sheath  forms  a  limit  not 
early  overstepped.  Amputation  of  the  limb  may,  however,  be 
required. 

Diseases  of  Sheaths  of  Tendons. 

The  synovial  membranes  which  line  the  sheaths  of  tendons  may 
become  inflamed  as  a  result  of  injury  or  infection. 

I.  Acute  Simple  Teno- Synovitis  often  follows  sprains  and  strains, 
and  is  most  commonly  seen  in  connection  with  the  extensor  muscles 
of  the  thumb.  A  puffy  swelling  in  the  course  of  the  tendons  is 
produced,  painful  on  movement  and  perhaps  tender  to  the  touch, 
giving  a  characteristic  fine  crepitus  whenever  the  parts  are  moved. 
All  that  is  needed  for  its  Treatment  is  to  immobilize  the  limb 
for  a  few  days,  and  apply  fomentations.  As  soon  as  the  more 
acute  symptoms  have  disappeared,  massage  and  pressure  are  em- 
ployed  to   hasten  the   absorption   of   the  fluid ;    whilst  active  and 


AFFECTIONS  OF  MUSCLES,   TENDOXS,   AND  BURSAS  417 

passive   movements    are    undertaken    to    prevent    the    formation  of 
adhesions. 

2.  Acute  Suppurative  Teno-Synovitis  may  result  from  a  punctured 
wound  of  the  synovial  sheath,  or  the  inflammation  may  spread  to  it 
from  neighbouring  tissues.  The  thecal  variet}'  of  Vfhitlow  (p.  248) 
is  of  this  nature.  Suppuration  may  extend  both  up  and  dowm  the 
sheath,  and  unless  promptly  treated  by  incision,  the  tendon  will 
slough,  or  may  contract  extensive  adhesions  to  neighbouring  parts ; 
in  either  case  considerable  impairment  of  function  is  likely  to  follow. 
When  the  tendon  survives,  active  and  passive  movements  must  be 
started  very  early  if  the  formation  of  serious  adhesions  is  to  be 
prevented.  The  suppuration  may  affect  neighbouring  articulations, 
leading  to  their  disorganization,  especially  in  the  case  of  the  tendon 
sheaths  around  the  wrist-joint. 

3.  Chronic  Simple  Teno-Synovitis  is  a  common  affection,  charac- 
terized by  a  passive  effusion  into  the  tendon  sheath  of  glairy  s}'novia, 
somewhat  resembling  uncooked  white  of  egg.  It  may  be  limited  in 
extent,  constituting  one  of  the  varieties  of  ganglion,  or  diffuse.  An 
elastic  fluctuating  swelling  forms  in  the  course  of  a  tendon,  usually 
associated  with  creaking.  There  is  no  pain  or  tenderness,  but  the 
affected  part  feels  weak.  Treatment  consists  in  counter-irritation 
and  pressure,  as  by  Scott's  dressing ;  failing  this,  the  part  may  be 
freely  incised,  the  synovia  removed,  and,  if  need  be,  the  cavity 
washed  out.  In  the  more  localized  forms  it  may  suffice  to  puncture 
the  cyst-like  swelhng  and  squeeze  out  the  contents,  pressure  being 
subsequently  applied. 

4.  Chronic  Tuberculous  Teno-Synovitis  is  of  two  types.  In  one 
the  sheath  is  lined  by  cedematous  granulation  tissue  of  some  thick- 
ness, containing  tuberculous  foci,  giving  rise  to  a  soft  elastic  swelling 
along  the  course  of  a  tendon,  which  increases  slowly  in  size,  and  is 
but  slightly  painful  or  tender.  Suppuration  may  follow,  and  sub- 
jacent bones  or  joints  be  involved.  Treatment  consists  in  immobiliz- 
ing the  part,  pressure,  passive  hyperaemia,  and  improvement  of  the 
general  health.  If  a  cure  is  not  quickly  established,  a  free  incision 
should  be  made  and  the  diseased  tissue  removed. 

The  other  form  of  tuberculous  disease  consists  in  a  passive  effusion 
into  the  synovial  space,  the  lining  membrane  of  which  becomes 
thickened  by  the  deposit  thereon  of  fibrinous  material.  This  is  often 
detached,  and  by  the  movements  of  the  part  the  loose  fragments  of 
fibrin  are  moulded  into  various  shapes.  In  tendon  sheaths  they  are 
often  elongated,  and  constitute  the  so-called  melon-seed  bodies;  but 
when  they  occur  in  joints,  they  remain  somewhat  flattened,  and  in 
bursae  approximate  more  to  the  spherical.  On  examination,  they 
are  found  to  be  structureless,  though  sometimes  laminated.  When 
numerous  they  give  rise  to  a  curious  and  characteristic  form  of 
crepitus.  That  they  are  of  a  tuberculous  nature  can  be  demonstrated 
by  inoculation  experiments ;  the  bacilli  contained  therein  are  not, 
however,  in  a  very  active  state,  and  the  prognosis  of  this  type  is 
more  favourable  than  of  the  former.  ^ 


4i8  A  MANUAL  OF  SURGERY 

If  Treatment  by  immobilization  and  pressure  (as  by  the  application 
of  Scott's  dressing)  fails,  the  part  should  be  opened,  the  effusion 
iremoved,  including  fibrin  and  melon-seed  bodies,  iodoform  gently 
rubbed  in,  and  the  cavity  closed,  after  filling  it  with  glycerine  and' 
iodoform  emulsion.  Should  the  trouble  recur,  a  free  incision  and 
removal  of  the  diseased  membrane  may  be  required. 

A  Ganglion  is  the  term  given  to  a  localized  cyst-like  swelling  forming 
in  connection  with  a  tendon  sheath  or  joint.  It  is  most  commonly 
met  with  at  the  back  of  the  wrist,  arising  from  the  tendons  of  the 
radial  extensors  of  the  carpus,  and  those  of  the  thumb  or  index-finger, 
but  it  sometimes  occurs  on  the  front  of  the  wrist  or  in  the  foot.  It 
varies  in  size  considerably,  and  contains  a  clear,  transparent  gelatinous 
or  colloid  substance.  A  rounded  firm  elastic  swelling  is  produced, 
usually  somewhat  moveable,  and  neither  painful  nor  tender  at  first, 
although  some  painful  weakness  of  the  part  may  be  experienced  as 
it  increases  in  size.  It  is  due  to  one  of  several  causes  :  thus,  it  may 
result  from  a  chronic  localized  teno-synovitis,  or  from  a  hernial 
protrusion  of  the  synovial  membrane  through  an  opening  in  the 
tendon  sheath.  Others  seem  to  originate  in  a  colloid  degeneration 
of  the  cells  lining  the  synovial  space  ;  whilst  certainly  some  few  arise 
in  connection  with  subjacent  articulations,  in  the  same  way  as  a 
Baker's  cyst.  Little  difficulty  arises  in  the  diagnosis,  although,  when 
situated  deeply  and  closely  attached  to  a  bone,  they  have  been 
mistaken  for  exostoses.  Treatment. — A  ganglion  may  often  be  ruptured 
by  manipulation  and  pressure  with  the  thumbs,  or  by  a  forcible  blow 
with  a  book,  but  it  is  apt  to  fill  again.  Failing  this,  a  rapid  cure  is 
usually  obtained  by  an  aseptic  puncture  of  the  cavity,  and  the  subse- 
quent application  of  firm  pressure.  In  some  cases  it  may  be  advisable 
to  lay  the  part  open  and  remove  the  cyst  wall  as  completely  as 
possible ;  such  treatment  requires  absolute  asepsis,  since,  if  infection 
occurs,  most  serious  consequences  may  ensue. 

A  Compound  Palmar  Ganglion  consists  in  a  tuberculous  affection  of 
the  common  synovial  membrane  surrounding  the  flexor  tendons  of 
the  wrist,  the  cavity  being  distended  in  the  early  stage  with  a  glairy 
fluid,  usually  containing  many  melon-seed  bodies,  and  perhaps  later 
on  with  pus.  In  the  early  stages  all  that  is  noted  is  a  fulness  about 
the  front  of  the  wrist  and  palm,  the  normal  hollow  being  obliterated. 
Later  on  a  more  definite  swelling  is  observed,  and  this  is  found  to 
extend  into  the  thenar  eminence,  due  to  the  involvement  of  the 
tendon  sheath  of  the  flexor  longus  pollicis.  The  condition  is  painless 
at  first,  and  there  is  but  little  interference  with  the  mobility  of  the 
tendons ;  but  in  the  later  stages  of  repair  the  tendons  may  become 
matted  together,  and  the  movements  of  the  fingers  hampered;  or 
if  the  disease  ends  in  suppuration,  the  pain  and  disability  become 
more  marked.  In  all  stages  fluctuation  can  usually  be  detected  above 
and  below  the  annular  ligament,  being  transmitted  beneath  it.  In 
the  Treatment,  rest  and  pressure,  as  by  Scott's  dressing,  together 
with  suitable  constitutional  remedies,  may  first  be  tried ;  and  failing 
this,  an  incision  is  made  both  above  and  below  the  annular  ligament, 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSjE  419 

the  cavity  being  well  washed  out,  and  all  melon-seed  bodies  and 
fibrinous  debris  removed.  The  cavity  is  then  filled  with  the  glycerine 
and  iodoform  emulsion,  some  of  which  may  be  gently  rubbed  into 
the  pockets  of  the  wound ;  both  incisions  are  firmly  sutured,  and  a 
further  period  of  rest  maintained.  Should  the  skin  become  thin 
and  undermined,  drainage  may  be  required,  and  even  in  a  few  cases 
division  of  the  annular  ligament,  in  order  to  deal  effectively  with 
the  trouble  by  the  sharp  spoon.  The  results  in  such  cases  are  not 
very  good,  as  the  tendons  get  matted  together  and  adherent  to  the 
skin,  and  the  movement  of  the  fingers  is  thereby  hampered. 

Operations  on  Tendons, 

I.  By  Tenotomy  is  meant  the  division  of  a  tendon  through  an  open 
or  subcutaneous  wound  with  the  object  either  of  remedying  some 
deformity,  such  as  talipes  or  torticollis,  or  of  assisting  in  the  reduc- 
tion of  some  displacement,  as  in  setting  a  fracture.  It  is  accomplished 
in  two  ways,  viz.,  by  subcutaneous  or  open  incision.  The  subcutaneous 
method  is  made  use  of  where  there  is  little  likelihood  of  injuring 
important  structures.  The  strictest  attention  to  asepsis  is  desirable, 
since  the  character  of  the  wound,  viz.,  a  puncture,  and  the  entire  absence 
of  drainage  are  most  favourable  to  the  development  of  organisms,  if 
entrance  is  once  given  to  them.  Moreover,  the  synovial  tendon  sheath 
is  often,  though  undesignedly,  wounded,  and  septic  inflammation  would 
spread  rapidly  along  this  structure,  and  give  rise  to  serious  consequences. 
The  operation  consists  in  inserting  a  sharp-pointed  tenotome  through 
the  skin  down  to  the  tendon.  This  is  then  withdrawn,  and  a  blunt- 
pointed  knife  passed  along  the  track  thus  made,  either  superficial  to 
or  beneath  the  tendon.  The  cutting  edge  is  turned  towards  it,  and 
the  tendon  divided  by  a  sawing  or  rocking  movement,  whilst  the 
structure  is  put  on  the  stretch.  It  is  undesirable  to  operate  through 
the  synovial  sheath,  since  even  if  the  wound  remains  aseptic,  the  tendon 
often  retracts  more  than  is  desirable,  and  in  healing  gains  adhesions  to 
the  sheath  which  considerably  limit  the  subsequent  freedom  of  move- 
ment of  the  part.  Opinions  vary  as  to  whether  it  is  better  to  pass  the 
knife  above  or  below  the  tendon ;  in  the  former  method  there  is  no 
likelihood  of  making  an  unduly  large  wound  in  the  skin,  and  there  is 
less  risk  of  dividing  the  lax  subjacent  structures  if  the  knife  is  turned 
towards  them.  On  the  other  hand,  if  the  knife  is  at  once  passed 
beneath  the  tendon,  and  any  subjacent  structures  are  by  mistake 
included,  their  division  is  a  matter  of  certainty.  Where,  however, 
there  is  any  risk  of  dividing  important  structures,  such  as  the  external 
popliteal  nerve  in  tenotomy  of  the  biceps  cruris,  it  is  wiser  to  adopt 
the  open  metliod.  In  this  an  incision  about  i  inch  in  length  is  made 
over  the  tendon,  which  can  thereby  be  exposed,  lifted  on  an  aneurism 
needle,  and  severed  without  danger.  There  is  no  haemorrhage  worth 
mentioning,  and  the  wound  is  closed  by  suture,  dressed  antiseptically, 
and  firmly  bandaged  to  prevent  extravasation.  The  malposition  is 
at  once  corrected,  and  the  part  immobilized  at  the  time,  or  in  the 


,420  A  MANUAL  OF  SURGERY 

course  of  forty-eight  hours,  in  plaster  of  Paris.  Passive  movements 
may  usually  commence  at  the  end  of  twelve  to  fourteen  days,  and 
gradually  be  increased  in  vigour,  until  active  movements  are 
allowed. 

Tenotomy  of  the  Tendo  A  chillis. — The  foot  is  placed  on  its  outer  cide, 
and  the  tendon  relaxed  by  pointing  the  toes  downwards.  The  teno- 
tome is  introduced  at  the  inner  margin  of  the  tendon,  about  i  inch 
above  its  insertion  (Fig.  109,  F),  either  superficial  to  or  beneath  it, 
and  it  is  readily  divided  when  the  foot  is  dorsiflexed.  If  the  surgeon 
cuts  towards  the  skin,  he  must  not  divide  the  last  few  fibres  too 
rapidly,  otherwise  a  considerable  external  wound  may  be  inflicted  by 
the  suddenly  liberated  knife. 

The  Tibialis  A  nticus  is  usually  divided  about  i  inch  above  its  inser- 
tion, as  it  crosses  the  scaphoid  (Fig.  1 1 1 ,  C).  There  is  here  no  synovial 
sheath,  and  the  arteria  dorsalis  pedis  is  separated  from  it  by  the 
tendon  of  the  extensor  proprius  hallucis.  It  is  first  relaxed  so  as 
to  allow  of  the  introduction  from  the  outer  side  of  the  sharp- 
pointed  tenotome  beneath  it ;  this  is  then  replaced  by  a  blunt-ended 
instrument,  and  the  section  is  readily  accomplished  when  the  foot  is 
abducted. 

The  Tibialis  Posticus  is  usually  divided  together  with  the  flexor 
longus  digitorum  just  above  the  base  of  the  inner  malleolus,  at  a  spot 
about  a  finger's  breadth  from  the  tip  of  that  process  in  an  infant,  and 
about  i|  inches  from  it  in  an  adult  (Fig.  log,  E).  A  small  tubercle 
can  usually  be  felt  at  this  spot,  and  the  section  must  be  made  just 
above.  The  knife  is  inserted  between  the  tibia  and  the  tendon,  and 
is  kept  as  near  the  bone  as  possible.  If  correctly  placed,  it  remains 
fixed  without  the  support  of  the  hand,  being  grasped  between  the 
tendon  and  the  bone.  The  blunt-ended  tenotome  is  then  introduced, 
and  the  edge  being  turned  towards  the  tendon,  the  latter  structure  is 
divided  when  the  foot  is  dorsiflexed.  The  posterior  tibial  vessels  may 
be  wounded  if  the  tendons  are  too  suddenly  severed,  but  even  should 
this  occur,  a  little  well-adjusted  pressure  will  suffice  to  prevent  any 
serious  consequences. 

The  Peronei  tendons  are  divided  just  above  the  base  of  the  outer 
malleolus,  at  a  spot  where  the  synovial  sheath  is  usually  absent 
(Fig.  no,  D).  The  tenotome  is  inserted  close  to  the  fibula,  between 
the  tendons  and  the  bone. 

The  Biceps  Cruris  tendon  is  best  divided  by  an  open  operation,  on 
account  of  the  close  propinquity  of  the  external  popliteal  nerve,  which 
has  often  been  wounded  in  the  subcutaneous  operation.  An  incision 
is  made  in  the  direction  of  the  tendon  just  above  its  insertion  into  the 
fibula.  It  is  then  lifted  upon  an  aneurism  needle  and  divided ; 
muscular  fibres  will  probably  be  found  quite  close  to  its  lower  end. 

The  Semi-membranosus  and  the  Semi-tendinosus  tendons  are  dealt  with 
just  above  the  knee-joint,  and  the  subcutaneous  operation  may  be 
conveniently  adopted  when  they  are  prominent  and  tense.  For 
division  of  the  Sterna -mastoid,  see  p.  428. 

2.  Lengthening  a  Tendon  is  sometimes  required,  in  order  to  over- 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSM 


421 


come  the  deformity  which  results  from  loss  of  substance  or  con- 
traction, where  simple  tenotomy  does  not  seem  desirable.  It  may 
be  possible  to  utilize  the  method  suggested  on  p.  413  for  the  union 
of  a  tendon  where  there  has  been  loss  of  substance,  viz.,  by  bridging 
the  interval  by  a  flap  turned  down  from  one  or  both  ends.  Perhaps 
a  more  efficient  method  is  the  so-called  Z-operation  (Fig.  140).  The 
tendon  is  split  longitudinally  (&c)  into  two  halves,  which  are  separated 
one  from  the  other  by  cross  cuts  made  on  opposite  sides,  one  at  each 
end  {ah  and  cd).  The  two  flaps  are  then  drawn  apart  for  a  distance 
corresponding  to  the  increase  in  length  required,  and  sutured  together; 
the  resulting  bond  of  union  will  be  as 
represented  in  Fig.  141. 

3.  Shortening  a  Tendon  is  under- 
taken in  some  forms  of  paralytic 
talipes.  The  Z -method  may  also, 
be  employed  here,  the  two  halves, 
after  they  have  been  separated,  being 
shortened  to  the  required  amount, 
and  then  stitched  together  (Fig.  142). 
This  operation  will  probably  give  a 
more  solid  bond  of  union  than  where 
a  transverse  or  an  oblique  section  is 
removed ;  in  such  the  sutures  are 
much  more  likely  to  cut  out. 

4.  Tenoplasty,  or  the  incorporation 
of  a  strong  tendon  into  a  weaker  one 
in  order  to  strengthen  it,  is  rarely 
undertaken  except  in  paralytic  de- 
formities, such  as  talipes.  It  is 
necessary  to  study  the  particular 
case  carefully,  especially  as  to  the 
electrical  reaction  of  the  muscles, 
and  it  is  desirable  that  the  rein- 
forcing tendon  should  be  derived 
from  a  synergic  and  not  from  an 
opposing    group.      In    order   to   act 

effectively,  the  divided  healthy  tendon  must  be  united  securely  to  the 
weak  and  atrophic  one,  and  this  may  perhaps  be  effected  best  by 
threading  the  one  through  the  other  and  suturing.  In  other  cases  a 
strip  from  the  strong  tendon  may  be  joined  to  the  weak  one,  and 
thereby  the  action  of  the  reinforcing  muscle  is  not  lost.  But  in  many 
instances  it  is  wisest  to  divide  the  reinforcing  muscle,  or  detach  it 
from  its  insertion,  and  secure  its  end  directly  to  the  periosteum  in 
some  situation  where  it  can  act  effectively.  Thus  in  paralytic  talipes 
varus  it  may  be  advisable  to  detach  the  tibialis  anticus  completely 
and  re-attach  it  to  the  periosteum  over  the  base  of  the  fifth  metatarsal 
bone.  The  results  of  some  of  these  proceedings  are  said  to  be 
satisfactory. 


i!iili 


Fig. 


Fig. 


140.      l^iG.   141.      riG.   142. 

Z-Operation   for   Lengthening 
OR  Shortening  of  Tendons. 

In  Fig.  140  the  method  of  dividing 
the  tendon  is  shown.  In  Fig.  141 
the  flaps  are  slipped  downwards, 
one  on  the  other,  so  as  to  lengthen 
the  tendon.  In  Fig.  142  equal 
portions  have  been  cut  away  from 
each  half,  and  the  remainders 
sutured,  so  as  to  shorten  it. 


422  A  MANUAL  OF  SURGERY 

Diseases  of  Bursse. 

Bursae  exist  as  normal  structures  in  many  parts  of  the  body  exposed 
to  pressure,  their  object  being  to  diminish  friction  and  permit  of  a 
gliding  movement.  Similar  cavities,  known  as  abnormal  or  Adven- 
titious Bursse,  are  developed  in  regions  where  exceptional  pressure 
is  brought  to  bear  on  some  prominent  structure  ;  they  consist  of  a 
fibrous  wall  lined  by  a  serous  membrane,  contain  a  small  quantity  of 
serum,  and  are  formed  either  by  dilatation  of  lymphatic  spaces,  or  as 
a  result  of  a  localized  effusion  into  the  tissues.  Examples  of  this  are 
met  with  in  men  following  special  occupations — e.g.,  over  the  vertebra 
prominens  of  Covent  Garden  porters,  and  then  known  as  a  '  hummy '; 
Billingsgate  fish-carriers  occasionally  have  bursae  under  the  centre  of 
the  scalp  ;  and  deal-runners  often  present  one  on  the  upper  part  of 
the  shoulder.  They  occur  over  bony  prominences  arising  from  mal- 
formation or  displacement — e.g.,  over  the  cuboid  in  talipes  equino- 
varus,  and  over  exostoses  ;  whilst  the  false  joint  or  pseudarthrosis 
which  occurs  in  unreduced  dislocations  or  ununited  fractures  is 
practically  of  this  nature. 

Wounds  of  bursae  may  be  caused  by  penetrating  injuries,  or  some- 
times by  the  skin  over  them  splitting,  as,  e.g.,  in  a  fall  on  the  point  of 
the  olecranon.  The  escape  of  bursal  fluid  which  results  often  pre- 
vents healing,  and  then  it  will  be  necessary  either  to  excise  the  bursa, 
or  to  open  it  freely,  so  that  it  can  be  stuffed  and  made  to  granulate 
from  the  bottom. 

The  following  are  the  morbid  conditions  which  arise  in  adven- 
titious as  well  as  normal  bursae  : 

1.  Acute  Simple  Bursitis  may  result  from  a  non-penetrating  injury, 
or  from  prolonged  irritation,  especially  in  gouty  or  rheumatic  indi- 
viduals. The  part  becomes  swollen,  painful,  and  tender,  and  if  super- 
ficial the  skin  over  it  may  be  hyperaemic.  Effusion  into  the  cavity 
quickly  occurs,  the  fluid  being  spontaneously  coagulable  in  the  early 
stages,  and,  if  resulting  from  traumatism,  mixed  with  blood.  Lymph 
is  deposited  on  the  serous  surface,  and  in  many  cases  results  in  the 
formation  of  adhesions,  and  possibly  obliteration  of  the  cavity.  Treat- 
ment consists  in  keeping  the  part  at  rest,  and  applying  fomentations, 
whilst  suitable  constitutional  remedies  are  administered.  If  the 
effusion  persists,  aspiration,  or  removal  with  trocar  and  cannula  under 
strict  asepsis,  may  be  employed,  or  even  the  whole  cavity  excised. 

2.  Acute  Suppurative  Bursitis  arises  from  infection  occurring  either 
from  without  or  within ;  it  not  uncommonly  follows  a  subcutaneous 
injury  of  a  chronically  inflamed  bursa,  leading  to  its  distension  with 
blood.  All  the  phenomena,  local  and  constitutional,  usually  associated 
with  the  formation  of  a  superficial  or  deep  abscess  are  present.  The 
pus,  formed  at  first  within  the  bursa,  may  travel  directly  to  the  surface, 
or,  bursting  through  the  capsule,  is  diffused  through  the  tissues. 
Where  this  occurs,  the  characteristic  features  suggesting  a  bursal 
origin  of  the  abscess  may  be  masked.  Thus,  in  suppuration  of  the 
bursa  patellae,  the  pus  often  finds  its  way  to  the  lateral  aspects  of  the 


AFFECTIONS  OF  MUSCLES,   TENDONS,  AND  BURSm  423 

limb,  allowing  the  patella  to  be  distinctly  felt  through  the  skin ;  the 
case  might  then  be  mistaken  for  suppuration  within  the  knee-joint, 
but  is  easily  distinguished  by  the  absence  of  the  more  acute  arthritic 
symptoms.  Implication  of  subjacent  bones  and  joints  sometimes 
occurs  ;  thus,  the  patella  or  olecranon  may  become  carious,  or  necrose. 
The  Treatment  of  suppurative  bursitis  resolves  itself  into  an  early 
free  incision,  and  drainage. 

3.  Chronic  Bursitis  with  Effusion  is,  perhaps,  the  most  common 
pathological  condition  met  with  in  connection  with  bursse.  The 
cavity  becomes  distended  with  a  serous  effusion  of  varying  amount, 
giving  rise  to  a  fluctuating  tumour.  The  walls  differ  in  thickness 
according  to  circumstances ;  if  the  condition  is  one  of  long  standing, 
with  frequent  recurrences,  the  bursal  wall  is  usually  reticulated  and 
dense,  and  adhesions,  papilliform  processes,  or  fibrous  cords  are  often 
produced.  Subacute  exacerbations  are  frequently  grafted  on  the 
more  chronic  variety.  Treatment  consists  in  rest  and  counter-irrita- 
tion, as  by  blistering  or  iodine  paint,  and  if  this  fails,  the  bursa  should 
be  dissected  out.  When  the  bursa  communicates  with  a  joint,  such  as 
that  under  the  semi-membranosus  tendon,  the  neck  must  be  isolated, 
and  its  communication  with  the  joint  shut  off  by  ligature. 

4.  Chronic  Fibroid  Bursitis. — In  this  variety  the  walls  of  the  bursa 
are  much  thickened,  as  a  result  of  prolonged  irritation,  constituting 
a  hard  fibroid  tumour,  in  the  centre  of  which  is  a  small  cavity. 
Possibly  a  syphilitic  element  is  present  in  this  condition.  The  only 
Treatment  is  complete  removal. 

5.  Chronic  Tuberculous  Bursitis  occurs  either  in  the  form  of  a 
fibrinous  deposit  on  the  inner  wall,  together  with  effusion  and  the 
presence  of  loose  fibrinous  bodies  ;  or  the  lining  membrane  under- 
goes a  change  analogous  to  that  described  as  pulpy  degeneration  of 
a  joint,  and  perhaps  leading  to  the  formation  of  a  chronic  abscess. 
Either  condition  may  be  secondary  to  a  tuberculous  arthritis,  or  may 
give  rise  to  it,  when  the  bursa  communicates  with  a  joint.  If  total 
removal  is  impracticable,  the  Treatment  consists  in  laying  the  part 
freely  open,  scraping  away  all  tuberculous  tissue,  and  packing  the 
cavity  with  gauze  impregnated  with  iodoform.  Sometimes  it  is 
possible  to  fill  the  cavity  with  sterilized  iodoform  emulsion  and  close 
it  entirely, 

6.  Syphilitic  Changes  may  also  occur  in  bursae,  in  the  shape  either 
of  a  symmetrical  bursitis  in  the  early  stages,  or  later  on  as  a  gum- 
matous peri-synovial  development. 

7.  Occasionally  G-outy  Deposits  are  observed  in  the  walls  of  bursae, 
constituting  tophi,  the  irritation  of  which  may  predispose  to  abscess 
formation,  pus  mixed  with  urate  of  soda  crystals  being  discharged. 
The  bursa  over  the  olecranon  is  said  to  be  most  frequently  affected  in 
this  way. 

Special  Bursse. 

The  bursa  patella  (Fig.  143),  which  lies  over  the  lower  half  of  the 
bone  and  not  over  its  centre,  is  very  liable,  from  its  exposed  situation. 


4^4 


A  MANUAL  OF  SURGERY 


to  injury  or  any  of  the  above-mentioned  varieties  of  bursitis.  In  its 
simplest  form  it  constitutes  the  condition  known  as  '  housemaid's 
knee,'  and  is  due  to  kneeling.  Caries  of  the  patella  may  follow  acute 
suppuration,  and  the  more  chronic  varieties  may  lead  to  osteoplastic 
periostitis.     The  knee-joint  itself  usually  escapes. 

The  bursa  beneath  the  ligamentiim  patellcB,  between  it  and  the  head  of 
the  tibia,  when  distended  with  fluid,  gives  rise  to  a  fluctuating 
swelling  felt  on  either  side  of  the  tendon,  more  especially  when  the 
limb  is  extended;  when  the  leg  is  flexed,  the  swelling  diminishes. 
Chronic  enlargement  of  this  bursa  may  push  the  ligamenta  alaria 
backward  into  the  joint,  so  that  they  are  nipped  between  the  bones 
whenever  the  patient  attempts  to  stand  with  the  leg  extended  ;  the 
pain  thereby  induced  is  somewhat  similar  to  that  caused  by  a  dis- 
placed semilunar  cartilage,  or  by  a  loose  foreign  body  in  the  joint. 


Fig.  143.— Enlarged  Bursa  Patella.     (From  a  Photograph.) 

The  presence  of  the  enlarged  bursa,  together  with  the  inability  to 
stand  with  a  straight  leg,  should  suffice  to  make  the  diagnosis  clear. 

The  bursts  in  the  popliteal  space  are  often  enlarged,  especially  that 
between  the  inner  head  of  the  gastrocnemius  and  the  semi-m.em- 
branosus,  leading  to  a  rounded  fluctuating  swelling,  sharply  limited 
on  its  outer  aspect,  and  more  fixed  and  less  defined  towards  the 
inner.  The  sensation  imparted  to  the  fingers  varies  according  to  the 
position  of  the  limb,  the  swelling  being  tense  in  extension  and  flaccid  in 
flexion,  as  occurs  in  most  of  these  peri-articular  bursae.  Owing  to  the 
proximity  of  the  popliteal  vessels,  pulsation  is  occasionally  detected, 
but  is  not  expansile  in  character.  Enlargement  of  this  bursa  is  often 
secondary  to  an  articular  lesion,  especially  tuberculous  disease  or 
osteo-arthritis,  and  before  undertaking  treatment  the  condition  of  the 
joint  should  be  ascertained.  If  the  joint  is  healthy,  the  bursa  may 
be  removed  by  dissection,  the  pedicle  being  closed  by  ligature  or  suture. 

The  bursa  beneath  the  insertion  of  the  semi-tendinosus  and  gracilis  is  some- 


AFFECTIONS  OF  MUSCLES,  TENDONS,  AND  BURSM  425 

times  inflamed,  and  is  very  liable  to  cause  osteoplastic  periostitis  ol 
the  subjacent  inner  surface  of  the  tibia. 

The  bursa  beneath  the  tendo  A  chillis,  if  enlarged,  presents  a  fluctu- 
ating swelling  on  either  side  of  that  structure,  somewhat  simulating 
disease  of  the  ankle-joint,  but  necessarily  limited  to  the  posterior 
aspect  of  the  joint.  Primary  tuberculous  disease  is  sometimes  present. 

Distension  of  the  bursa  beneath  the  psoas  tendon  gives  rise  to  a  fluid 
swelling  which  usually  projects  anteriorly,  presenting  either  on  the 
outer  or  inner  side  of  Scarpa's  triangle.  If  painful,  it  necessitates 
flexion  of  the  thigh,  and  thus  leads  to  symptoms  resembling  those  of 
hip-joint  disease  or  of  a  psoas  abscess.  It  must  not  be  forgotten  that 
this  bursa  often  communicates  with  the  joint. 

The  gluteal  bursa,  situated  between  the  insertion  of  the  gluteus 
maximus  and  the  great  trochanter,  is  not  uncommonly  the  seat  of 
tuberculous  disease.  It  presents  as  a  rounded  swelling,  obliterating 
the  hollow  behind  the  trochanter,  and  in  its  more  acute  manifestations 
may  be  accompanied  by  abduction  and  eversion  of  the  limb,  in  order 
to  relax  as  far  as  possible  the  gluteus.  It  may  thereby  somewhat 
resemble  the  earlier  stages  of  hip  disease,  but  is  known  from  it  by  the 
absence  of  flexion,  and  the  fact  that  passive  movements,  including 
even  the  so-called  test-movement  for  hip  disease,  can  be  undertaken 
with  but  little  or  no  pain.  Should  suppuration  occur,  the  pus  may 
burrow  widely  beneath  the  gluteus.  Treatment  consists  of  complete 
excision,  if  possible,  or  incision  with  scraping  and  disinfecting  the 
interior,  and  allowing  it  to  heal  from  the  bottom.  Necessarily  part 
of  the  insertion  of  the  gluteus  maximus  will  require  division,  and 
must  be  subsequently  sutured. 

The  bursa  over  the  tuber  ischii,  if  inflamed,  gives  rise  to  the  condition 
known  as  '  weavers'  bottom  ' ;  it  causes  great  discomfort  in  sitting, 
and  is  often  solid  and  symmetrical.  If  troublesome,  it  should  be 
removed. 

Enlargement  of  the  bursa  over  the  olecranon  constitutes  the  condition 
known  as  '  miners'  elbow ' ;  suppuration  within  it  is  not  uncommon, 
leading  to  necrosis  of  the  underlying  bone ;  the  elbow-joint  is  but 
rarely  affected. 

The  large  multilocular  subdeltoid  bursa  is  occasionally  enlarged ;  it 
leads  to  prominence  of  the  deltoid,  and  expansion  of  the  shoulder. 
(For  diagnosis  from  effusion  into  the  shoulder-joint,  see  Chapter  XXI.) 


CHAPTER  XVIII. 
DEFORMITIES. 

Torticollis. 

Torticollis,  or  wry-neck,  is  a  deformity  produced  by  a  contraction 
of  the  sterno-mastoid  muscle,  the  trapezius  and  deep  fascia  being  also 
frequently  affected,  and  occasionally  the  short  muscles  at  the  back  of 

the  neck.  It  is  characterized 
by  the  affected  side  of  the 
head  being  drawn  down  to- 
wards the  shoulder,  whilst 
the  face  is  turned  towards 
the  sound  side,  as  shown  in 
Fig.  144.  When  this  has 
lasted  for  some  time,  espe- 
cially in  congenital  cases  and 
those  commencing  in  child- 
hood, the  affected  side  of 
the  head  and  face  becomes 
atrophic.  The  measurement 
from  the  external  canthus  to 
the  angle  of  the  mouth  is 
smaller,  the  eyebrow  is  less 
arched,  the  nose  somewhat 
flattened,  and  the  cheek  less 
full  than  on  the  sound  side. 
These  phenomena  are  prob- 
ably due  to  imperfect  vas- 
cular supply,  resulting  from 
the  limited  mobility.  The 
cervical  spine  becomes  later- 
ally curved,  with  its  con- 
cavity to  the  affected  side, 
and  a  secondary  compensa- 
tory curve  is  also  present 
in  the  dorsal  region,  so  as  to  maintain  the  eyes  as  far  as  possible 
on  a  level. 

The  Causes  and  Varieties  of  torticollis  may  be  classified  as  follows : 
I.  Congenital  torticollis,  the  result  of  malformation  or  malposition 
in  utero,  or  of  some  intra-uterine  muscular  contraction. 

426 


Fig. 


144. — Torticollis. 
Photograph.) 


(From 


The  left  sterno-mastoid  is  contracted,  and  the 
corresponding  half  of  the  face  atrophic. 


DEFORMITIES  427 

2.  Muscular  torticollis,  due  to  intrinsic  contraction  of  the  sterno- 
mastoid,  apart  from  nervous  influences,  as  in  cicatricial  shortening 
after  intramuscular  abscess  or  gumma.  In  children  it  usually  follows 
the  congenital  induration  of  the  muscle,  due  to  laceration  during 
birth,  or  is  quite  possibly  caused  by  a  myositis  fibrosa,  akin  to 
Volkmann's  ischaemic  contracture  {q-v-)-  As  a  temporary  de- 
formity it  is  not  an  unusual  result  of  exposure  to  draught  or  cold 
(rheumatic  myositis,  or  stifF-neck). 

3.  Torticollis  arising  from  nervous  causes,  including  spasm  and 
paralysis.  Spasmodic  torticollis  (tonic  or  clonic)  may  result  [a)  from 
the  direct  irritation  of  the  spinal  accessory  or  its  roots,  as  by  inflamed 
cervical  glands  or  cervical  caries ;  ip)  possibly  from  reflex  irritation, 
as  by  carious  teeth,  or  otorrhoea ;  and  (c)  from  irritation  of  the  deep 
or  cortical  centres.  This  latter  variety  is  usually  of  the  clonic  type, 
and  often  affects  the  deep  cervical  muscles  as  well  as  the  sterno- 
mastoid.  The  character  of  the  movements  varies  with  the  actual 
muscles  involved.  It  occurs  most  frequently,  though  not  exclusively, 
in  women  of  about  thirty  years  of  age,  and  there  is  often  a  family 
history  of  nervous  diseases,  such  as  epilepsy,  etc.  The  prognosis  in 
these  cases  is  almost  always  unfavourable,  since,  even  if  the  localized 
spasm  is  cured  by  appropriate  operative  treatment,  other  parts  are 
likely  to  become  affected.  Paralytic  torticollis  arises  either  from 
infantile  paralysis  of  one  muscle,  leading  to  unbalanced  action  of 
that  on  the  other  side,  or  from  some  peripheral  nerve  lesion. 

4.  Hysteria  is  also  responsible  for  a  certain  number  of  cases. 
Most    commonly   the  sternal   portion   is    contracted,    whilst    the 

clavicular  half  may  be  quite  relaxed.  In  congenital  and  cicatricial 
cases  the  muscle  stands  out  as  a  hard  tense  band,  an  excess  of 
fibrous  tissue  being  present,  or  the  muscular  substance  almost  en- 
tirely absent ;  but  in  spasmodic  cases  the  muscle  may  be  well 
developed  and  not  specially  prominent.  The  deep  fascia  always 
becomes  secondarily  contracted  and  shortened,  and  if  the  deformity 
has  lasted  long  the  posterior  cervical  muscles  are  similarly  affected, 
whilst  changes  in  the  shape  of  the  vertebrae  may  also  be  induced, 
the  bodies  becoming  wedge-shaped  and  thickest  towards  the  convexity 
of  the  curve. 

The  Diagnosis  of  torticollis  is  readily  made.  It  must  not  be  con- 
founded with  cicatricial  contraction  of  the  skin  of  the  neck  following 
burns,  or  the  attitude  temporarily  assumed  by  a  patient  with  an  acute 
deep-seated  abscess  of  the  neck,  or  with  tuberculous  caries  of  the 
spine  associated  with  lateral  deviation.  The  rigidity  of  the  neck  in 
the  latter  case,  together  with  the  pain  caused  by  movement  of  or 
pressure  over  the  vertebrae,  should  suffice  to  make  the  diagnosis  clear. 
Rheumatic  inflammation  of  the  deeper  ligaments  and  muscles  of  the 
cervical  spine  (rheumatic  spondylitis)  may  also  be  mistaken  for 
torticollis,  but  it  comes  on  rapidly,  and  is  associated  with  tenderness 
on  deep  pressure.  The  fact  that  in  tonic  cases  the  muscle  is  evidently 
contracted,  and  stands  out  as  a  tense  band  in  the  neck,  is  sufficiently 
characteristic.    Spasmodic  torticollis,  again,  cannot  well  be  mistaken 


428  A  MANUAL  OF  SURGERY 

for  any  other  condition,  but  it  may  be  difficult  to  distinguish  its  cause 
or  to  localize  the  affected  muscles. 

The  Treatment  of  torticollis  necessarily  varies  with  the  cause,  and 
thus  either  antiphlogistic,  antineurotic,  antirheumatic,  or  antisyphilitic 
remedies  may  be  required.  When,  however,  it  is  due  to  congenital  or 
tonic  contraction  of  the  muscle  or  its  tendon,  massage  and  manipula- 
tion may  be  first  tried,  or  even  some  form  of  mechanical  apparatus ; 
but  in  the  majority  of  cases  tenotomy  or  myotomy  will  give  a  more 
satisfactory  result,  and  is  less  tedious  and  troublesome. 

Two  methods  of  dividing  the  sterno-mastoid  have  been  employed  : 
(i)  The  subcutaneous  operation  is  a  somewhat  undesirable  proceeding, 
on  account  of  the  important  structures  placed  immediately  beneath 
it.  There  is  but  little  danger  or  difficulty  in  dealing  with  the  sternal 
head,  a  tenotome  being  passed  down  to  it  beneath  the  skin,  and  the 
incision  made  from  before  backwards ;  the  tension  to  which  it  is 
exposed  suffices  to  draw  it  well  forwards  out  of  harm's  way.  The 
clavicular  portion,  on  the  other  hand,  should  always  be  divided 
through  an  open  incision.  (2)  The  open  method  is  far  preferable,  as 
thereby  all  danger  is  obviated.  The  skin,  about  |-  inch  above  the 
clavicle,  is  incised  across  the  muscle,  its  anterior  and  posterior  borders 
are  defined,  and  its  fibres  completely  divided.  Tense  portions  of  the 
deep  cervical  fascia  on  its  deep  aspect  may  also  be  carefully  cut 
across,  keeping  in  view  the  importance  of  the  underlying  structures. 
The  position  of  the  head  is  then  rectified,  and  fixed  by  plaster  of 
Paris  or  some  other  suitable  apparatus.  A  simple  and  satisfactory 
arrangement  consists  of  a  padded  leather  strap  passed  round  the 
forehead  and  occiput,  and  another  under  the  axillae.  A  chain  or 
elastic  band  is  secured  to  the  forehead  strap  above  the  mastoid 
process  of  the  side  which  is  not  affected,  and  traction  made  by  fixing; 
it  to  the  front  of  the  lower  belt  on  the  opposite  side  of  the  body.. 
Thus,  if  the  left  sterno-mastoid  is  contracted  and  has  been  divided^ 
the  chain  is  attached  above  over  the  right  mastoid  process  and  below 
over  the  front  of  the  left  axilla,  traction  being  thus  made  in  the 
direction  of  the  weakened  right  sterno-mastoid  muscle.  In  some 
cases  more  efficient  support  is  necessary,  and  may  be  obtained  by  the 
use  of  Chance's  back  splint  (p.  435),  to  the  upper  end  of  which  arms 
are  attached,  bringing  pressure  to  bear  upon  each  side  of  the  head 
in  suitable  directions.  Where,  however,  osseous  changes  are  present, 
the  deformity  may  persist  to  a  great  extent,  in  spite  of  combined 
operative  and  mechanical  treatment. 

In  cases  of  clonic  torticollis  it  may  be  necessary  to  cut  down  on, 
and  stretch  or  excise,  the  spinal  accessory  nerve  (p.  388).  This  is 
not  attempted  until  hygienic  and  tonic  treatment  has  failed.  Where 
the  cause  is  peripheral,  good  results  may  follow  ;  but  when  due  to 
central  lesions,  as  is  usually  the  case,  we  have  already  stated  that 
failure  is  not  uncommon.  In  such  patients,  division  of  the  posterior 
cervical  nerves,  as  they  lie  on  the  semi-spinalis  colli,  will  occasionally 
bring  about  a  cure  (Keen) ;  should  this  fail,  it  may  be  justifiable  to 
deal  with  the  cortical  centres. 


DEFORMITIES  420 

•  A  Cervical  Rib  is  a  deformity  of  not  uncommon  occurrence, 
generally  noticed  about  the  age  of  puberty.  It  is  usually  bilateral, 
and  arises  most  frequently  from  the  anterior  transverse  process  of 
the  seventh  cervical  vertebra,  but  a  similar  outgrowth  sometimes 
occurs  from  the  sixth.  It  is  composed  mainly  of  cartilage  at  first, 
but  as  age  advances  it  becomes  osseous.  It  passes  down  behind  the 
nerves  to  unite  with  the  central  portion  of  the  iirst  rib,  and  occasion- 
ally consists  of  two  portions,  an  upper  and  a  lower,  united  together 
by  a  synchondrosis.  No  symptoms  are  produced  until  the  mass  by  its 
growth  compresses  the  roots  of  the  brachial  plexus,  or  pushes  the 
subclavian  artery  forwards,  thus  leading  to  trophic  and  vascular  dis- 
turbances, terminating  perhaps  in  gangrene  of  the  finger-tips,  as  well 
as  to  neuralgia  in  the  region  of  the  ulnar  nerve,  and  some  weak- 
ness or  loss  of  power  in  the  arm.  It  presents  as  a  hard  swelling 
above  the  clavicle,  and  can  be  readily  recognised  by  radiography. 
Nothing  should  be  done  to  it  unless  pressure  symptoms  are  present, 
when  removal  may  be  required.  An  incision  is  made  parallel  to 
the  anterior  border  of  the  lower  portion  of  the  trapezius ;  the  nerves 
and  vessels  are  separated  from  the  mass  of  cartilage  and  drawn  aside, 
and  the  growth  carefully  excised  with  gouge,  chisel,  or  cutting  pliers. 

Deformities  of  tlie  Spine. 

Scoliosis. — By  scoliosis  is  meant  a  lateral  curvature  of  the  spine 
accompanied  by  rotation  of  the  vertebrae.  Conditions  are  met  with 
in  which  the  spine  becomes  deflected  laterally  as  an  occasional  result 
of  Pott's  disease,  or  in  fractures  ;  such,  however,  are  not  generally 
considered  to  be  genuine  scoliosis. 

.etiology. — The  following  are  the  chief  causes  of  scoliosis  :  i.  It 
is  said  to  occur  very  rarely  as  a  congenital  deformity,  owing  to  mal- 
formation of  the  vertebrae.  2.  It  may  commence  in  young  children 
as  a  result  of  rickets,  owing  partly  to  the  softened  condition  of  the 
bones,  partly  to  their  irregular  growth.  It  is  probably  often  induced 
by  the  method  in  vogue  with  nursemaids  of  always  carrying  children 
on  the  same  arm.  The  primary  curve  in  this  type  is  usually  one 
directed  towards  the  left  in  the  dorsi-lumbar  region.  A  similar  change, 
due  to  the  so-called  '  adolescent  rickets,'  may  also  occur  in  children 
who  are  able  to  run  about.  3.  Any  condition  of  asymmetry  of  the 
body  may  lead  to  what  is  known  as  statical  scoliosis — e.g.,  congenital 
shortness  of  one  leg,  unilateral  dislocation  of  the  hip,  contractions  of 
the  knee-  or  hip-joint,  genu  valgum,  falling  in  of  the  chest  wall  as  a 
result  of  empyema,  and  even  old-standing  torticollis.  If  the  cause 
exists  in  one  of  the  lower  extremities,  the  pelvis  is  tilted  down  on  the 
side  of  the  shorter  limb,  producing  a  lumbar  curve  with  the  con- 
vexity towards  that  side,  whilst  a  compensatory  dorsal  curve  in  the 
opposite  direction  is  subsequently  added  in  order  to  maintain  the 
general  axis  of  the  body.  If,  however,  the  short  leg  is  also  persistently 
adducted,  as  in  old  hip  disease,  the  spine  will  probably  be  curved  in 
the  opposite  direction.  When  due  to  empyema,  a  primary  dorsal 
curvature  is  produced,  with  its  convexity  towards  the  sound  side.     In 


430  A  MANUAL  OF  SURGERY 

torticollis  the  cervical  curve  is  primary,  and  a  compensatory  curve  in 
the  opposite  direction  in  the  dorsal  region  usually  follows.  4.  The  most 
common  type,  however,  is  the  scoliosis  of  adolescents,  met  with  in  yoimg 
people  about  the  age  of  puberty,  or  a  little  older,  who  are  in  a  weak 
and  asthenic  condition,  often  as  a  result  of  rapid  growth,  combined 
possibly  with  improper  or  insufficient  food,  defective  hygienic  sur- 
roundings, or  exposure  to  hard  work,  whereby  undue  muscular  fatigue 
is  induced.  Young  women  of  an  anaemic  type  who  suffer  from 
amenorrhoea,  and  who  as  housemaids  or  factory  hands  have  to  under- 
take a  good  deal  of  lifting,  are  especially  liable  to  this  condition.  It 
is  due  to  a  relaxed  state  of  the  ligaments  and  muscles,  which  have 
not  developed  pari  passu  with  the  weight  and  length  of  the  skeleton ; 
it  is  therefore  not  unfrequently  associated  with  flat  foot  and  genu 
valgum.  Prolonged  standing  in  a  position  of  ease  or  rest,  in  which 
the  weight  is  mainly  carried  on  one  leg,  may  determine  its  occurrence, 
as  also  faulty  positions  occupied  by  children  at  school,  owing  to  low 
desks  and  want  of  support  to  the  feet.  The  lumbar  curve  usually 
forms  first,  its  convexity  being  to  the  left  side,  a  compensatory  dorsal 
curve,  with  its  convexity  to  the  right,  being  subsequently  developed. 

The  Phenomena  vary  considerably  according  to  the  character  and 
extent  of  the  lesion.  Sometimes  the  whole  spine  is  involved  in  one 
curve  (total  scoliosis) ;  but  more  usually  two  curves  are  present,  one 
primary,  the  other  compensatory.  It  is  by  no  means  uncommon  for 
this  condition  to  be  associated  with  kyphosis,  but  the  absence  of  the 
latter,  in  what  is  sometimes  termed  the  '  flat-backed  '  type,  is  no 
criterion  of  the  slightness  of  the  case.  The  most  usual  variety  is  that 
in  which  there  is  a  double  curve,  with  the  dorsal  convexity  to  the 
right  and  the  lumbar  to  the  left.  It  will  be  desirable  to  describe 
this  carefully,  whilst  for  the  opposite  condition  all  that  is  necessary 
is  to  transpose  the  words  'right'  and  'left,'  or,  as  Hoffa  has  put  it, 
one  variety  is  the  '  mirror  picture '  of  the  other. 

In  addition  to  the  lateral  displacement,  rotation  of  the  bodies  of  the 
vertebra  (Fig.  146)  towards  the  convexity  of  the  curves  is  always 
present.  This  is  probably  a  purely  mechanical  act,  and  due  to  the 
more  firm  support  given  to,  and  the  interlocking  of,  the  posterior  parts 
of  the  vertebrae.  As  a  result,  the  spinous  processes  are  directed 
towards  the  concavity,  and  hence  will  always  indicate  a  smaller 
amount  of  distortion  than  really  exists.  Occasionally  there  may  be  some 
backward  projection  of  the  spines  at  the  junction  of  the  two  curves. 

The  thoracic  walls  necessarily  participate  in  the  process,  and  the 
amount  of  thoracic  deformity  is  perhaps  the  best  measure  of  the  degree 
of  rotation  of  the  vertebrae.  The  ribs  on  the  right  side  become  to 
some  extent  separated  from  one  another,  and  project  posteriorly  on 
account  of  this  rotation  (Fig.  147) ;  the  amount  of  curvature  at  the 
angle  is  consequently  increased,  whilst  the  front  of  the  chest  on  this 
side  of  the  body  becomes  flattened.  On  the  left  side  the  ribs  are 
huddled  together,  and  the  curve  at  the  angle  diminished,  the  ribs  being 
thereby  opened  out ;  consequently,  the  thorax  is  flattened  posteriorly 
on  that  side,  but   projects  in  front ;    the  left   breast   may  thus  be 


DEFORMITIES 


431 


rendered  prominent.  In  fact,  the  thorax  becomes  more  or  less 
rhomboidal  in  shape.  The  sternum  also  is  somewhat  displaced 
towards  the  concavity,  and  twisted  so  that  the  anterior  surface  looks 
towards  the  right.  The  capacity  of  the  thorax  is  not  as  a  rule  affected 
at  first,  but  in  the  later  stages  it  is  considerably  diminished,  and  the 
abdominal  viscera  may  even  be  displaced.  The  scapula  follow  the 
thoracic  wall,  and  hence  the  right  shoulder  is  pushed  upwards  and 


Fig.  145. — Photograph  of  Ordin- 
ary Type  of  Adolescent 
Scoliosis. 


Fig.   146. — Spine  in  Scoliosis  seen 
FROM  IN  Front.     (Tillmanns.) 


The   apparent    asymmetry  of  the  legs  is  in  this  case  a  photographic  error ; 
in  reality  they  were  both  well  developed. 

outwards,  and  this,  it  is  said,  in  the  worst  cases  may  progress  to  such 
an  extent  as  to  cause  the  sternal  end  of  the  clavicle  to  be  dislocated 
backwards  spontaneously.  It  is  for  this  '  growing  out  of  the  shoulder* 
in  5'^oung  women  that  the  majority  of  cases  come  under  observation. 
The  left  scapula  is  generally  somewhat  lower  than  the  right.  The 
effect  on  the  waist  varies  with  the  situation  and  extent  of  the  curves ; 


432 


A  MANUAL  OF  SURGERY 


if  the  dorsal  and  lumbar  curves  are  nearly  equal,  then  the  true  waist 
on  the  right  side  becomes  more  marked  than  usual,  corresponding  to 
the  lumbar  concavity,  and  in  advanced  cases  a  distinct  sulcus  may  be 
present  between  the  lower  ribs  and  the  crest  of  the  ilium.  On  the  left 
side  the  hip  appears  to  project  ('growing  out'),  owing  to  the  defl(jction 
of  the  trunk  towards  the  right  side  (Fig.  145),  whilst  the  dorsal  con- 
cavity higher  up  may  simulate 
-«^S^ai^  a  false  waist.    In  addition  to 

the  above  phenomena,  the 
buttocks  maybe  noticed  to  be 
asymmetrical,  if  the  scoliosis 
is  of  statical  origin.  The 
erector  spinae  muscle  stands 
out  unduly  on  the  left  owing 
to  the  rotation  of  the  ver- 
tebrae, whilst  the  transverse 
processes  on  this  side  may 
be  unusually  evident. 

In  the  early  stages  the 
characteristic  deformity  dis- 
appears on  extension  of  the 
trunk,  as  by  hanging  from  a 
trapeze,  or  on  bending  for- 
wards ;  but  as  it  progresses, 
the  spine  becomes  more  and 
more  fixed,  and  but  little 
alteration  is  produced  by 
suspension  of  the  patient.  In  the  worst  cases  the  deformity  becomes 
so  marked  as  to  simulate  the  '  hump '  formed  in  Pott's  disease, 
especially  when  associated  with  kyphosis,  and  the  patient's  stature 
becomes  dwarfed  and  stunted. 

Subjective  symptoms,  such  as  neuralgic  pain  and  weakness,  are  also 
present,  but  usually  they  are  not  very  prominent  features. 

Anatomical  Changes. — The  structure  of  the  spinal  column  is  at 
first  not  manifestly  altered,  but  as  soon  as  the  deformity  becomes 
chronic,  the  individual  vertebrae  become  mis-shapen.  The  bodies 
are  somewhat  wedge-like  on  section,  being  thicker  on  the  convex  than 
on  the  concave  side.  The  intervertebral  discs  are  similarly  changed, 
whilst  the  articular  processes  are  unduly  pressed  together  on  the  con- 
cave side,  and  separated  from  one  another  on  the  convex.  The  trans- 
verse and  spinous  processes  are  also  approximated  to  one  another  on 
the  side  of  the  concavity,  and  often  curved.  The  ligaments,  which  in 
the  early  stages  are  relaxed,  become  secondarily  shortened  on  the 
concave  side,  and  may  indeed  disappear,  the  bodies  of  the  vertebrae 
being  ankylosed.  The  muscles  are  also  relaxed  in  the  early  stages, 
but  accommodate  themselves  afterwards  to  the  altered  curves  of  the 
spine,  and  hence  are  contracted  on  the  concave  side  and  stretched 
on  the  convex. 

It  is  most  esiiential  that  a  correct  Diagnosis  be  made  as  soon  as 


Fig.   147.— Section  of  Thorax  in  Scolio- 
sis.    (After  Holmes  and  Hulke.) 


Deformities  433 

possible,  since  so  much  depends  upon  early  treatment.  A  thorough 
examination  should  be  made  with  the  clothes  stripped  to  below  the 
waist,  so  that  the  whole  back  can  be  seen.  The  patient  should  be 
made  to  sit  straight  up  on  a  stool  or  chair  placed  sideways,  and  the 
surgeon  stands  behind  her.  The  general  appearance  is  first  noted, 
and  then  the  spinous  processes  are  marked  out  one  after  another  with 
a  spot  of  ink  or  with  a  flesh  pencil.  The  shape  of  the  thorax,  the 
curvature  of  the  ribs,  and  the  position  of  the  scapulse,  are  also  ascer- 
tained. The  patient  is  then  made  to  stand,  to  hang  from  a  bar,  and 
to  bend  forwards,  and  the  effects  of  these  respective  movements 
noted  ;  by  this  means  some  idea  can  be  obtained  of  the  extent  and 
nature  of  the  deformity. .  There  can  be  but  little  risk  of  mistaking  it 
for  Pott's  disease,  since  the  rigidity,  deformity,  and  localized  pain  of 
the  latter  are  so  characteristic  ;  in  those  cases  of  scoliosis,  however, 
where  there  is  a  projection  of  the  spinous  processes  backwards,  a 
mistake  might  easily  arise  if  only  a  careless  examination  were  made. 

The  Prognosis  necessarily  varies  with  the  stage  which  the  affection 
has  reached.  In  early  days,  before  the  deformity  has  become  set, 
and  when  it  disappears  on  extension  of  the  spine,  it  is  almost  certain 
to  be  entirely  cured,  if  suitable  precautions  are  taken.  Later  on  it 
can  be  improved  to  some  extent,  but  in  bad  cases  all  that  can  be 
expected  is  to  prevent  it  from  getting  worse. 

In  the  Treatment  of  scoliosis,  the  cause  of  the  trouble  must  not  be 
overlooked,  since  in  many  cases  the  deformity  may  be  remedied,  or 
at  any  rate  prevented  from  increasing,  by  attending  to  this.  Thus, 
inequality  in  the  length  of  the  limbs  necessitates  the  wearing  of  a 
high-heeled  boot,  whilst  contractions  of  the  knee-  or  hip-joints  should, 
if  possible,  be  corrected.  In  that  variety  which  occurs  in  young 
people  from  constitutional  or  local  debility,  the  general  health  must 
be  improved  by  a  visit  to  the  seaside,  or  the  administration  of  tonics 
such  as  iron  and  arsenic.  Carefully-regulated  rest  and  exercise  must 
also  be  recommended,  so  as  to  improve  the  muscular  tone  of  the 
back  without  unduly  fatiguing  the  patient ;  for  a  similar  reason 
massage  and  cold  baths  are  beneficial.  All  errors  of  position  must 
be  corrected,  and  suitable  desks,  forms,  and  chairs  utilized.  In  the 
slighter  cases  it  often  suffices  to  order  the  patient  to  rest  in  the 
supine  position  on  an  inclined  board  for  an  hour  or  two  daily,  the 
head  being  thus  raised  and  the  spine  extended.  Calisthenic  move- 
ments and  gymnastic  exercises,  especially  on  the  horizontal  bar  and 
trapeze,  are  also  valuable.  Of  course,  these  must  be  arranged  so  as 
to  exercise  the  weak  muscles  and  counteract  the  deformity.  Space 
forbids  us  describing  them  here,  and  we  must  refer  readers  to  special 
textbooks.  A  spinal  support  is  often  useful,  but  should  not  be  worn 
continuously,  except  in  bad  cases,  as  it  renders  the  muscles  of  the 
back  weak  from  disuse.  All  that  is  needed  in  the  early  stages  is  the 
support  of  a  firm,  carefully-fitted  corset ;  but  should  the  deformity 
increase,  stronger  steel  instruments  may  be  employed  in  which  springs 
are  incorporated,  whereby  it  is  hoped  that  correction  of  the  curvature 
may  be  brought  about.     In  the  more  severe  cases,  which  are  often 

2S 


434 


A  MANUAL  OF  SURGERY 


Fig.    148. — 
Kyphosis. 


associated  with  considerable  pain,  such  a  contrivance  with  axillary 
crutches  is  absolutely  essential.  Plaster  of  Paris,  appHed  according 
to  Sayre's  method,  is  certainly  objectionable,  since  it  is  irremoveable, 
and  all  other  local  treatment  to  the  back  is  thus  prevented. 

Kyphosis. — By  this  term  is  meant  a  condition  of  in- 
creased dorsal  convexity  of  the  back  (Fig.  148),  whioh 
is  often  associated  with  loss  of  the  lumbar  concavity,  so 
that  the  whole  spine  is  arched  backwards.  Occasionally, 
however,  a  marked  lumbar  lordosis  is  present  as  a 
compensatory  condition. 

The  chief  varieties  of  kyphosis  are  as  follows  : 

1.  Kyphosis  from  defective,  growth  or  habit.  This 
may  occur  (a)  in  children  under  the  age  of  four,  result- 
ing from  rickets  ;  (b)  in  adolescents  up  to  the  age  of 
sixteen  (round  shoulders),  from  a  continuous  habit  of 
stooping,  as  in  reading  or  writing,  especially  in  those 
suffering  from  myopia ;  (c)  various  forms  of  occupation, 
which  involve  the  carrying  of  heavy  weights,  or  stoop- 
ing over  work,  lead  to  its  appearance  in  adults,  as  in 
porters  and  cobblers ;  (d)  in  old  men  it  results  from 
senile  atrophy. 

2.  Kyphosis  from  general 
diseases  of  the  spine  is  a  marked  feature 
in  spondylitis  deform'ans,  osteitis  defor- 
mans, osteo-malacia,  hypertrophic  osteo- 
arthropathy, and  acromegaly.  In  the 
latter  disease  the  condition  is  limited  to 
the  dorsal  region. 

3.  Kyphosis  from  localized  injury  or 
disease  of  the  spine  is  sometimes  described, 
although  it  is  more  commonly  known  by 
the  contradictory  term  '  angular  curva- 
ture.' It  results  from  fractures,  Pott's 
disease,  gumma,  or  cancer  (q.v.). 

Treatment  is  impossible  in  the  majority 
of  cases,  but  the  round  shoulders  of  young 
people  come  so  commonly  under  observa- 
tion that  a  little  more  notice  of  the  condi- 
tion is  needed. 

Round  Shoulders  occur  most  frequently 
in  girls  who  have  grown  rapidly,  and 
perhaps  developed  precociously.  The  con- 
dition is  often  due  to  defective  habits  of 
sitting  and  standing,  especially  at  school, 
and  may  be  induced  by  faulty  desks  and 
chairs,  whilst  other  intrinsic  conditions, 
such  as  myopia  or  adenoids,  may  also  be 
primarily  responsible.  The  spine  becomes 
bent  forwards  in  the  cervico-dorsal  region 
can  be  voluntarily  corrected,  but  not  so  later  on. 


Fig.  149. — Acquired  Occu- 
pation Kyphosis  in  a 
Young  Man,from  Exces- 
sive Weight-carrying. 

at  first  the  deformity 


DEFORMITIES 


435 


Treatment. — In  the  first  place  the  cause  must  be  ascertained,  and 
if  possible,  removed;  in  particular,  chairs  and  desks  must  be  arranged 
so  as  to  insure  that  the  child  sits  in  a  good  position.  The  essential 
point  in  the  treatment  is  to  increase  the  power  of  the  muscles  of  the 
back,  especially  the  trapezii,  the  erectores  spinae,  the  rhomboidei,  and 
the  serrati.  This  may  be  accomplished  by  massage,  electricity,  and 
exercises,  the  latter  necessarily  directed  towards  extension  of  the 
back.  The  girl  should  never  be  allowed  to  fatigue  herself  unduly, 
and  must  rest  on  her  back  two  or  three  times  a  day  for  half  an  hour. 
At  night  she  should  lie  on  her  back,  without  a  bolster,  and  with  a 
pillow  beneath  the  curve.  The  general  nutrition  and  health  must  also 
be  attended  to,  and  a  course  of  suitable  tonics  prescribed.  In  bad 
cases  where  the  deformity  is  marked  and  it  is  feared  it  may  be  pro- 
gressive, a  light  support  may  be  required  ;  a  Chance's  splint*  will  do 
as  well  as  any,  but  of  course  the  exercises  must  be  persisted  in. 

Lordosis  (Fig.  150)  is  almost  invariably  a  secondary  or  compensa- 
tory condition,  and  consists  in  an  increased  anterior  curvature  of  the 
spine  in  the  lumbar  region.  It  is  usually  produced 
by  continued  flexion  of  the  hip,  whether  due  to  con- 
genital displacement,  unreduced  dislocation,  malunited 
fracture,  or  to  hip  disease,  and  in  such  cases  it  is 
irremediable  unless  the  malposition  of  the  femur  can 
be  corrected. 

It  is  seen  as  a  temporary  condition  in  pregnancy, 
and  as  a  more  constant  phenomenon  in  bad  cases  of 
uterine  fibroids,  owing  to  the  increased  weight  of  the 
uterus  or  its  contents,  necessitating  backward  displace- 
ment of  the  upper  part  of  the  spine  in  order  to  adjust 
correctly  the  centre  of  gravity  of  the  body.  The  same 
may  be  noticed  in  persons  with  large,  fat,  and  pendu- 
lous abdomens. 

It  is  occasionally  present  in  progressive  muscular 
atrophy  where  the  lumbar  and  abdominal  muscles 
are  weakened,  and  usually  in  pseudo-hypertrophic 
paralysis  from  loss  of  power  in  the  gastrocnemii  and 
other  muscles  engaged  in  maintaining  the  erect  posture.  In  both 
cases  the  centre  of  gravity  of  the  body  is  displaced  forwards, 
necessitating  the  throwing  backwards  of  the  head  and  shoulders  in 
order  to  maintain  the  equilibrium. 

Spondylo-listliesis  is  the  term  applied  to  a  curious  and  somewhat 
uncommon  deformity,  in  which  the  lumbar  vertebrae  slip  forwards 
and  downwards  from  the  top  of  the  sacrum.  It  arises  from  fracture 
of  the  articular  processes  of  the  lumbo-sacral  synchondrosis,  or  from 
imperfect  development  of  the  laminae  or  pedicles  of  the  lowest  lumbar 
vertebra,  as  a  result  of  which  the  pressure  of  loads  carried  on  the 

*  Many  modifications  of  Chance's  original  splint  have  appeared,  but  the 
essential  features  of  all  are  the  presence  of  a  metal  pelvic  band,  from  which  rises 
a  single  or  double  bar  of  malleable  iron,  fitted  to  the  back,  and  capable  of  having 
its  curve  altered.  Lateral  supports  spring  from  the  central  bars  or  bar,  and 
straps  to  fix  it  in  position  are  also  provided. 


Fig. 


150. — Lor- 
dosis. 


436  A  MANUAL  OF  SURGERY 

shoulders  or  the  weight  of  a  pregnant  uterus  brings  about  the  dis- 
placement. In  the  latter  instance  the  enforced  lordosis  aggravates 
this  tendency.  The  effects  produced  are  shortening  of  the  stature, 
together  with  the  formation  of  a  marked  hollow  above  the  sacrum, 
whilst  the  lumbar  vertebras  are  unduly  prominent  anteriorly.  The 
condition  is  accompanied  by  neuralgic  pain  and  weakness.  The  only 
treatment  is  prolonged  rest  in  the  recumbent  posture,  and  possibly  the 
application  of  a  leather  jacket,  moulded  to  the  pelvis,  and  supplied 
with  crutches,  so  as  to  carry  part  of  the  weight  downwards  from  the 
axillae  to  the  pelvic  support  without  utilizing  the  spine. 

Deformities  of  the  Upper  Extremity. 

In  Congenital  Elevation  of  the  Scapula  (Sprengel's  Shoulder)  the 
scapula  may  be  normal  in  size  or  a  little  smaller  than  usual,  but  is 
situated  above  its  proper  position,  thereby  causing  deformity,  and  is 
generally  rotated  so  that  its  lower  angle  is  approximated  to  the  middle 


Fig.   151. — Winged  Scapula.     (From  a  Photograph.) 

line.  The  muscles  attached  to  its  upper  border  are  prominent ;  in  a 
few  instances  an  osseous  band  has  replaced  them,  passing  between 
the  upper  angle  of  the  bone  and  the  seventh  ceirvical  vertebra.  The 
lower  third  of  the  trapezius  is  often  defective,  as  also  the  serratus 
magnus.  The  amount  of  disability,  which  is  usually  slight,  depends 
on  the  condition  of  these  muscles,  but  the  affected  arm  is  sometimes 
smaller  than  its  fellow.  A  slight  degree  of  scoliosis  develops  as  a 
compensatory  phenomenon.  The  condition  is  supposed  to  result 
from  abnormal  intra-uterine  pressure  in  the  same  way  as  congenital 
torticollis  and  talipes.  The'  only  treatment  consists  in  dealing 
with  the  affected    muscles  by   operation,  if    necessary.      This  de- 


DEFORMITIES  437 

formity  is  distinguished  from  the  '  growing-out  shoulder  '  of  ordinary 
scoliosis  by  the  muscular  defects  and  by  the  slightness  of  the  scoliotic 
curve. 

A  Winged  Scapula  is  a  condition  characterized  by  projection  back- 
wards of  the  vertebral  border  and  lower  angle  of  that  bone  when  the 
arm  is  thrust  forwards  (Fig.  151).  It  is  due  to  paralysis  of  the 
serratus  magnus  and  rhomboids,  resulting  from  neuritis,  traumatic 
or  otherwise,  of  the  roots  of  the  fifth  and  sixth  cervical  nerves,  or  of 
the  special  branches  to  these  muscles ;  the  nerve-roots  are  not  un- 
frequently  tender  on  pressure.  Treatment  consists  in  massage  and 
faradism,  whilst,  if  persistent,  a  suitable  appliance  may  correct  the 
deformity. 

Various  types  of  Club-hand  occur,  in  which  the  hand  is  deflected  to 
one  or  the  other  side,  or  is  hyper-extended  or  flexed.  Perhaps  the 
most  frequent  cause  is  a  congenital  absence  of  the  radius,  under  which 
circumstances  the  hand  is  radially  abducted  to  a  marked  degree,  the 
ulna  is  shortened  and  curved,  and  its  lower  epiphysis  much  altered 
in  shape  and  expanded,  so  as  to  articulate  with  the  carpal  bones. 
Where  the  bones  are  normal,  the  hand  is  usually  flexed  and  adducted 
towards  the  ulnar  side.  In  any  of  these  deformities  skiagraphy 
should  be  employed,  so  as  to  ascertain  the  exact  relation  of  the 
bones  to  each  other. 

Congenital  Deformities  of  the  Finger  are  much  more  common,  and 
the  account  here  given  of  such  defects  of  the  upper  extremity  applies 
with  equal  force  to  those  which  occur  in  the  lower.  The  following 
varieties  may  be  alluded  to  : 

Polydactylism  consists  in  the  presence  of  supernumerary  fingers 
and  toes.  There  may  be  from  one  to  seven  additional  digits,  and  the 
condition  is  usually  symmetrical.  One  case  is  on  record  with  twelve 
and  thirteen  fingers  on  the  hands,  and  twelve  toes  on  each  foot.  The 
accessory  digits  are  often  stunted,  and  smaller  in  size  than  the  normal, 
but  may  be  of  average  dimensions.  Usually  they  are  separated  from 
the  true  digits,  but  now  and  then  may  be  blended  with  them.  The 
correct  number  of  metacarpal  or  metatarsal  bones  may  be  present, 
or  they  also  may  be  multiplied.  In  one  of  our  cases  there  were  six 
digits  and  six  metatarsal  bones ;  but  the  last  two  digits  were  sup- 
ported by  an  accessory  metatarsal  apparently  springing  from  the 
outer  side  of  the  fourth.  The  condition  is  frequently  inherited.  The 
Treatment  consists  in  removing  the  supernumerary  digits,  if  useless, 
obtrusive,  or  troublesome.  Sometimes  the  patients  are  proud  of  their 
abnormality,  and  refuse  to  part  with  it.  '\ 

Ectrodactylism,  or  the  absence  of  one  or  more  of  the  digits,  is 
occasionally  seen,  as  also  partial  arrests  of  development  of  fingers  or 
toes,  or  intra-uterine  amputation  at  a  higher  level. 

Macrodactyly  (Fig.  152)  consists  in  a  congenital  overgrowth  of  one 
or  more  fingers  or  toes.  The  structures  are  perfectly  normal  in 
character,  and  merely  gigantic  in  size  for  the  age  of  the  individual. 
Amputation  or  excision  may  be  needed  in  these  cases,  as  the  de- 
formed parts  grow  out  of  all  proportion  to  the  neighbouring  tissues. 


438  A   MANUAL  OF  SURGERY 

Thus,  an  infant  with  enormous  overgrowth  of  the  second  toe  of  the 
right  foot  was  successfully  treated  by  excision  of  the  digit,  together 
with  a  V-shaped  portion  of  the  foot,  which  was  by  thi^  means 
reduced  to  normal  shape  and  size. 

Syndactylism,  or  webbed  fingers,  is  a  condition  in  which  two  or  mo''e 
fingers  are  joined  together  laterally,  either  by  a  thin  web  consisting 
mainly  of  skin,  or  by  a  thick  fleshy  bond  of  union.  In  the  foot  no 
treatment  is  required,  but  in  the  hand  the  fingers  must  be  separated. 
If  there  is  merely  a  thin  web,  this  may  be  divided  by  scissors ;  but  to 
prevent  its  re-formation  from  above  downwards,  as  healing  proceeds, 
a  flap  of  skin  must  be  transplanted  into  the  angle  between  the  fingers, 
or  an  opening  in  the  base  of  the  web  may  be  made  and  maintained, 
and  the  edges  allowed  to  cicatrize  before  the  web  itself  is  divided. 


V 


Fig.  152. — Macrodactyly  and  Syndactyly. 

In  this  case  a  child,  aged  two  and  a  half  years,  had  the  ring  and  middle  fingers 
united  laterally  into  a  large  mass  which  projected  far  beyond  the  others. 
The  middle  finger  was  normal  in  size,  the  ring  finger  was  hypertrophic.  A 
fruitless  attempt  was  made  to  save  the  middle  finger,  but  both  had  finally  to 
be  amputated. 

Where  the  union,  however,  is  thick  and  fleshy,  a  more  extensive 
operation  is  needed.  Two  flaps  of  skin  as  long  as  the  web,  and  ha'.f 
the  width  of  a  finger,  are  respectively  raised  from  the  dorsal  aspect  of 
one  finger  and  from  the  palmar  aspect  of  the  other,  in  such  a  manner 
that,  after  the  web  has  been  divided,  the  denuded  surfaces  can  be 
covered  by  wrapping  the  flaps  round  the  lateral  aspects  of  the  fingers 
and  suturing  them  in  position.  An  additional  flap  of  skin  must  also 
be  fixed  in  the  angle  between  the  separated  digits. 

Congenital  Contraction  of  the  Fingers  is  not  a  very  rare  deformity, 
being  frequently  inherited ;  it  is  usually  limited  to  the  little  finger  and 
may  be  associated  with  congenital  hammer-toe.  It  is  due  to  contrac- 
tion of  the  central  prolongation  of  the  palmar  fascia  in  the  finger, 
whereas  in  Dupuytren's  contraction  it  is  the  palmar  fascia  itself  and 


DEFORMITIES  439 

its  lateral  prolongations  into  the  fingers  that  are  involved.  Moreover, 
the  character  of  the  deformity  differs ;  in  the  congenital  variety  the 
first  phalanx  is  hyper-extended,  and  the  second  and  third  flexed, 
whereas  in  the  acquired  form  the  first  and  second  phalanges  are  flexed 
and  the  third  is  hyper-extended.  Treatment. — It  often  suffices  to  use 
massage  and  apply  a  splint,  but  in  bad  cases  division  of  the  fascial 
bands  may  be  needed. 

Acquired  Deformities  of  the  Hand. — After  burns  the  hand  may  be 
contracted  into  a  useless  mass  in  which  the  fingers  are  drawn  into 
the  palm  and  united  by  cicatricial  tissue  to  the  palmar  structures,  so 
that  all  treatment  is  hopeless. 

Spring-,  Jerk-,  or  Snap-Finger  is  a  condition  in  which,  when  the 
patient  attempts  to  open  his  hand,  one  finger  or  the  thumb  remains 
flexed,  and  on  extending  it  with  the  other  hand  it  flies  open  with  a 
jerk  or  snap.  Slight  tenderness  is  usually  felt  near  the  metacarpo- 
phalangeal articulation,  and  the  cause  of  the  trouble  is  some  obstruc- 
tion to  the  free  working  of  the  long  tendons  under  the  transverse 
ligament  at  the  root  of  the  fingers,  or  between  the  sesamoid  bones  of 
the  thumb.  In  a  few  cases  a  ganglion  has  been  present  here,  but  in 
most  instances  the  condition  is  due  to  an  increase  in  size  of  the  sesamoid 
bone  which  the  X  rays  have  taught  us  occurs  constantly  in  this  situation. 
Treatment  consists  in  an  aseptic  incision  to  remove  the  cause  of  the 
obstruction. 

A  Mallet  Finger  is  one  in  which  the  terminal  phalanx  is  maintained 
in  a  state  of  flexion  owing  to  some  damage  to  the  extensor  aponeurosis. 
It  usually  follows  injuries,  which  lead  either  to  a  separation  of  the 
tendon  from  the  bone,  or  to  a  thinning  of  its  texture,  whereby  the 
flexor  tendon  is  able  to  act  with  undue  power.  The  Treatment  consists 
in  the  application  of  an  anterior  finger-splint  in  the  early  stages,  but 
later  on,  should  the  deformity  be  persistent,  an  incision  is  made  on  the 
posterior  aspect  of  the  joint,  and  the  weak  tendon  isolated  and  stitched 
down  in  such  a  way  as  to  give  it  a  better  attachment  to  the  bone. 

Contraction  of  the  Palmar  Fascia  (Dupuytren's  Contraction). — This 
condition  is  usually  met  with  in  middle-aged  individuals  of  a  gouty 
temperament,  more  often  in  men  than  women,  and  not  unfrequently 
on  both  sides  of  the  body.  It  may  or  may  not  be  associated  with 
direct  irritation  of  the  palmi,  as  by  leaning  much  on  a  round-headed 
cane,  or  from  the  constant  use  of  some  instrument,  such  as  an  awl, 
whilst  heredity  is  an  important  causative  factor.  Pathologically,  it 
is  due  to  a  chronic  overgrowth  and  contraction  of  the  fascia,  inflam- 
matory in  nature,  and  cirrhotic  or  sclerosing  in  type.  It  commences 
as  an  indurated  subcutaneous  nodule  in  the  palm  of  the  hand,  about 
the  situation  of  the  most  marked  transverse  crease,  and  affects  most 
commonly  the  ring  and  little  fingers  first,  the  other  fingers  and  thumb 
being  less  often  involved.  The  induration  spreads  slowly  both  up  and 
down  the  fascial  bands  into  the  fingers,  which,  as  it  increases,  are 
gradually  dravv^n  into  the  palm  and  fixed,  so  that  extension  becomes 
impossible  (Fig.  153).  The  flexion  is  limited  to  the  first  and  second 
phalanges,    ""he   third   remaining   extended,  and,    indeed,  sometimes 


440  A  MANUAL  OF  SURGERY     ' 

assuming  a  position  of  hyper-extension,  owing  to  the  injudicious 
appHcation  of  a  spHnt.  The  skin  over  the  indurated  masses  is  sooner 
or  later  incorporated  with  them,  and  may  become  dimpled  or  creased 
by  the  traction  of  the  subcutaneous  connecting  bands. 

The  Diagnosis  of  Dupuytren's  contraction  is  exceedingly  easy,  the 
only  condition  for  which  it  is  likely  to  be  mistaken  being  the  congenital 
contraction  already  noted,  and  the  flexion  of  the  finger  due  to  contrac- 
tion, division,  or  destruction  of  the  long  tendons.  In  the  latter  case 
there  is,  as  a  rule,  no  palmar  induration,  but  there  will  be  a  history 
of  injury  or  inflammation,  and  some  scarring  (see  p.  414). 

The  only  satisfactory  Treatment  is  by  operation,  and  the  following 
methods  are  those  which  are  most  successful :  (a)  Adams'  subcutaneous 
section  of  the  fascia  and  its  prolongations  consists  in  dividing  the 
indurated  bands  by  a  tenotome  in  several  places,  where  they  can  be 


Fig.   153. — Dupuytren's  Contraction.     (From  a  Photograph.) 

felt  tense.  One  puncture  and  division  must  be  made  in  the  centre 
of  the  palm  ;  a  second  divides  the  same  band  as  near  the  finger  as 
possible,  whilst  the  third  and  fourth  deal  with  the  lateral  prolongations 
at  the  sides  of  the  finger ;  if  other  bands  still  exist,  they  are  treated 
similarly,  the  tenotome,  if  possible,  in  all  cases  being  inserted  between 
the  skin  and  the  fascia.  The  improvement  thus  produced  must  be 
maintained  and  increased  by  the  subsequent  use  of  suitable  apparatus 
and  passive  movements,  but  the  final  results  are  not  very  satisfactory. 
(b)  Kocher's  method  consists  in  the  total  extirpation  of  the  thickened 
bands  and  their  prolongations  through  longitudinal  incisions.  The 
fingers  are  at  once  straightened,  and  subsequent  contraction  is 
prevented  by  mechanical  appliances.  Many  excellent  and  lasting 
cures  have  resulted  from  the  latter  operation. 

Deformities  of  the  Lower  Extremity. 

Congenital  Dislocation  of  the  Hip  is  by  no  means  rare,  although  its 
causation  is  still  quite  uncertain  ;  probably  it  is  due  in  some  cases  to 


DEFORMITIES 


44-r 


malposition  of  the  foetus  in  the  uterus  or  to  some  irregularity  in  the 
shape  of  the  uterine  wall — e.g.,  such  as  results  from  the  presence  of 
fibroids.  The  malformation  is  frequently  bilateral,  though  more  com- 
monly unilateral ;  it  occurs  much  more  often  in  girls  than  in  boys. 
It  may  pass  unnoticed  until  the  child  begins  to  walk,  and  then  the 
characteristic  signs  become  evident.  .  The  limb  is  shortened  and 
flexed  on  the  pelvis,  owing  to  the  traction  of  the  ilio-psoas  muscle, 
necessitating  a  considerable  amount  of  lordosis  to  maintain  the  body 
in  a  vertical  position  (Fig.  155),  whilst  scoliosis  is  well  marked  in 


\   "I 


Fig.   154.  Fig.  155. 

Congenital  Dislocation  of  Both  Hips  in  a  Girl  of  Fifteen  Years,  seen. 
FROM  THE  Front  and  Side.  (From  Photographs  kjndly  lent  by 
Mr.  J.  Jackson  Clarke.) 

one-sided  cases.  Since  the  head  of  the  femur  is  displaced  from  the 
middle  hne,  a  gap  is  usually  noticed  between  the  thighs  close  to  the 
perineum.  Considerable  adduction  of  the  lower  end  of  the  femur 
(Fig-.  154)  may  result  from  muscular  contraction  (adductors), 
and  in  bilateral  cases  a  scissor-leg  deformity  may  ensue.  The 
patient's  gait  is  of  a  curious  waddling  character,  which  becomes 
very  marked  if  one  side  alone  is  affected.  Since  the  head  of  the 
bone  is  only  maintained  in  position  by  its  ligamentous  and  muscular 
attachments,  it  can  often  be  drawn  down  at  first,  and  the  leg  thus 
lengthened  to  the  extent  of  an  inch  or  two;  moreover,  it  is  often 


442 


A  MANUAL  OF  SURGERY 


easy  to  reduce  the  displacement  and  put  the  head  of  the  bone  in  the 
acetabulum  in  children  that  have  not  walked  much.  It  is  sometimes 
necessary  to  invert,  sometimes  to  evert,  the  limb,  as  well  as  make 
traction,  in  order  to  accomplish  this,  the  head  of  the  bone  not  being 
always  in  the  same  place.  At  a  subsequent  date  strains  to  the 
limb  are  almost  entirely  borne  by  the  ligamentous  tissues,  and 
hence  attacks  of  synovitis  are  common. 

The  Pathological  Anatomy  varies  considerably  according  to  whether 


Fig.  156. — Skiagram  of  Double  Congenital  Dislocation  of  the  Hip-joint. 

The  noticeable  points  are  the  absence  of  the  acetabular  cavities  and  the  displace- 
ment upwards  and  distortion  of  the  heads  of  the  femora. 

or  not  the  child  has  walked.  At  birth  the  head  and  neck  are  some- 
times nearly  normal  in  shape,  and  located  near  the  acetabulum  ; 
generally,  however,  the  head  is  rather  small  and  perhaps  flattened 
at  the  spot  where  it  rests  against  the  innominate  bone,  and  the  neck 
is  short  and  stunted.  The  ligamentum  teres  is  long,  thin,  and  band- 
like. The  acetabulum  is  smaller  and  more  shallow  than  usual ;  it 
can  often  receive  the  head  of  the  bone,  though  it  cannot  retain  it.  The 
capsule  is  large  and  roomy.     After  the  child  has  walked,  sundry  modi- 


DISLOCATIONS  443 

fications  make  themselves  evident.  The  head  of  the  bone  becomes 
more  and  more  displaced,  so  that  finally  it  may  lie  well  above  the 
acetabulum  on  the  dorsum  ihi  (Fig.  156).  The  capsule  becomes 
stretched  over  the  displaced  head,  and  much  thicker  than  usual ;  the 
ligamentum  teres  is  elongated.  The  head  of  the  bone  is  considerably 
altered  and  often  much  deformed ;  the  acetabulum  becomes  triangular 
in  shape,  owing  chiefly  to  want  of  growth  of  the  iliac  portion ;  whilst 
the  muscles  are  necessarily  modified  as  to  their  length.  A  new,  but 
very  imperfect,  acetabulum  forms  on  that  portion  of  the  dorsum  i'ii 
where  the  head  of  the  bone  usually  rests. 

Treatment  is  usually  delayed  until  the  child  is  two  or  three  years 
old,  and  able  to  walk.  In  the  meantime,  if  a  diagnosis  is  made,  the 
head  of  the  bone  is  drawn  down  into  the  socket  night  and  morning 
(a  matter  of  no  difficulty,  as  a  rule),  and  worked  about  therein,  with 
massage  to  the  surrounding  muscles.  Some  surgeons  recommend 
the  use  of  prolonged  traction  even  at  this  early  period. 

At  a  later  age  (up  to  five  or  six  years)  Lorenz's  bloodless  method  of 
treatment  may  be  employed  with  good  hopes  of  a  successful  issue,  at 
any  rate,  in  unilateral  cases,  (i)  The  head  of  the  bone  is  first  drawn 
down  to  the  level  of  the  acetabulum.  Some  surgeons  recommend 
this  to  be  effected  by  gradual  extension  ;  others  do  it  at  one  sitting 
under  an  anaesthetic.  The  adductor  muscles  are  the  chief  hindrance, 
and  will  require  a  good  deal  of  kneading,  or  even  possibly  section 
with  a  tenotome.  (2)  The  head  of  the  bone  is  to  be  replaced  in  the 
acetabulum,  and  as  this  cavity  is  small  and  chink-like,  and  some- 
times covered  in  by  the  front  of  the  capsule,  a  good  deal  of  difficulty 
may  be  here  experienced.  The  limb  is  fully  flexed  and  then  forcibly 
abducted,  extended  and  everted,  no  undue  violence  being  permissible, 
or  the  bone  may  be  fractured.  The  head  of  the  bone  can  sometimes 
be  felt  to  slip  into  the  acetabulum,  and  the  manoeuvre  should  be 
repeated  several  times,  as  it  were,  grinding  the  head  of  the  femur 
into  the  cavity.  (3)  The  limb  is  then  put  up  in  plaster  of  Paris 
from  the  pelvis  to  the  knee  in  a  position  of  abduction  and  slight 
eversion,  and  with  the  leg  flexed.  It  is  maintained  in  this  position 
for  ten  or  twelve  weeks,  and  it  is  well  to  ascertain  by  skiagraphy 
that  the  bone  has  not  slipped.  At  the  end  of  that  period  it  will 
probably  be  found  that  a  less  degree  of  abduction  will  suffice  in 
order  to  keep  the  bone  in  place,  and  a  fresh  case  of  plaster  is  applied 
with  the  limb  in  this  new  position,  the  extension  and  outward  rota- 
tion being  maintained.  As  soon  as  possible  the  child  is  encouraged 
to  walk  on  the  limb  in  this  position  of  abduction,  so  as  to  force  the 
head  of  the  bone  still  deeper  into  the  acetabulum  ;  crutches  are 
required  at  first,  but  he  will  soon  do  without  them.  The  plaster 
casing  is  usually  needed  for  six  months. 

In  older  children  (from  five  to  ten  years)  treatment  by  open  operation 
can  be  undertaken  with  some  prospect  of  success.  Hoffa  and  Lorenz 
have  been  the  great  exponents  of  this  proceeding,  though  for  children 
under  five  years  they  both  admit  the  value  of  the  bloodless  method. 
Their  operations  consist  in  opening  the  joint  from  the  back  and  front 


444 


A  MANUAL  OF  SURGERY 


respectively,  shaping  up  the  head  of  the  bone,  enlarging  the  aceta- 
bulum so  that  the  head  can  be  replaced  in  it,  and  dividing  any  tense 
structures  which  prevent  reduction.  The  limb  is  subsequently 
immobilized  in  a  position  of  eversion  and  abduction,  but  for  as  short 
a  time  as  possible.  Even  if  ankylosis  results,  the  patient's  gait  is 
considerably  improved. 

Coxa  Vara,  or  incurvation  of  the  neck  of  the  femur  (Fig.  157),  is  a 
condition  in  which  the  neck  of  the  bone,  instead  of  passing  obliquely 
upwards,  is  horizontal,  or  in  bad  cases  directed  downwards,  whilst 
shortening  from  interstitial  absorption  also  occurs,  and  the  head 
becomes  mushroom-shaped.  At  first  the  osseous  tissue  is  softened, 
but  after  a  while  sclerosis  supervenes.  It  is  met  with  in  children  as 
a  result  of  rickets,  or  perhaps  more  frequently  in  young  adults,  when 

it  is  sometimes  due  to  the  adolescent 
form  of  the  same  disease.  Certainly 
it  is  seen  most  frequently  in  those  who 
have  to  do  much  walking  or  carrying 
of  heavy  weights.  In  some  cases  it  re- 
sults from  a  gradual  slipping  down  or 
traumatic  separation  of  the  epiphysis, 
which  constitutes  the  head  of  the  bone, 
or  from  a  fracture  of  the  neck  in  a  child, 
followed  by  yielding  of  the  callus. 

The  Symptoms  commence  with  pain 
in  the  region  of  the  hip,  followed  by 
a  distinct  limp.  As  the  neck  of  the 
bone  becomes  absorbed  or  curved,  the 
trochanter  rises  above  Nelaton's  line, 
and  real  shortening  of  the  limb  occurs, 
even  up  to  i^  inches.  The  limb  is  also 
everted  and  the  trochanter  increasingly 
prominent,  especially  on  flexing  the 
thighs.  The  movements  of  the  joint 
are  limited,  particularly  in  the  direc- 
tion of  internal  rotation  and  abduction, 
the  latter  being  practically  impossible 
owing  to  the  base  of  the  trochanter 
hitching  against  the  lip  of  the  acetabulum.  On  flexing  the  limb, 
the  thigh  sometimes  lies  across  the  sound  one,  whilst  in  the  later 
stages  the  adduction  may  be  so  marked  that  a  scissor-legged  con- 
dition occurs  if  both  sides  are  affected.  As  distinguishing  features 
may  be  mentioned :  the  absence  of  local  swelling  or  tenderness  on 
pressure,  as  also  of  the  up-and-down  movement  on  traction,  so  well 
marked  in  congenital  dislocation,  whilst  suppuration  never  follows, 
and  thickening  of  the  trochanter  is  not  observed. 

Treatment. — rin  the  early  stages  rest  is  the  essential,  and  thereby 
any  increase  in  the  deformity  already  existing  is  prevented ;  local 
massage  and  manipulation  are  also  advisable,  whilst  in  children 
prolonged  extension  with  inversion  may  do  good.     In  the  later  stages, 


Fig.  157. — Coxa  Vara. 

The  dotted  lines  represent  the 

normal  neck  of  the  femur. 

in   the   more   severe  cases, 


DEFORMITIES 


44S 


subtrochanteric  osteotomy,  in  order  to  alter  the  axis  of  the  bone,  is 
perhaps  the  best  measure  to  undertake,  although  a  cuneiform  oste- 
otomy of  the  neck  is  recommended  by  some.  The  subsequent  shorten- 
ing may  be  dealt  with  by  means  of  a  thick  sole  on  the  under-surface 
of  the  boot. 

Coxa  Valga  is  the  term  applied  to  the  opposite  deformity,  in 
which  the  axis  of  the  neck  of  the  femur  approaches  more  to  that 
of  the  shaft,  and  the  angle 
of  inclination  between  the 
two  is  greater  than  the  normal 
125°.  It  is  usually  a  secondary 
condition,  associated  with  con- 
genital dislocation  or  infantile 
paralysis,  and  is  then  largely 
due  to  the  absence  of  the 
transmission  of  the  body 
weight.  It  may  be  compen- 
satory to  shortness  of  the  leg, 
or  occasionally  results  from 
rickets  or  traumatism.  The 
limb  is  usually  abducted  and 
rotated  outwards,  and  there 
is  some  limitation  of  adduc- 
tion and  internal  rotation 
The  trochanter  is  flattened 
and  displaced  below  Nelaton's 
line.  Treatment,  if  neces- 
sary, is  usually  directed  to 
the  cause  ;  but  if  the  result- 
ing limp  is  seriously  notice- 
able, a  sub-trochanteric  os- 
teotomy of  the  former  may 
be  desirable.  ^'°-  ^58.- 

Genu  Valgum,  or  knock-knee,  _, 

is  a  deformity  in  which,  if  the  ^\l?'^u^''^  ^^'  a  chUd  aged  twelve  years, 
,  <,  ,     .     '  .         ,        and  the  cause  of  the  deformity  was  rickets. 

The  femora  were  curved  antero-posteriorly, 
but  skiagraphy  demonstrated  that  the 
trouble  in  the  right  leg  was  as  much  tibial 
as  femoral  in  origin.  Cuneiform  osteotomy 
of  both  tibia  and  femur  was  needed  on  the 
right  side,  whilst  simple  osteotomy  of  the 
femur  suf3&ced  to  correct  the  left  side. 


-Genu  Valgum  of  Rachitic 
Origin. 


knees  are  allowed  to  touch 
with  the  patellae  looking  for- 
wards, the  malleoli  are  separ- 
ated one  from  the  other — i.e., 
it  is  a  condition  of  fixed  ab- 
duction of  the  legs  from  the 
middle  line,  with  some  ex- 
ternal rotation  (Fig.  158).  One  or  both  limbs  may  be  affected,  but 
if  due  to  general  causes  the  double  form  is  more  common.  Occa- 
sionally genu  valgum  occurs  in  one  leg,  whilst  the  other  is  in  a  con- 
dition of  genu  varum. 

There  are  two  main  varieties  of  the  disease,  viz.  :  (i)  The  rachitic 
genu  valgum  of  young  children,  and  (2)  the  static  form  occurring  in 
adolescents. 


446  A  MANUAL  OF  SURGERY 

The  genu  valgum  of  young  children  due  to  rickets  arises  from  the 
irregular  epiphyseal  development  induced  thereby.  In  some  cases 
there  is  a  primary  increased  growth  on  the  inner  side  ;  in  others,  an 
arrest  of  development  on  the  outer  ;  in  the  majority,  both  conditions 
are  present.  The  location  of  the  mischief,  whether  mainly  femoral 
or  tibial,  also  varies  in  different  cases,  but  the  femoral  type  is  more 
common  than  the  tibial.  In  some  an  antero-lateral  rachitic  curvature 
of  the  diaphysis  of  the  femur  is  an  important  element. 

The  static  genu  valgum  of  adolescents  occurs  most  commonly  in  young 
people  of  relaxed  constitution,  and  particularly  in  those  who  have  to 
carry  heavy  weights.  Thus,  anaemic  young  women  who  act  as 
nursemaids,  and  young  bricklayers,  smiths,  and  porters,  are  very 
liable  to  it.  The  method  of  origin  is  probably  as  follows :  In  the 
erect  posture  the  femur  is  normally  set  at  an  angle  to  the  tibia  (which 
is  vertical)  in  such  a  way  that  the  weight  of  the  trunk,  transmitted  in 
a  vertical  line  from  the  head  of  the  femur  to  the  ground,  passes 
rather  through  the  outer  than  the  inner  condyle,  whilst  the  latter 
structure  is  lengthened  in  order  to  keep  the  plane  of  the  knee-joint 
horizontal.  This  position  naturally  throws  a  certain  amount  of 
strain  and  tension  on  the  internal  lateral  ligament,  even  in  a  healthy 
person  (hence  its  insertion  into  the  shaft  and  not  merely  into  the 
upper  epiphysis  of  the  tibia) ;  and  this  strain  is  increased  when  the 
natural  position  of  rest — i.e.,  with  the  feet  separated  and  slightly 
abducted — is  adopted.  A  long  continuance  of  this  posture  tires  those 
muscles  on  the  inner  side  of  the  limb  which  tend  to  counterbalance 
this  strain,  especially  if  a  certain  amount  of  additional  weight  has  to 
be  carried,  and  particularly  in  those  whose  bones  have  rapidly  increased 
in  length  and  weight  without  any  coincident  increase  in  power  of 
muscles  or  ligaments.  Hence  the  internal  lateral  ligament  becomes 
more  and  more  stretched,  and  not  unfrequently  a  certain  amount  of 
lateral  mobility  of  the  knee  is  noticed  in  the  early  stages.  Subse- 
quently the  outer  condyle  becomes  atrophied  from  more  weight  being 
transmitted  through  it,  and  the  inner  condyle  becomes  lengthened 
from  overgrowth.  Flat-foot  and  lateral  curvature  of  the  spine  often 
accompany  this  form  of  genu  valgum,  the  former  being  also  usually 
due  to  ligamentous  relaxation,  whilst  the  latter  may  be  merely 
compensatory  if  the  deformity  in  the  knee  is  unilateral. 

Occasionally  genu  valgum  is  due  to  traumatic  causes,  such  as  fracture 
of  the  tibia  or  femur  close  to  the  joint,  or  lateral  dislocation  of  the 
knee ;  whilst,  again,  it  may  be  caused  by  atrophy  consequent  on  inter- 
ference with  the  epiphysis  from  local  injury  or  diseases  other  than 
rickets.  It  is  sometimes  observed,  as  a  result  of  riding,  in  those  with 
long  legs,  as  in  cavalry  soldiers  ;  short-legged  individuals,  such  as 
jockeys,  are  more  liable  to  develop  a  condition  of  genu  varum. 

The  Physical  Condition  of  the  parts  about  the  knee  may  be  sum- 
marized as  follows :  [a)  The  inner  condyle  of  the  femur  is  elongated 
and  prominent ;  the  increase  in  size  is  mainly  in  the  vertical  and 
transverse  directions,  and  but  very  little  antero-posteriorly,  so  that, 
on  flexion  of  the  joint,  the  deformity  to  a  large  extent  disappears: 


DEFORMITIES  447 

[h)  impaired  growth  and  atrophy  of  the  outer  femoral  condyle  and 
tibial  tuberosity  are  present  owing  to  the  weight  of  the  body  being 
transmitted  more  directly  through  these  structures  :  {c)  relaxation  of 
the  ligamentous  and  muscular  tissues  takes  place  on  the  inner  side  of 
the  joint ;  this,  however,  is  not  constant,  especially  in  the  later 
stages,  or  in  cases  which  are  stationary :  (d)  the  tendons  and  liga- 
ments on  the  outer  aspect  of  the  joint  are  contracted  and  shortened, 
especially  the  external  lateral  ligament,  the  ilio-tibial  band,  and  the 
tendon  of  the  biceps :  [e)  the  patella  tends  to  be  thrown  outwards 
from  the  angular  deformity  existing  at  the  knee-joint ;  occasionally 
the  bone  is  actually  dislocated,  and  when  this  has  once  happened  the 
displacement  is  very  likely  to  recur  from  time  to  time :  (/)  in 
rachitic  cases  a  localized  bony  outgrowth  can  usually  be  detected  on 
the  inner  surface  of  the  tibia  about  2  or  3  inches  from  the  joint,  and 
probably  due  to  a  localized  periostitis  at  the  point  of  attachment  of 
the  internal  lateral  ligament. 

The  following  conditions  are  also  observed  not  unfrequently — viz. : 
The  feet  are  displaced  outwards,  or  occasionally  inwards,  as  best  suits 
the  convenience  of  the  patient  in  obtaining  as  good  a  footing  as 
possible  ;  the  bones  of  the  legs  and  of  the  thighs  are  often  bent ; 
whilst,  if  unilateral,  the  pelvis  is  tilted  downwards  on  the  affected  side, 
and  the  spine  laterally  curved.  In  well-marked  cases  the  gait  of  the 
patient  is  of  a  rolling  or  waddling  type,  and  very  characteristic.  The 
legs  are  partially  flexed,  and  as  the  condyles  touch  or  overlap,  they 
have  to  be  separated  at  each  step  to  allow  of  progression. 

Treatment. — In  rachitic  cases,  the  infant  requires  the  adoption  of 
dietetic  and  therapeutic  measures  suitable  to  the  condition  present.  For 
the  local  deformity  absolute  rest  in  bed  is  enforced  ;  the  limbs  are  well 
rubbed  daily,  and  such  manipulation  and  pressure  employed  as  will 
help  to  straighten  the  limb.  By  perseverance  slow  but  appreciable 
progress  may  be  made  until  the  deformity  is  corrected.  In  older 
children,  splints  may  be  applied  on  the  outer  side  of  the  limbs, 
reaching  from  the  waist  or  axilla  down  to  the  outer  malleoli,  or,  if 
they  are  to  be  kept  off  their  feet,  beyond  them.  These  are  retained 
in  position  by  water-glass  bandages,  put  on  firmly  enough  to  draw  the 
knees  outwards.  Such  an  arrangement  is  often  sufficient  in  early 
cases  to  bring  about  a  cure  in  the  course  of  a  few  months.  Some 
authorities  have  recommended  forcible  correction  of  the  deformity, 
and  subsequent  fixation  in  plaster  of  Paris,  but  the  condition  of  the 
epiphyses,  and  the  ease  with  which  they  are  detached  are  good, 
reasons  against  adopting  any  such  method. 

In  the  static  cases  the  administration  of  tonics,  such  as  iron  and 
arsenic,  combined  with  rest,  massage,  and  possibly  a  change  of  air, 
will  frequently  suffice  to  determine  a  cure  in  the  early  stages. 

When  the  deformity  is  somewhat  more  advanced,  more  complicated 
apparatus  is  needed  ;  that  usually  employed  consists  of  an  outside 
iron  stem,  jointed  at  the  knee,  fixed  below  into  a  slot  in  the  heel  of  a 
well-made  boot,  and  attached  above  to  a  pelvic  band.  From  it  several 
well-padded  straps  pass  round  the  limb,  and  at  the  knee  itself  a  much 


448  A  MANUAL  OF  SURGERY 

broader  one  covers  the  projecting  inner  condyle  ;  by  tightening  these, 
the  hmb  is  drawn  out  towards  the  rod.  The  apparatus  is  somewhat 
heavy,  but  if  carefully  applied  for  some  months  may  effect  a  cure. 
It  is  possible  that  division  of  the  tense  structures  on  the  outer  side  of 
the  joint  may  considerably  assist  the  process. 

When,  however,  the  osseous  deformity  is  fixed,  and  the  patient  of 
such  an  age  as  to  preclude  the  hope  of  a  cure  by  mechanical  means, 
osteotomy  will  be  required,  and  the  operation  devised  by  Macewen,  or 
some  modification  of  it,  is  that  generally  employed.  It  consists  in  the 
division  of  the  femur  transversely  about  a  finger's  breadth  above  the 
upper  border  of  the  external  condyle,  so  as  to  be  well  away  from 
the  epiphyseal  cartilage.  Macewen  himself  uses  an  osteotome*  for 
the  purpose,  introducing  it  through  an  incision  made  |  inch  in  front  of 
the  tendon  of  the  adductor  magnus,  and  turning  it  so  as  to  lie  at  right 
angles  to  the  long  axis  of  the  shaft ;  he  divides  the  bone  for  three- 
quarters  of  its  diameter,  and  breaks  the  remainder.  A  similar  method 
may  be  employed  from  the  outer  side,  the  force  used  in  breaking  the 
inner  layer  of  compact  bone  comminuting  and  compressing  that 
portion,  and  so  diminishing  the  deformity.  Many  surgeons,  however, 
prefer  to  divide  the  bone  with  a  saw,  previously  making  a  track  for  it 
along  the  front  of  the  femur,  and  we  certainly  consider  that  such  an 
operation  is  simpler,  and  equally  efficacious.  The  limb,  having  been 
straightened,  is  either  put  up  at  once  in  plaster  of  Paris,  or,  perhaps, 
at  first  in  a  Gooch's  splint,  which  allows  the  wound  to  be  looked  at  and 
dressed,  and  subsequently  in  plaster.  Union  is  complete  in  six  weeks, 
but  an  immoveable  apparatus  should  be  kept  on  for  three  months. 

In  a  few  cases  due  to  rickets  it  may  be  necessary  to  divide  the  tibia 
just  below  the  tubercle  in  addition  to  dealing  with  the  femur.  This 
is  best  accomplished  as  a  first  step,  and  the  fibula  will  also  have  to 
be  divided.  When  these  wounds  have  consolidated,  the  femur  is 
dealt  with,  if  necessary. 

Genu  Varum,  or  how-leg,  is  a  less  common  condition,  characterized 
by  a  fixed  separation  of  the  knees  when  the  ankles  are  in  contact 
(Fig.  159).  It  arises  from  three  chief  causes  :  (i.)  Occupation,  and 
particularly  that  of  a  jockey,  the  short  legs  being  constantly  apposed 
to  the  sides  of  the  horse  ;  (ii.)  traumatism,  especially  if  directed  to 
the  femoral  condyles  ;  and  (iii.)  rickets,  the  lesion  usually  present  being 
a  well-marked  excurvation  of  the  femoral  shafts,  with  possibly  a 
similar  curve  of  the  tibiae.  The  condition  is  usually  bilateral,  but 
occasionally  one  side  only  is  affected,  and  then  the  other  leg  is  in  a 
state  of  genu  valgum.  Treatment  in  the  early  stage  is  by  splints,  in 
the  latter  by  operation,  which  consists  either  in  simple  osteotomy 
above  the  knee,  or  in  cuneiform  osteotomy  of  the  shaft  of  the  femur. 

Genu  Recurvatum,  or  back-knee,  is  a  deformity  occasionally  met  with, 
in  which  the  joint  is  hyper-extended,  the  limb  describing  a  curve  with 
the  concavity  forwards ;  it  is  necessarily  associated  with  relaxation  or 
stretching  of  the  crucial  ligaments,  and  is  usually  due  to  a  congenital 

*  An  osteotome  differs  from  a  chisel  is  the  fact  that  the  former  in  bevelled  en 
both  sides,  whilst  the  latter  is  merely  bevelled  on  one  side. 


DEFORMITIES 


449 


displacement,  possibly  the  result  of  the  limbs  not  being  flexed  in  utevo, 
but  extended  with  the  feet  under  the  chin.  It  is  sometimes  the  result 
of  paralysis  of  the  flexor  muscles  of  the  knee  and  of  the  popliteus,  or 
of  Charcot's  disease  of  the  knee-joint ;  or  it  may  arise  from  irregular 
growth  along  the  epiphyseal  line,  possibly  as  a  sequela  of  tuberculous 
or.  other  disease  of  limited  extent  in  that  region.  It  has  also  been 
known  to  occur  as  an  acquired'  accomplishment  in  fakirs  and  con- 
tortionists. Treatment  must  be  suited 
to  the  special  requirements  of  the  indi- 
vidual case. 

Contractions  of  the  Knee  may  arise 
from  intra-  or  extra-articular  causes. 
The  extra-articular  causes  (i)  occur  in 
the  skin  and  subcutaneous  tissues  from 
the  contraction  of  cicatrices  of  burns 
or  ulcers ;  or  (2)  the  flexor  muscles  may 
become  contracted  in  consequence  of 
diffuse  suppuration  within  their  sheaths, 
or  of  infantile  paralysis  of  the  ex- 
tensors, or  as  a  secondary  result  of  in- 
flammatory troubles"  in  the  knee-joint. 
(3)  The  contraction  is  in  some  cases 
hysterical,  the  joint  being  fixed  by 
muscular  action,  but  remaining  healthy, 
although  much  pain  and  superficial 
tenderness  are  complained  of.  The 
diagnosis  is  readily  made  by  inducing 
anaesthesia,  or  taking  the  patient  un- 
awares, when  the  limb  is  found  freely 
moveable  and  can  be  easily  straightened. 

The  articular  causes  are  as  follows : 
(i)  Where  the  capsule  and  ligaments 
are  mainly  affected  owing  to  rheumatic 
or  gonorrhoeal  inflammation.  The  limb 
is  fixed,  but  there  is  no  actual  displace- 
ment of  the  tibia.  (2)  Fibrous  ad- 
hesions of  greater  or  less  density  may 
pass  between  the  articular  surfaces,  as 
a  result  either  of  acute  synovitis,  or 
of  tuberculous  or  acute  arthritis.  In 
the    former    case    some   mobility  ,may 

be  present,  but  in  the  latter  the  movements  may  be  very  defec- 
tive. (3)  Osseous  ankylosis  may  follow  tuberculous  or  acute 
arthritis,  the  position  of  the  limb  depending  on  the  previous  treat- 
ment. Thus,  in  neglected  cases  the  tibia  is  occasionally  flexed 
on  the  femur,  whilst  its  upper  surface  is  displaced  horizontally 
backwards,  and  the  lower  limb  rotated  outwards,  constituting  what 
is  known  as  the  triple  displacement.  If  the  limb  has  been  allowed 
to    lie   on    its   outer    side   whilst    disorganization  was    proceeding. 


Fig.   159. 


—  Bilateral   Genu 
Varum. 


The  patient  was  a  girl  of  thirteen 
years,  who  had  developed  this 
condition  during  two  years,  and 
was  the  subject  of  adolescent 
rickets.  Enlargement  of  the 
epiphyseal  ends  of  the  radius 
and  ulna,  and  of  the  costo-chon- 
dral  junctions,  was  also  present. 


450  A  MANUAL  OF  SURGERY 

there  may  be  an  additional  outward  displacement  of  the  tibia.  (4) 
After  partial  excision  in  early  life,  the  knee  may  become  flexed  or 
hyper-extended  years  later,  as  a  result  of  irregular  growth  at  the 
epiphyseal  line.  Flexion  is  much  more  common  than  extension.  It 
must  not  be  forgotten  that  in  all  these  articular  conditions  the 
muscles  and  soft  parts  become  secondarily  contracted  to  accommodate 
themselves  to  the  condition  of  affairs  ;  and  this  accommodative  shorten- 
ing may  seriously  hamper  the  efforts  of  the  surgeon  to  reduce  the 
deformity. 

The  Treatment  of  these  conditions  necessarily  depends  on  their 
nature.  Where  adhesions  exist  within  the  joint,  or  the  ligaments 
alone  are  contracted,  it  may  be  possible  to  straighten  the  limb  under 
an  anaesthetic  by  forcible  manipulation.  Where  the  contraction  is 
associated  with  osseous  ankylosis,  a  suitable  wedge-shaped  piece  of 
bone  should  be  removed  (cuneiform  osteotomy).  In  the  triple  displace- 
ment ordinary  excision  may 'be  undertaken,  but  it  is  often  a  difficult 
matter  to  remedy  the  backward  displacement  of  the  tibia.  The  bones 
should  subsequently  be  kept  in  position  by  silver-wire  sutures,  or 
other  means. 

Rachitic  Tibia  and  Fibula. — These  bones  are  liable  to  a  considerable 
amount  of  distortion  in  the  course  of  an  attack  6f  rickets  if  the  child 
is  allowed  to  run  about.  As  a  rule,  the  antero-posterior  curve  is 
increased,  and  some  amount  of  ab-  or  ad-duction  may  also  be 
present.  The  bones,  too,  are  usually  flattened  from  side  to  side, 
presenting  a  sharp  edge  in  front,  with  a  buttress-like  support  reaching 
along  the  concavity ;  they  become  exceedingly  dense  and  sclerosed. 
Operations  should  never  be  undertaken  until  all  active  signs  of  rickets 
have  disappeared.  The  bones  may  simply  be  divided  at  their  most 
prominent  part,  or,  if  necessary,  a  wedge-shaped  portion  may  be  re- 
moved from  the  tibia  [cuneiform  osteotomy),  the  sections  being  made  at 
right  angles  to  the  upper  and  lower  segments  of  the  bone  respectively. 
The  fibula  never  needs  more  than  simple  division,  and  this  is 
accomplished  through  a  separate  incision. 

The  tibia  and  fibula  also  become  distorted  and  curved  antero- 
posteriorly  as  the  result  of  inherited  syphilis  ;  this  usually  comes  under 
notice  at  a  later  date  than  the  rachitic  change.  The  deformity  is 
purely  antero-posterior,  without  lateral  deviation,  whilst  the  sub- 
cutaneous margin  of  the  tibia  is  rounded,  and  not  sharp  as  in  ricketSt 
Moreover,  the  curve  generally  involves  the  centre  of  the  bone,  whilst 
in  rickets  the  chief  deformity  occurs  either  near  the  knee  or  a  little 
above  the  ankle. 

Talipes. 

By  talipes,  or  club-foot,  is  meant  a  deformity  of  the  foot  due  to 
muscular,  ligamentous,  or  osseous  causes,  the  displacement  occurring 
mainly  at  the  ankle  and  mid-tarsal  joints. 

Causes. — Talipes  may  be  congenital  or  acquired. 

Congenital  malformation  is  responsible  for  a  certain  percentage  of 
the  cases,  resulting  from  imperfect  formation  of  the  bones  of  the 


DEFORMITIES  451 

foot,  occasionally  from  absence  of  the  lower  end  of  the  tibia  or  fibula, 
or  very  rarely  from  intra-uterine  paralysis  of  central  origin.  Other 
cases  are  due  to  malposition  of  the  feet  in  utero,  possibly  resulting  from 
a  deficient  amount  of  liquor  amnii,  as  a  result  of  which  the  feet  are 
abnormally  compressed  and  held  in  one  position.  Naturally  the  legs 
of  the  foetus  are  in  a  state  of  flexion,  and  the  feet  usually  in  a  position 
corresponding  to  that  of  talipes  varus ;  it  is  easy  then  to  understand 
that  in  an  unusually  small  uterus  this  position  may  become  fixed. 
Spina  bifida  in  the  lumbar  region  is  occasionally  associated  with 
congenital  talipes,  which  is  then  probably  due  to  impairment  of 
nervous  control.  The  congenital  variety  is  often  hereditary,  and  may 
occur  in  several  members  of  the  same  family,  or  be  transmitted 
through  many  generations. 

The  acquired  varieties  arise  from  some  derangement  of  the  equili- 
brium normally  maintained  between  opposing  groups  of  muscles,  in 
consequence  of  which  the  more  powerful  group  draws  the  foot  into 
an  abnormal  position.  Thus  it  may  be  due  to :  (a)  Paralysis  of 
central  origin,  one  of  the  commonest  causes  of  talipes ;  in  young 
children  this  form  is  usually  the  result  of  infantile  palsy  (anterior 
polio-myelitis),  whilst  a  similar  affection  is  occasionally  seen  in  adults. 
(b)  Cicatricial  contraction  of  muscles  from  diffuse  suppuration,  or 
arising  from  burns  or  disease  of  neighbouring  bones ;  thus  necrosis 
or  caries  of  the  tibia  may  lead  to  the  formation  of  an  abscess  in  the 
sheaths  of  the  tibialis  anticus  or  posticus,  and  contraction  of  one  or 
both  of  these  muscles  may  cause  talipes  varus,  (c)  Essential  muscular 
shrinking,  resulting  from  a  chronic  myositis  fibrosa,  is  occasionally 
met  with  in  elderly  people,  (d)  Affections  of  the  main  peripheral 
nerve-trunks  of  the  leg  also  lead  to  talipes.  If  the  internal  popliteal 
nerve  is  involved,  talipes  calcaneo-valgus  will  ensue,  whilst  a  lesion  of 
the  external  popliteal  nerve  produces  talipes  equino-varus,  but  never 
to  any  marked  degree,  (e)  Certain  diseases  of  the  cord  of  a  sclerosing 
type  occasionally  cause  a  spastic  variety  of  talipes.  (/)  Shortening  of 
the  leg  from  hip  or  knee  mischief  often  induces  a  compensatory  talipes 
equinus,  whilst  injuries  or  diseases  of  one  of  the  epiphyses  of  the  leg 
bones  may  stop  its  growth,  and  then  the  continued  development  of 
the  other  bone  forces  the  foot  to  one  side  or  the  other,  {g)  It  is  a 
question  whether  the  condition  known  as  flat-foot,  arising  from  pro- 
longed standing,  is  to  be  classed  as  a  form  of  talipes ;  some  surgeons 
draw  but  little  difference  between  it  and  talipes  valgus,  {h)  Finally, 
prolonged  maintenance  of  the  foot  in  a  bad  position  may  lead  to 
permanent  deformity,  as  in  the  variety  known  as  talipes  decubitus. 

Four  primary  forms  of  taMpes  are  described,  viz. :  T.  Equinus,  in 
which  the  heel  is  drawn  up,  the  patient  walking  on  the  toes  (plantar- 
flexion)  ;  T.  Calcaneus,  in  which  the  toes  are  raised  from  the  ground 
(dorsi-flexion) ;  T.  Varus,  in  which  the  anterior  half  of  the  foot  is 
adducted  and  inverted,  and  the  inner  side  of  the  foot  is  raised,  the 
patient  walking  on  the  outer  ;  and  T.  Valgus,  due  to  abduction  and 
eversion  of  the  anterior  half  of  the  foot,  or  to  yielding  of  the  longi- 
tudinal arch  on  the  inner  side.     Not  unfrequently  mixed  forms  occur, 


452 


A  MANUAL  OF  SURGERY 


due  to  the  association  of  two  of  the  above — e.g.,  T.  equino-varus,  or 
T.  equino-valgus,  or  T.  calcaneo-valgus. 

As  to  the  relative  frequency  of  these  different  forms,  there  is  not  the 
shghtest  question  that  T.  equino-varus  is  by  far  the  commonest.  If, 
however,  we  exclude  congenital  cases  and  flat-foot,  T.  equinus  is  in 
all  probability  the  variety  most  frequently  observed. 

Talipes  Equinus.  (Fig.  i6o,  A,  B,  and  C)  is  almost  always  acquired ; 
as  a  congenital  lesion  it  is  very  uncommon.  It  is  usually  due  to 
paralysis  of  the  extensor  muscles,  either  from  infantile  palsy  or  injury 
to  the  anterior  tibial  nerve  ;  secondary  contraction  of  the  calf  muscles 
follows,  the  tendo  Achillis  being  tense  and  rigid.  It  also  occurs  as  a 
compensatory  manifestation  where  the  limb  has  been  shortened,  as 
after  hip  disease,  and  may  result  from  prolonged  pressure  of  the  bed- 
clothes on  the  dorsum  of  the  foot  of  a  bed-ridden  patient  (T.  decubitus). 


B 

Fig.   i6o. — Various  Forms  of  Talipes  Equinds. 


In  the  slightest  cases  all  that  is  noticed  is  that  the  foot  cannot  be 
dorsi-flexed  beyond  a  right  angle  (right-angled  contraction  of  the 
ankle).  When  more  marked,  the  heel  is  drawn  up,  and  the  patient 
walks  on  the  heads  of  the  metatarsal  bones  and  on  the  toes,  which  are 
usually  hyper-extended.  In  neglected  cases  due  to  paralysis,  the  toes 
sometimes  become  plantar-flexed,  the  patient  walking  on  their  upper 
surface  (Fig.  i6o,  C) ;  the  whole  dorsum  of  the  foot  may  even  in  time 
be  turned  downwards.  The  astragalus  is  displaced  forwards  from 
under  the  malleolar  arch,  only  the  posterior  part  of  the  articular 
surface  being  in  contact  with  the  tibia.  In  the  paralytic  type  the 
anterior  segment  of  the  foot  drops  at  the  mid-tarsal  joint,  so  that  the 
head  of  the  astragalus  and  scaphoid  constitute  a  marked '  prominence 
beneath  the  skin.  In  all  cases  the  sole  of  the  foot  is  shortened  by 
contraction  of  the  plantar  fascia  and. of  the  short  plantar  muscles  (pes 
cavus),  and  a  certain  amount  of  varus  is  frequently  present.  In  this, 
as  in  all  forms  of   talipes,  callosities,  and  perhaps  bursae  beneath 


DEFORMITIES 


453 


them,  form  over  points  of  pressure — viz.,  under  the  heads  of  all  the 
metatarsal  bones. 

Talipes  Varus,  or,  as  it  is  most  frequently  termed,  Equino-varus,  is 
the  commonest  variety  of  congenital  club-foot,  but  it  is  not  a  very 
unusual  result  of  infantile  palsy  of  the  extensor  and  peroneal  muscles, 


Fig.  i6i. — Double  Talipes  EgtiNO- 
VARUs  OF  Congenital  Origin. 


Fig.  162. — The  Same,  seen  from 
Behind. 


with  secondary  shortening  of  the  tibialis  anticus  and  posticus,  the 
flexor  longus  digitorum,  and  of  the  tendo  Achillis.  Other  cases  are 
due  to  a  primary  spastic  contraction  of  these  muscles. 

The  heel  is  drawn  up,  and  the  anterior  half  of  the  foot  adducted  and 
drawn  inwards  (Figs.  161  and  162).  The  inner  border  of  the  foot  is 
concave,  and  a  well-marked  transverse  crease  crosses  the  sole  on  a 
level  with  the  mid-tarsal  joint ;  the  outer  border 
is  convex,  and  in  adults  who  have  walked  a 
thick  bursal  formation  is  usually  present  over 
the  cuboid.  In  neglected  cases  the  patient  may 
even  stand  on  the  dorsal  aspect  of  the  latter 
bone  (Fig.  164,  A).  The  sole  of  the  foot  is 
arched  from  secondary  contraction  of  the 
plantar  fascia  and  short  muscles  of  the  sole, 
especially  the  abductor  hallucis,  and  a  longi- 
tudinal crease  may  run  down  the  centre  of 
the  sole,  owing  to  doubling  over  of  the  outer 
metatarsal  bones  (Fig.  164,  B). 

The  most  marked  Anatomical  Changes  in  the 
congenital  type  are  found  in  the  astragalus. 
In  infants  the  head  and  neck  are  normally  set 
at  an  angle  to  the  body  of  the  bone,  being 
directed  slightly  inwards ;  as  growth  proceeds,  this  diminishes  from 
about  35°  to  10°,  so  that  in  the  adult  there  is  but  little  obliquity 
of  the  neck.  In  Talipes  varus  this  angle  is  increased,  often  amount- 
ing to  50°  or  more,  the  neck  at  the  same  time  being  longer  than 
usual,  a  condition  simulating  that  found  in  some  of  the  higher  apes. 
The  bone  also  projects  forwards  from  under  the  tibio-fibular  arch,. 


Fig.  163.  —  Paralytic 
Form  of  Talipes 
Equino-varus. 


454 


A   MANUAL  OF  SURGERY 


the  posterior  portion  of  the  upper  articular  facet  alone  remaining 
in  contact  with  it.  The  scaphoid  is  displaced  to  the  inner  side  of  the 
head  of  the  astragalus,  and  its  tubercle  is  usually  in  close  proximity 
to,  or  may  even  touch,  the  inner  malleolus.  The  os  calcis  and  other 
tarsal  bones  are  also  modified  in  position  and  shape  to  correspond 
with  these  changes.  The  dorsal  tendons  are  displaced  inwards,  usually 
occupying  the  centre  of  the  concavity  between  the  foot  and  the  leg. 
The  ligaments  on  the  inner  side  of  the  foot  are  contracted,  especially 
the  anterior  portion  of  the  deltoid,  the  inferior  calcaneo-scaphoid,  and 
to  a  less  extent  the  long  and  short  plantar  ligaments. 


A  B 

Fig.  164. — Neglected  Case  of  Talipes  Varus. 

The  following  table  (slightly  modified  from  Mr.  Tubby's  work  o: 
Deformities*)  indicates  the  chief  diagnostic  points  between  congenita 
and  paralytic  T.  equino-varus  : 

CONGKNITAL.  PARALYTIC. 

History Affection  has  existed    Affection  not  developed  till  th« 

from  birth.  second   or    third    year,    and 

ushered  in  by  convulsions, 
fever,  etc. 

Feet  affected  Usually  bilateral.  More  often  unilateral. 

Circulation Good.  Feeble  ;  limb  is  sometimes  cold, 

blue,  and  clammy. 

Muscles    But  little  wasting.  Extreme  wasting. 

Electrical  Reactions  Not  much  impaired.  Almost  entirely  absent  in  para- 
lyzed muscles. 

Growth  OF  Bones.  .. .     Much  as  usual.  Considerably  diminished. 

Creases  in  Sole Present.  Absent. 

Talipes  Calcaneus  is  an  unfrequent  variety  of  the  deformity,  and  may  , 
be  either  congenital  or  acquired.  In  the  congenital  form  (Fig.  165) 
the  toes  are  drawn  upwards  so  that  the  heel  alone  comes  into  contact 
with  the  ground,  the  sole  pointing  forwards.  The  extensor  tendons 
are  contracted,  but  the  toes  may  be  flexed  owing  to  the  ten-sion  of  the 
flexor  longus  digitorum.    It  is  sometimes  associated  with  deviation  of 

*  Macmillan,  1896,  p.  398, 


DEFORMITIES 


455 


the  foot  inwards  or  outwards,  constituting  a  condition  of  T.  calcaneo- 
varus  or  -valgus.  The  acquired  variety  (Fig.  i66)  is  generally  due  to 
infantile  palsy  of  the  calf  muscles,  or  occasionally  to  overstretching 
of  the  tendo  Achillis  after  tenotomy.  The  longitudinal  arch  of  the 
foot  is  increased,  partly  from  the  development  of  a  large  pad  of  fat 


Fig  165. — Congenital  Talipes 
Calcaneus. 


F:g.  166.  —Paralytic  Talipes  Calcaneus, 
WITH  well-marked  Hallux  Flexus. 


over  the  calcaneal  tuberosities,  but  mainly  from  the  dropping  of  the 
anterior  half  of  the  foot  from  the  mid-tarsal  joint  owing  to  secondary 
contraction  of  the  plantar  fascia  and  short  muscles  of  the  sole. 

Talipes  Valgus  is  a  condition  seldom  met  with  as  a  congenital  de- 
formity, except  in  association  with  T.  equinus.     In  it  the  outer  side 


Fig.  167. — Talipes  Valgus  (Congenital), 
WITH  a  Little  Tendency  to  Calcaneus. 


-Acquired  Talipes 
Valgus. 


of  the  foot  is  adducted  and  everted,  owing  to  contraction  of  the  peronei 
muscles.  The  sole  becomes  flattened,  and  the  inner  border  of  the 
foot  comes  in  contact  with  the  ground  (Fig.  167).  Considerable  pain 
is  usually  experienced  after  walking  a  short  distance.  This  deformity 
is  occasionally  due  to  absence  of  the  fibula.     The  acquired  variety 


45^ 


A  MANUAL  OF  SURGERY   ^ 


which  is  not  uncommon  (Fig.  i68)  results  from  paralysis  of  the  tibial 
muscles,  or  from  spastic  contraction  of  the  peronei,  the  condition  in 
these  cases  closely  simulating  flat-foot. 

The  Diagnosis  of  the  different  varieties  of  talipes  is,  as  a  rule,  easily 
made,  although  the  cause  of  the  deformity  is  not  always  so  readily 
ascertained.  In  paralytic  cases  the  limb  is  generally  atrophied,  bluish 
in  colour,  and  feels  cold  and  clammy.  Trophic  lesions  are  not 
uncommon  in  the  form  of  recurrent  ulceration,  and  even  ulcers  of  the 
perforating  type  may  develop,  especially  in  cases  due  to  nerve  lesions, 
whether  central  or  peripheral.  The  trouble  is  often  unilateral,  and  the 
muscles  are  wasted  and  flabby.  In  congenital  cases  the  condition  is 
usually  symmetrical,  and  of  course  present  from  birth  ;  considerable 
resistance  is  felt  on  any  attempt  being  made  to  correct  the  deformity, 
and  the  limbs  look  healthy,  are  well  nourished,  at  any  rate  at  first, 
and  free  from  trophic  lesions.  In  spastic  cases  (most  frequently  T. 
equinus)  spasm  or  contraction  of  other  parts  is  usually  present, 
which  renders  the  diagnosis  obvious ;  one  or  both  limbs  may  be 
affected  ;  the  muscles,  at  first  firmly  contracted,  may  finally  atrophy. 
The  Treatment  of  talipes  is  always  tedious,  demanding  care  and 
patience  on  the  part  of  all  concerned.  In  the.  congenital  variety  no 
time  should  be  lost  in  correcting  the  deformity,  and,  in  fact,  treatment 
should  commence  as  soon  after  birth  as  possible.  The  nurse  must 
be  instructed  to  manipulate  the  foot  into  a  good  position,  holding  it 
there  for  some  time  daily,  and  the  medical  attendant  may  attempt 
more  forcible  correction  two  or  three  times  a  week.  At  the  same 
time  the  muscles  on  the  offending  side  of  the  limb  should  be  rubbed 
and  stimulated.  In  the  early  stages  of  the  paralytic  variety  friction 
and  faradization  of  the  paralyzed  muscles  must  be  regularly  under- 
taken. At  a  somewhat  later  date  treatment  by  the  application  of 
suitable  mechanical  apparatus  may  suffice  to  restore  the  foot  to  its 

normal  position.  If  this 
is  unsuccessful,  division  of 
the  contracted  tendons,  liga- 
ments, and  fasciae  will  be 
necessary,  whilst  in  severe 
and  neglected  cases  more 
extensive  operations  in  the 
shape  of  tarsectomy  or  tar- 
sotomy may  have  to  be 
performed. 

Talipes  equinus,  if 
secondary  to  hip  disease, 
should  not,  as  a  rule,  be 
interfered  with.  In  other 
early  cases  it  may  be 
remedied  by  what  is  known 
This  consists  in  the  application  of 


Fig.   169. — Sayre's  Apparatus  for  Talipes 

Equinus. 

The  upper  figure  shows  how  the  strapping  is 

fixed  to  the  plantar  spUnt. 


as  Sayre's  apparatus  (Fig.  169). 

a  plantar  splint  which  projects  slightly  beyond  the  toes,  and  from  the 

anterior  end  of  which  a  piece  of  adhesive  strapping  is  carried  to  just 


DEFORMITIES 


457 


below  the  knee,  to  which  it  is  appHed  and  fixed  by  a  firm  bandage. 
Each  day  the  bandage  is  carried  a  little  lower  down  the  limb,  and 
as  the  traction  of  the  strapping  is  thereby  increased,  the  foot  is 
gradually  extended.  In  the  more  serious  varieties  tenotomy  of  the 
tendo  Achillis  may  be  required,  accompanied,  if  necessary,  by  division 
of  the  plantar  fascia,  whilst  in  neglected  cases,  or  where  tenotomy 
has  failed,  excision  of  the  astragalus  gives  most  excellent  results,  the 
patient  being  able  to  walk  subsequently  with  a  plantigrade  foot. 

Talipes  equino-vavus  may  be  treated  in  the  early  stages  by  applying 
to  the  foot  a  carefully-fitted  malleable  splint  (Fig.  170),  the  shape  of 
which  is  gradually  altered  so  as  to  bring  it  in  time  to  a  normal  position, 
or  by  a  series  of  casings  of  plaster  of  Paris,  a  little  improvement  being 
obtained  at  each  change.  By  care  and  patience  many  a  cure  will 
thus  be  obtained.  In  some  cases  the  tendo  Achillis  and  plantar 
fascia  may  be  divided  and  the  equinus  and  cavus  elements  cured, 
thereby  rendering  the  varus  condition  more  amenable  to  pressure. 

In  cases  where  such  early  treatment  has  not  been  undertaken,  or 
where  the  deformity  has  not  been  improved  thereby,  forcible  correction 
{vedressement  modelant)  may  be  attempted.  The  child  is  placed  under 
an  anaesthetic,  and  the  foot  is  forcibly  wrenched  and  moulded  into  a 
good  position,  a  Thomas's  wrench  being  employed,  if  need  be.  It  is 
essential  that  the  foot  should 
remain  in  good  position  when 
all  force  is  removed  from  it. 
Possibly  division  of  the  tibial 
tendons  may  assist  in  this  pro- 
cedure, as  also  section  of  the 
tense  ligaments  on  the  inner 
side  of  the  foot  {syndesmotomy), 
but  if  such  can  be  avoided,  so 
much  the  better.  The  foot  is 
then  placed  in  plaster  of  Paris 
for  five  or  six  weeks,  and  sub- 
sequently massage  and  suitable 
exercises  are  employed  before  Fig. 
walking  is  allowed. 

It  is,  however,  only  in  the 
early  stages  that  such  treat- 
ment is  advisable.  At  the 
age  of  eighteen  to  twenty-four 
months  considerable  growth  of 
the  limb  has  determined  such 
osseous  development  as  almost 
forbids  one  to  expect  benefit 
from  it,  without  the  exercise  of 
undue  force.  Hence,  if  treat- 
ment is  not  commenced  till  the  child  is  two  years  of  age,  and  still  more 
if  the  child  has  walked  or  is  older,  other  methods  must  be  employed. 
Of  these,  two  chief  plans  have  been  advocated,  viz.,  tarsectomy  and 


170.  —  Malleable  Splint  for 
Treatment  of  Congenital  Talipes 
Eqdino-varus. 

It  consists  of  two  plates  of  metal,  shaped 
to  fit  the  sole  of  the  foot  and  the  lower 
part  of  the  leg  respectively  ;  these  are 
united  by  a  malleable  curved  bar  of 
copper.  The  foot-piece  is  first  fixed, 
and  then  the  foot  brought  into  as  good 
a  position  as  possible,  and  the  leg-piece 
bandaged  on.  Each  week  the  foot-piece 
is  bent  a  little  more  towards  the  normal 
position. 


458  A  MANUAL  OF  SURGERY 

Phelps'  operation,  i.  In  tarsectomy,  a  wedge-shaped  portion  of  bone 
is  removed  from  the  outer  aspect  of  the  foot.  This  is  accompHshed 
through  a  semilunar  incision  on  the  outer  aspect  of  the  foot,  a 
flap  being  turned  up  so  as  to  allow  it  to  be  shortened  before  the 
operation  is  completed,  so  that  the  skin  being  tense  may  help  to 
keep  the  foot  in  good  position.  The  thick  subcutaneous  structures, 
including  the  bursa,  are  removed,  and  the  extensor  tendons,  already 
somewhat  displaced  inwards,  are  stripped  from  the  bones  by  a 
raspatory,  and  held  aside  by  retractors.  The  tarsus  is  now  divided 
by  a  chisel  in  two  places  in  such  a  way  that  a  wedge  of  bone 
can  be  removed,  the  base  being  on  the  outer  aspect,  and  the  apex 
on  the  inner.  The  position  of  the  joints  need  not  be  taken  much 
into  consideration,  and  as  far  as  possible  the  sections  are  made 
at  right  angles  to  the  anterior  and  posterior  segments  of  the  foot 
respectively,  sufficient  bone  being  removed  to  allow  the  foot  to 
come  into  good  position  without  difficulty.  After  closing  the  wound, 
the  foot  is  kept  in  position,  at  first  by  ordinary  splints  and  subse- 
quently by  plaster  of  Paris  for  six  or  eight  weeks.  The  results  are 
excellent,  the  foot,  although  a  little  shortened,  being  firm  and 
plantigrade.  2.  Phelps'  operation  consists  in  dividing  all  the  structures 
on  the  inner  aspect  of  the  foot  through  a  vertical  incision,  starting 
above  just  in  front  of  the  internal  malleolus.  The  mid-tarsal  joint  is 
usually  opened,  tendons  and  ligaments  are  divided,  and  the  foot  put 
up  in  a  good  position  with  the  wound  gaping.  Healing  may  be 
accelerated  by  skin  grafting.  The  results  are  at  first  quite  as  good  as 
those  attained  by  tarsectomy,  but  the  deformity  is  likely  to  recur 
as  cicatrization  advances.  In  successful  cases  the  longitudinal  arch 
of  the  foot  is  lost,  and  the  cosmetic  result  is  anything  but  perfect, 
whilst  the  patient  usually  requires  an  instep  support.  In  our  opinion 
tarsectomy  is  much  the  better  operation,  and  even  when  undertaken 
in  children  need  not  interfere  with  the  subsequent  growth  of  the  foot. 

In  paralytic  Talipes  varus  the  foot  will  probably  remain  weak  and 
flail-like  in  spite  of  treatment,  and  a  suitable  boot  with  leg  irons  to 
steady  it  will  be  required.  The  character  of  the  treatment  neces- 
sarily varies  with  the  extent  of  the  paralysis,  but  occasionally  help 
is  obtained  by  displacing  the  attachment  of  a  healthy  tibialis  amicus 
from  the  inner  to  the  outer  side  of  the  foot.  In  very  bad  cases 
arthrodesis  of  the  ankle  {i.e.,  its  fixation  by  removal  of  the  articular 
cartilage  and  subsequent  synostosis)  may  secure  to  the  patient  a 
firm  basis  of  support. 

In  congenital  Talipes  calcaneus  all  that  may  be  needed  is  division 
of  the  extensor  tendons ;  but  in  the  paralytic  variety  some  form  of 
apparatus  must  always  be  worn.  Where  the  tendo  Achillis  is  thin 
and  attenuated,  a  portion  of  it  may  be  excised,  and  the  ends  united 
by  suture ;  or  the  tubercle  of  the  os  calcis  into  which  the  latter  is 
inserted  may  be  sawn  off  and  re-attached  by  a  nail  or  peg  to  the 
bone  at  a  lower  level  (Walsham) ;  but  the  prognosis  in  all  forms  due 
to  paralysis  is  unsatisfactory. 

Talipes  valgus,  if  unrelieved  by  the  application  of  suitable  boots, 


DEFORMITIES 


459 


may  need  division  of  the  peroneal  tendons,  or  in  severer  cases 
wrenching  the  foot  into  position,  and  fixation  in  plaster  of  Paris. 
Removal  of  a  wedge-shaped  portion  of  bone  from  the  inner  aspect 
of  the  foot  may  be  undertaken,  but  is  not  very  successful. 

Flat-foot  {syn.  :  Splay-foot  or  Spurious  Valgus)  is  a  condition  fre- 
quently seen  in  young  adults  whose  occupation  exposes  them  to 
over-fatigue,  or  the  carrying  of  heavy  weights — e.g.,  in  nurse-girls  or 
shop-boys  who  have  only  recently  left  school.  It  occurs  as  a  natural 
condition  in  many  of  the  negro  races,  and  is  more  often  seen  in  long 
than  in  short  feet.  It  also  results  from  rupture  of  the  inferior 
calcaneo-scaphoid  ligament,  fracture  of  the  neck  of  the  astragalus,  of 
the  sustentaculum  tali,  or  of  the  greater  process  of  the  calcaneum 
{traumatic  flat-foot) . 

Mechanism. — In  the  majority  of  non-traumatic  cases  it  is  due  to 
relaxation  of  the  inferior  calcaneo-scaphoid  ligament,  which  supports 
the  under  surface  of  the  head  of  the  astragalus,  and  thus  keeps  up 
the  longitudinal  arch  of  the  foot.  This  in  its  turn  is  braced  up  by 
the  tendon  of  the  tibialis  posticus  and  an  expansion  backwards  there- 
from to  the  OS  calcis,  as  also  by  the  plantar  fascia  and  ligaments, 
and  by  the  short  muscles  of  the  sole.  A  rapid  increase  in  the 
length  and  weight  of  the  skeleton  apart  from  an  equivalent  in- 
crease in  strength  of  muscles  and  hgaments  throws  undue  strain 
upon  this  structure,  especially  if  the  patient  is  suddenly  exposed 
to  long  hours  of  standing  or  weight-carrying.  The  ligament 
stretches,  the  head  of  the  astragalus  sinks,  the  anterior  portion 
of  the  foot  becomes  abducted  at  the  mid-tarsal  joint,  and  the 
typical  splay-foot  results.  The  tibialis  posticus  is  often  relaxed  or 
even  paretic,  and  the  peronei  tendons  are  in  the  later  stages  con- 
tracted. Occasionally  the 
deformity  is  due  to  a 
gonorrhoeal  inflammation 
of  the  inferior  calcaneo- 
scaphoid  ligament,  which 
becomes  relaxed  and 
yields  under  the  weight  of 
the  body.  However  pro- 
duced, the  deformity  is 
tolerably  characteristic 
(Fig.  171).  The  sole  of 
the  foot  is  flat,  and  in 
well-marked  cases  comes 
in  contact  with  the  ground 
throughout  the  whole  of 
its  extent.  The  inner 
border  is  convex  and  somewhat  lengthened,  whilst  the  anterior  half  is 
abducted.  The  head  of  the  astragalus  is  felt  a  little  in  front  of  and 
below  the  internal  malleolus,  whilst  the  sustentaculum  tali,  which  is 
normally  distinguishable  about  f  inch  below  the  malleolus,  is  buried 
by  this  displacement.     The  tubercle  of  the  scaphoid  is  less  evident 


Fig.  171. — Flat-foot. 


46o 


A  MANUAL  OF  SURGERY 


than  usual,  being  situated  below  and  in  front  of  the  head  of  the 
astragalus.  In  the  early  stages  the  patient  complains  of  a  sensation 
of  fatigue  or  weakness  along  the  inner  side  of  the  leg,  foot,  or  ankle, 
increased  by  exertion.  Later  on,  the  gait  becomes  somewhat 
shuffling,  and  severe  pain  is  experienced,  not  only  in  the  sole,  but 
also  on  the  dorsum  over  the  astragalo-scaphoid  joint.  Sometimes 
it  is  extremely  marked  in  the  metatarso-phalangeal  joint  of  the  great 
toe,  which  may  be  enlarged  and  inflamed,  owing  to  an  associated 
chronic  arthritis  (vide  Hallux  rigidus). 

Treatment. — In  the  earliest  stages,  when  the  deformity,  though 
threatening,  has  not  yet  actually  developed,  all  that  is  required  in 
many  cases  is  rest,  so  as  to  allow  the  overstrained  muscles  and  liga- 
ments to  recover  themselves ;  at  the  same  time  the  parts  should  be 
massaged,  and  tonics  administered  to  improve  the  general  tone  of 
the  system.  Square-toed  boots  without  high  heels  must  be  used,  so  as 
to  check  any  tendency  to  a  valgoid  position  of  the  foot,  and  the  heels 


Fig.  172. — Mr.  Golding-Bird's  Sling 
OF  Soft  Webbing  for  Supporting 
THE  Arch  of  the  Foot. 


Fig.  173. — The  Sling  applied. 


may  sometimes  be  slightly  thickened  on  the  inner  side.  The  patient 
must  walk  with  the  toes  pointed  forwards  or  even  inwards,  and  in 
some  cases  assistance  may  be  obtained  by  ordering  him  to  sit  cross- 
kneed,  in  the  tailor  position,  so  as  to  exercise  a  certain  amount  of 
constant  pressure  inwards  upon  the  front  of  the  feet.  Regular 
exercises  ought  to  be  instituted,  such  as  raising  the  body  on  tiptoe 
with  the  feet  inverted  ;  such  can  only  be  undertaken  for  a  short 
time  at  first,  but  as  the  muscles  regain  their  tone  a  longer  period 
can  be  tolerated.  In  a  later  stage  elastic  tension  applied  to  the 
sunken  arch  is  sometimes  useful ;  Golding-Bird's  shng  can  be 
employed  for  this  purpose.  It  consists  of  a  loop  of  soft  webbing 
passed  round  the  ankle  and  then  under  the  instep,  its  free  end  being 
drawn  up  on  the  inner  side  and  attached  to  an  elastic  accumulator 
which  is  connected  with  a  steel  garter-piece  (Figs.  172  and  173). 


DEFORMITIES 


461 


In  worse  cases  a  metal  spring  or  instep  pad  may  be  required  to 
support  the  foot  whilst  walking,  but  it  must  be  remembered  that 
it  has  no  curative  function,  and  indeed  by  its  pressure  tends  still 
further  to  weaken  the  structures  on  the  inner  side  of  the  foot.  It 
must  fit  the  instep  accurately  and  be  made  to  pattern  for  each  par- 
ticular case,  extending  from  the  root  of  the  toes  to  the  heel. 

When  the  affection  has  reached  a  later  stage,  and  the  deformity 
cannot  be  remedied  by  ordinary  manipulation,  forcible  rectification 
under  an  anaesthetic  may  be  employed.  The  foot  is  firmly  grasped 
in  the  two  hands  or  in  a  Thomas's  wrench  (Fig.  174),  and  the  anterior 
portion  is  forced  inwards  and  backwards  in  such  a  way'las  to  draw 
the  scaphoid  round  the  head  of  the  astragalus  as  a  fulcrum,  and  thus 
restore  the  arch.  Probably  a  number  of  adhesions  in  the  astragalo- 
scaphoid  and  other  joints  will  be  felt  to  give  way  during  this  manipu- 
lation.    Tenotomy  of  the  peronei  is  sometimes  required  before  recti- 


FiG.  174. — Thomas's  Wrench.     (Down  Bros.) 
The  two  cross-bars  are  protected  by  thick  indiarubber,  and  can  be  approximated 
or  separated  by  rotation  of  the  handle.     The  anterior  portion  of  the  foot  is 
firmly  grasped  between  them,  one  being  placed  on  the  dorsal  and  one  on  the 
plantar  aspect,  and  forcible  wrenching  movements  can  then  be  carried  out. 

fication  of  the  position  is  possible.  The  foot  is  then  put  up  in  plaster 
of  Paris  and  kept  at  rest  for  some  weeks.  Satisfactory  results  have 
followed. 

In  neglected  cases  operative  proceedings  may  be  necessary  for  the 
relief  of  pain.  The  removal  of  a  wedge-shaped  section  from  the 
inner  side  of  the  foot,  and  the  production  of  bony  ankylosis  between 
the  scaphoid  and  astragalus  (as  recommended  by  Ogston),  is  the  only 
operative  procedure  worthy  of  consideration.  Prolonged  rest  and 
a  suitable  course  of  exercises  and  massage  will  be  required  sub- 
sequently, whilst  an  instep  pad  may  still  have  to  be  worn. 

Pes  Cavus  (Hollow  or  Claw  Foot)  is  a  condition  characterized  by 
increased  concavity  of  the  plantar  arch,  so  that  when  the  individual 
stands  there  is  a  greater  interspace  than  usual,  if  not  an  absolute 
break,  between  the  impressions  produced  by  the  anterior  and  pos- 
terior segments  of  the  foot  (Fig.  160,  B).  Corresponding  to  the 
plantar  concavity,  there  is  a  marked  dorsal  convexity,  whilst  the  toes 
are  generally  in  a  condition  to  be  immediately  described  as  hammer- 
toe ;  the  heads  of  the  metatarsal  bones  are  unduly  prominent  below, 
and  callosities  often  form  beneath  them,  causing  considerable  pain. 
The  condition  is  almost  always  associated  with  a  slight  degree  of 
talipes  equinus  (right-angled  contraction),  and  its  method  of  pro- 
duction from  this  cause   is  as  follows :    The  weight   is   normally 


402 


A  MANUAL  OF  SURGERY 


carried  to  the  ground  mainly  through  the  heel,  but  also  partly 
through  the  toes  ;  in  these  cases  it  is  only  transmitted  through  the 
toes  and  front  of  the  foot,  and  since  the  anterior  extensor  muscles 
are  probably  weak,  the  short  flexors  act  at  an  advantage,  and  by  con- 
tracting draw  the  heel  downwards  so  as  to  reach  the  ground,  and  thus 
the  arch  is  increased.  Treatment  in  the  early  stages  consists  in 
friction  applied  to  the  weakened  muscles  of  the  leg,  together,  possibly, 
with  the  application  of  a  splint  to  the  sole.  In  more  marked  cases 
division  of  the  tendo  Achillis  is  needed,  together  with  subcutaneous 
section  of  the  tense  plantar  fascia.  The  deformity  of  the  toes  usually 
disappears  when  the  equinus  is  corrected. 

Hallux  Rigidus  (syn.  :  H.  flexus)  is  a  painful  condition  of  the  great 
toe,  due  to  a  chronic  arthritis  of  its  metatarso-phalangeal  articulation. 
It  usually  occurs  in  young  males  with  flat  feet.  The  foot  is  abnor- 
mally long  ;  its  circulation  is  defective  ;  the  toe  itself  may  be  in  good 
position,  but  not  unfrequently  the  first  phalanx  is  flexed  (Fig.  i66) 
and  the  distal  one  hyper-extended.  It  is  probably  due  to  abnormal 
pressure  owing  to  the  valgoid  position  of  the  foot,  and  possibly  to  wear- 
ing too  short  a  boot.  Treatment. — In  the  early  stages  correct  the 
flat-foot,  and  see  that  suitable  boots  are  worn.  Failing  this,  careful 
strapping  with  Scott's  dressing  may  give  relief,  but  in  bad  cases 
excision  of  the  head  of  the  metatarsal  may  be  required. 

Hallux  Valgus  (Fig.  175)  consists  in  a  displacement  outwards  of 
the  great  toe  from  the  median  line  of  the  body,  as  a  result  of  which 
the  other  toes  are  huddled  together,  and  in  extreme  cases  the  hallux 
is  placed  over  or  under  them.  It  is 
present  in  the  majority  of  people  in 
some  measure,  owing  to  the  usual  shape 
in  which  boots  are  made ;  but  in  its 
severer  forms  it  generally  occurs  in 
elderly  people,  a.nd  is  often  associated 
with  a  chronic  arthritis  of  the  meta- 
tarso-phalangeal joint  of  the  hallux,  the 
greater  power  of  the  adductor  group  of 
muscles  explaining  the  deformity.  The 
cartilaginous  surface  of  the  head  of  the 
first  metatarsal  bone  becomes  inflamed 
owing  to  the  partial  dislocation  of  the 
toe  and  the  pressure  of  the  boot ;  its 
structure  and  shape  are  thereby  altered, 
and  the  joint  is  more  or  less  disorganized. 
a  frequent  result  of  this  deformity,  viz.,  bunion  and  hammer-toe. 

A  bunion  consists  in  the  formation  of  a  bursa  over  the  head  of  the 
first  metatarsal  bone,  which  becomes  inflamed  from  cold  or  injury, 
and  may  even  suppurate,  the  abscess  often  communicating  with 
the  joint,  and  leading  to  its  disorganization.  A  marked  bony  out- 
growth is  usually  found  under  the  bursa,  springing  from  the  inner 
side  of  the  head  of  the  bone,  and  due  to  a  localized  chronic  periostitis. 

The  Treatment  of  hallux  valgus  in  its  earliest  stages  consists  in 


Fig. 


175. —Hallux   Valgus 
WITH  Bunion. 


Two  other  conditions  are 


DEFORMITIES 


463 


the  use  of  correctly-shaped  boots,  with  the  inner  border  straight  from 
toe  to  heel,  whilst  the  sock  or  stocking  should  have  a  separate  com- 
partment for  the  great  toe.  The  introduction  of  a  toe-post  between 
the  great  toe  and  its  neighbour  is  sometimes  effective  in  giving 
relief.  In  more  severe  types  excision  of  the  projecting  head  of  the 
metatarsal  bone  gives  admirable  results.  The  operation  is  best 
conducted  by  turning  up  a  flap  of  skin  and  subcutaneous  tissues 
over  the  inner  aspect  of  the  head  of  the  metatarsal  with  its  con- 
vexity forwards.  The  bone  is  then  divided  by  a  chisel,  and  the  head 
removed,  allowing  the  toe  to  be  easily  replaced  in  a  normal  position. 
The  skin  is  then  laid  down  in  place,  and  if  need  be  shortened  to  meet 
the  requirements  of  the  case.  Very  rarely  ought  the  secord  toe  to 
be  removed  for  this  condition,  as  the  lateral  support  of  the  great  toe 
is  thus  weakened,  and  the  deformity  is  probably  aggravated.  An 
inflamed  hiinion  is  treated  by  removing  all  local  pressure,  and  applying 
fomentations.  If  the  joint  is  involved  in  suppurative  disease,  excision 
of  the  head  of  the  bone,  or  amputation  of  the  toe,  may  be  required. 
In  less  serious  cases  it  may  suffice  merely  to  remove  the  thickened 
bursa,  and  to  chisel  away  the  projecting  portion  of  the  bone. 

Hammer-toe. — This  deformity  is  constituted  by  hyper-extension  of 
the  first  phalanx,  marked  flexion  to  an  acute  angle  of  the  second, 
and  either  flexion  or  extension  of  the  terminal  phalanx,  so  that  the 
first  inter-phalangeal  joint  projects  under  the  upper  leather  of  the 
boot,  whilst  the  patient  walks  on  the  extremity  of  the  ungual 
phalanx,  or  even   on   the  nail   (Fig.    176).     Corns    form  upon   the 

points  of  pressure  ( I,  2,  and  3),  especially 
on  the  dorsal  aspect,  and  a  subcutaneous 
bursa  over  the  head  of  the  first  pha- 
lanx (4),  giving  rise  to  great  pain  and 
inconvenience.  The  second  toe  is  that 
most  frequently  affected,  with  or  without 
the  others,  but  it  is  uncommon  for  the 
hallux  to  be  thus  deformed.  The  ex- 
tensor tendons  often  stand  out  very 
evidently  beneath  the  skin.  The  flexion 
of  the  second  phalanx  on  the  first  is 
carried  to  such  a  degree  that  the  former 
bone  is  semi-dislocated.  The  prolonga- 
tions of  the  plantar  fascia  on  either  side 
tarsal  bone  in  sole  ;  2,  callosity  are  much  shortened,  and  the  lower  por- 
over  end  of  toe  ;  3,  callosity  or  ^-jq^s  of  the  lateral  ligaments  of  these 
corn  over  head  01  first  phalanx;        ,■      1    <_•  1  .        -    j 

4,  adventitious  bursa  over  the  articulations  are  also  contracted.  ^ 

same  bony  point.  Causos. — It  IS  occasionally  congenital, 

but  more  often  acquired,  and  then  (a)  it 
may  be  secondary  to  hallux  valgus  ;  [b)  it  may  result  from  wearing 
short  and  pointed  boots,  or  very  high  heels  ;  in  either  case  the  toes 
are  crowded  together  and  drawn  up  out  of  the  way  of  pressure  ; 
[c)  it  follows  contraction  of  the  plantar  fascia,  and  is  then  associated 
with  pes  cavus  and  talipes  equinus. 


2  I 

Fig.  176. — Hammer-toe. 
(After  Keen  and  White.) 

I,  Callosity  over  head  of  meta- 


464  ■      A  MANUAL  OF  SURGERY 

Treatment  may  be  commenced  by  the  use  of  correctly- shaped  boots, 
but  the  case  has  usually  progressed  to  such  an  extent  when  the  patient 
is  first  seen  that  no  palliative  measures  are  of  any  avail.  Operation 
is  then  necessary,  and  probably  the  second  phalanx  Is  so  much  dis- 
placed that  nothing  short  of  removal  of  the  head  of  the  first  phalanx 
holds  out  any  prospect  of  permanent  relief.  An  incision  is  made 
longitudinally  over  the  joint,  the  extensor  tendon  being  split  down  the 
middle ;  the  head  of  the  bone  is  then  cleared  by  the  raspatory,  and 
nipped  off  by  cutting-pliers.  No  splint  is  required,  as  the  pressure  of 
the  dressings  suffices  to  keep  the  toes  in  good  position.  Sometimes 
there  is  but  little  room  between  the  great  and  third  toes,  so  that  even 
if  one  corrected  the  deformity  of  the  second  toe  there  is  no  space  for 
it  to  lie  comfortably  ;  amputation  should  then  be  performed. 

Metatarsalgia,  or  Morton's  Disease,  is  characterized  by  severe  pain 
of  a  neuralgic  type  located  primarily  about  the  head  of  one  or  more  of 
the  metatarsal  bones,  usually  the  fourth,  but  also  radiating  thence  up 
and  down  the  limb.  It  often  occurs  in  gouty  or  rheumatic  subjects, 
and  may  be  attributed  to  some  injury  ;  a  slight  degree  of  flat-foot  and 
the  wearing  of  tight  boots  certainly  predispose  to  it.  It  is  probably 
due  to  compression  of  the  digital  nerves  between  the  heads  of  the 
metatarsal  bones  and  the  ground.  The  foot  is  found  to  be  broader 
than  usual,  and  the  anterior  transverse  arch  formed  by  the  heads 
of  the  metatarsals  flattened  out.  Marked  callosities  or  corns  are 
observed  on  the  under  surface  close  to  the  heads  of  the  bones,  one  or 
more  of  which  may  be  unduly  prominent.  In  a  few  cases  small  bony 
enlargements  have  projected  from  the  heads  of  the  metatarsal  bones, 
and  in  others  definite  fibrous  growths  have  been  found  in  the  subcu- 
taneous tissues ;  in  other  cases  a  simple  peripheral  neuritis  may  explain 
the  manifestations.  The  pain  is  generally  induced  by  walking,  and 
comes  on  in  characteristic  paroxysms.  Lateral  pressure  over  the 
metatarsal  bones  sometimes  relieves  the  pain.  Occasionally  evidences 
of  osteo-arthritis  are  manifested  in  one  of  the  neighbouring  joints. 

Treatment  consists  in  resting  the  foot,  whilst  suitable  diet  and  drugs 
are  ordered  to  combat  any  gouty  or  rheumatic  tendency.  At  the  end 
of  a  few  weeks  the  patient  may  be  allowed  to  walk  again  with  boots, 
which  are  broad  anteriorly,  and  fitted  with  an  instep  pad  if  necessary. 
Morton's  recommendation — viz.,  excision  of  the  head  of  the  metatarsal 
bone — may  be  reserved  for  the  more  aggravated  and  serious  forms. 


CHAPTER  XIX. 

INJURIES  OF  BONES— FRACTUEES. 

Contusion  of  a  Bone  and  of  its  periosteum  is  usually  a  matter  .of  no 
great  moment,  although  the  part  becomes  painful  and  swollen. 
Occasionally  a  subacute  periostitis  is  caused  in  people  liable  to 
rheumatism  or  gout,  or  in  the  subjects  of  syphilis ;  whilst  in  those 
who  are  thoroughly  out  of  health,  and  with  low  germicidal  power, 
acute  infective  periostitis  or  osteo -myelitis,  resulting  in  necrosis,  may 
supervene.  The  Treatment  of  an  uncomplicated  case  consists  merely 
in  the  use  of  cooling  lotions  or  of  a  bandage,  whilst  if  periosteal 
thickening  results,  iodide  of  potassium  may  be  given,  and  iodine  paint 
applied  locally. 

Bending  of  Bone  may  or  may  not  be  associated  with  fracture. 
Bending  without  fracture  occurs  mainly  in  children,  and  in  adults  is 
only  the  result  of  some  local  disease.  More  commonly  a  partial  or 
green-stick  fracture  is  produced  (p.  467),  and  in  this  the  deformity 
can  generally  be  corrected  without  much  difficulty. 

Fractures. 

A  fracture  may  be  defined  as  a  sudden  solution  of  continuity  in  a 
bone,  usually  resulting  from  external  violence. 

Predisposing  Causes  of  Fracture. — Age  has  a  considerable  influence 
in  the  determination  of  fractures  for  two  reasons :  firstly,  because 
the  strength  and  elasticity  of  bones  vary  considerably  at  different 
periods  of  life  ;  and,  secondly,  because  the  exposure  to  injury  is  like- 
wise variable.  From  two  to  four  fractures  are  not  uncommon,  owing 
to  the  unsteady  gait  and  frequent  falls  to  which  little  children  are 
liable ;  from  four  to  six  they  are  less  common,  the  bones  often  bend- 
ing so  as  to  cause  green-stick  fractures,  whilst  injuries  near  joints 
induce  separation  of  epiphyses  ;  from  six  years  onwards  fractures 
increase  in  frequency  with  the  age,  old  people  being  peculiarly  liable 
to  this  form  of  accident. 

Sex. — As  might  be  expected,  fractures  are  more  common  in  the 
male  sex  "during  boyhood  and  adult  life ;  but  up  to  the  age  of  four  or 
five  they  are  equally  frequent  in  the  two  sexes,  whilst  after  forty- 
five  they  are  more  common  in  women,  owing  to  their  great  liability 
to  intracapsular  fracture  of  the  cervix  femoris  and  to  Colles's  fracture. 

Morbid  Conditions  of  the  Bones  predispose  to  fracture  in  a  marked 

465  30 


466        .  A  MANUAL  OF  SURGERit 

manner,  often  leading  to  what  is  known  as  Spontaneous  Fracture,  in 
which  the  determining  force  cannot  be  recognised  or  is  very  shght. 
Under  this  heading  may  be  included :  (i)  Atrophy  of  bone,  which 
may  be  of  the  senile  type,  as  manifested  especially  in  the  cervix 
femoris ;  or  is  due  to  want  of  use,  as  in  a  paralysed  limb  or  from  an 
ankylosed  joint.  (2)  Patients  afflicted  with  certain  mental  or  nervous 
diseases,  such  as  general  paralysis  or  tabes  dorsalis,  are  unduly  liable 
to  fracture,  which  may  result  from  atrophy,  but  may  also  occur  in 
apparently  healthy  bones.  Thus,  a  man  suffering  from  tabes  was  sit- 
ting with  his  thigh  abducted  and  everted  in  order  that  he  might  examine 
and  dress  a  perforating  ulcer  on  the  sole  of  the  foot,  when  the  shaft 
of  the  femur,  subsequently  shown  to  be  of  normal  dimensions,  and 
apparently  of  normal  density,  snapped  in  two.  (3)  Fragilitas  ossium 
or  osteo-psathyrosis  consists  in  an  inherited  tendency  to  spontaneous 
fracture.  It  results  in  a  multiplicity  of  fractures,  occurring  even  in 
children ;  thus,  a  girl,  aged  twelve  and  a  half  years,  had  suffered 
from  forty-one  fractures  since  the  second  year  of  life.  No  explana- 
tion of  this  condition  is  known  ;  the  lesions  often  unite  perfectly, 
though  sometimes  with  a  good  deal  of  deformity.  (4)  General  bone 
diseases,  such  as  rickets  and  osteo-malacia,  also  predispose  to  fracture ; 
in  the  latter  affection  the  bones  often  bend  considerably  before  break- 
ing, and  there  is  usually  but  little  attempt  at  repair.  (5)  Local  bone 
disease  may  also  constitute  an  important  predisposing  factor  by 
weakening  its  structure.  Thus,  sarcoma  and  secondary  cancer  -of 
bone  are  often  first  recognised  by  causing  a  spontaneous  fracture ; 
the  erosion  of  an  aneurism  and  the  destruction  of  the  para- epiphyseal 
region  in  acute  osteo-myelitis  may  lead  to  a  similar  result. 

The  Exciting  Causes  of  Fracture  are  threefold:  (i)  Direct  violence, 
the  fracture  occurring  at  the  spot  struck,  and  being  often  transverse, 
not  unfrequently  comminuted,  and  sometimes  complicated  with 
injuries  to  the  adjacent  soft  parts.  (2)  When  due  to  indirect  violence, 
the  accident  is  usua-lly  produced  by  the  compression  or  bending  of 
the  bone  with  such  force  as  to  exceed  the  limits  of  its  natural 
elasticity,  so  that  it  yields  at  the  weakest  spot.  Thus,  when  a 
person  jumps  from  a  height,  the  leg  bones  are  compressed  between 
the  weight  of  the  body  and  the  resistance  of  the  ground,  and,  if  the 
violence  is  excessive,  a  fracture  occurs  at  some  point  of  mechanical 
disadvantage.  If  the  stress  falls  chiefly  on  the  shaft,  an  oblique  or 
spiral  fracture  ensues,  often  with  much  longitudinal  displacement, 
and  possibly  becoming  compound.  If,  on  the  other  hand,  the  violence 
expends  itself  on  a  mass  of  cancellous  tissue,  such  as  the  os  calcis, 
astragalus,  or  upper  end  of  the  tibia,  the  bone  may  be  fissured  in 
various  directions,  comminuted,  or  even  '  pulped ' ;  such  a  condition 
is  sometimes  termed  a  compression  fracture.  (3)  Muscular  action  is 
most  commonly  the  cause  of  fracture  of  small  bones  or  of  osseous 
prominences,  into  which  powerful  muscles  are  inserted.  The  patella 
and  olecranon  are  not  unfrequently  broken  in  this  way,  the  former 
often  occurring  from  sudden  and  vigorous  efforts  to  avert  a  fall. 
Occasionally  one  of  the  long  bones,  such  as  the  humerus  or  clavicle, 


INJURIES  OF  BONES— FRACTURES  467 

has  been  broken  by  violent  muscular  exertion,  as  by  throwing  a 
cricket-ball. 

Intra-uterine  Fractures  are  caused  by  blows  upon  the  mother's 
abdomen,  or  by  abnormal  or  violent  uterine  contractions,  especially 
if  the  liquor  amnii  is  deficient  in  amount,  or  if  the  formation  of  bone 
is  defective,  as  in  osteogenesis  imperfecta  (p.  594).  They  are  usually 
followed  by  considerable  deformity,  which  must  be  clearly  distin- 
guished from  that  due  to  imperfect  development.  Fractures  also  occur 
as  a  result  of  undue  violence  used  by  the  accoucheur  during  delivery. 
Varieties. — A  Simple  Fracture  is  one  in  which  the 
skin  is  unbroken  or,  at  any  rate,  where  the  external 
air  has  no  admission  to  the  site  of  injury.  A  Com- 
pound Fracture  is  present  when  the  skin  or  mucous 
membrane  is  so  lacerated  that  there  is-  direct  or 
"indirect  communication  between  the  fracture  and 
the  external  air.  In  the  base  of  the  skull,  a  fracture 
may  open  up  one  of  the  deeper  air-sinuses,  and  thus 
it  becomes  compound  without  any  apparent  external 
lesion.  These  terms,  though  sanctioned  by  the 
approval  of  centuries,  are  neither  of  them  good, 
subcutaneous  and  open  being  preferable.  A  subcu- 
taneous fracture  is  often  anything  but  a  simple 
injury,  and  may  result  in  the  most  disastrous  con- 
sequences, whilst  an  open  fracture  may  be  a  matter 
of  comparatively  little  importance.  Indeed,  with 
our  present  appliances  and  methods  of  treatment 
open  fractures  often  give  better  results  than  those 
that  are  called  simple. 

^  ^  Fractures  are  complete  or  incomplete,  according 

Fig.  177. — Green-   ,  -u    .v,  .    .f  .•      -^        r  ^i       1  • 

STICK  Fracture  ^°  whether  or-  not   the  contmuity   of  the   bone   is 

OF  Radius.  entirely  interrupted.     Various  forms  of  Incomplete 

Fracture  are  described,  and  indeed  the  introduction 

of  skiagraphy  has  shown  that  they  are  much  more  common  than  was 

formerly  supposed.     A  green-stick  fracture   (Fig.   177)  is  one  which 

only  occurs  in  young  children,  and  most  often  in    those  that   are 

rickety ;  curved  bones,  such  as  the  clavicle,  are  usually  affected,  and 

the  fracture  merely  involves  the  convexity  of  the  curve,  whilst  the 

concave  half  is  bent,  just  as  when  a  green  bough  or  twig  is  partially 

broken.     Depressions  of  the  skull  m.ay  be  similarly  incomplete  when 

the  outer  table  is  driven  in  without  fracture  and  the  inner  table 

alone  splintered.     Fissured  fractures  also  are  often  only  partial. 

Complete  Fractures  may  be  transverse,  though  this  is  not  very 
common  ;  oblique,  arising  usually  from  indirect  violence  ;  spiral,  when 
the  force  acts  in  a  rotary  direction  as  well  as  longitudinally ;  it 
occurs  most  frequently  in  the  tibia  or  femur,  and  the  lower  fragment 
often  has  a  sharp  triangular  upper  end,  giving  it  somewhat  the  ap- 
pearance of  the  mouthpiece  of  a  clarionet  (fracture  eti  bee  de  flute ; 
Fig.  178).  Not  uncommonly  a  second  fissure  runs  downwards  from 
the  main  line  of  fracture,  separating  off  a  long  narrow  fragment  of 


468 


A  MANUAL  OF  SURGERY 


impacted, 
when  more 


when    one 
than  on 


fragment 
3  fracture 


the  shaft.     A  longitudinal  fracture  is  one  due  to  Assuring  or  spHt- 
ting  of  the  bone  in  its  long  axis ;  it  is  most  common  as  the  result  of 
gunshot  injuries.     If   it  is  combined  with  a  transverse  fissure,  it 
is  often  termed  T-shaped.     Comminuted  is  a  term  used  to  describe  . 
the  condition  when  the  bone  is  broken  into  more  than  two  pieces ; 

is  driven  into  the  other ;  multiple, 
exists  ;  complicated,  when  important 
structures,  such  as  an  artery  or 
joint,  are  damaged  as  well  as  the 
bone. 

The  Separation  of  an  Epiphysis  re- 
sults in  young  people  from  violence 
directed  to  the  ends  of  the  bones, 
but  occasionally  from  disease  of 
the  epiphysis  or  of  the  adjacent 
portion  of  the  diaphysis — e.g.,  from 
inherited  syphilis,  acute  infective 
osteo-myelitis,  or  tuberculous 
epiphysitis.  The  femur,  humerus, 
or  radius  are  the  bones  most  often 
affected.  The  line  of  cleavage 
usually  runs  through  the  soft  spongy 
tissue  on  the  diaphyseal  side  of  the 
cartilage,  so  that  there  is  cartilage 
with  spicules  of  bone  on  one  side, 
and  spongy  bone  on  the  other.  In 
very  young  children,  where  the 
epiphysis  is  entirely  or  mainly  carti- 
laginous, the  lesion  is  almost  always 
a  pure  separation  of  the  epiphysis 
from  the  shaft ;  but  at  a  later  date  it 
not  unusually  extends  in  part  through 
the  adjacent  end  of  the  diaphysis 
(Fig.  207).  A  marked  feature  is 
the  stripping  up  of  the  periosteum, 
which,  though  loosely  attached  to 
the  shaft  and  easily  separated  from 
it  in  children,  is  firmly  adherent  to 
the  epiphyseal  cartilage,  and  hence 
retains  its  connection  with  it,  thus  frequently  limiting  displacement. 
If,  however,  the  force  is  sufficient,  the  end  of  the  shaft  penetrates 
the  periosteum,  which  may  grasp  it  closely,  and  this  periosteal '  sleeve ' 
may  seriously  hinder  reduction.  Union  usually  occurs  by  means  of 
bone,  and  arrest  of  the  longitudinal  growth  may  follow  if  the  parts 
are  not  replaced  in  exact  apposition.  This  is  a  matter  of  importance 
when,  one  of  the  bones  of  the  leg  or  forearm  is  affected,  since  de- 
formity of  the  hand  or  foot  results  if  the  injured  bone  ceases  to 
grow  and  the  uninjured  one  continues  its  development.  Suppuration 
sometimes  occurs  as  a  sequela  in  unhealthy  children,  or  when  the 


Fig.  178. 


-Fracture  of  the  Tibia 
J  EEC  DE  Flute.' 


There  was  but  little  shortening  in 
this  case  ;  it  was  impossible,  how- 
ever, to  reduce  the  deformity  even 
under  an  anaesthetic,  and  opera- 
tion was  required. 


INJURIES  OF  BONES— FRACTURES  469 

accident  is  compound,  and  may  result  in  acute  osteo-myelitis  and 
necrosis. 

Partial  detachment  of  an  epiphysis  (the  juxta-epiphyseal  strain  of 
Oilier)  often  occurs,  giving  rise  to  phenomena  similar  to  those  of  a 
sprain ;  if  overlooked  and  neglected,  it  is  likely  to  prove  a  fertile 
source  of  tuberculous  disease,  or  may  interfere  with  the  growth  of 
the  limb.  The  essential  feature  is  a  more  or  less  tender,  but  very 
distinct  swelling  of  the  bone  close  to  the  epiphysis,  but  the  neigh- 
bouring joint  remains  unaffected.  Treatment  consists  in  immobiliza- 
tion in  plaster  of  Paris. 

Signs  of  Fracture. — The  history  usually  given  by  the  patient  is 
that,  as  the  result  of  some  accident,  he  felt,  or  perhaps  heard,  some- 
thing give  way  with  a  snap,  and  experienced  sharp  pain,  which 
became  much  intensified  on  attempting  to  move  the  limb.  On 
examining  the  injured  part  and  contrasting  it  with  the  opposite  side, 
the  following  points  are  usually  noticed  : 

1.  The  signs  of  a  local  trauma,  viz.,  pain,  bruising,  and  swelling,  as  a 
result  of  the  effusion  of  blood  from  the  torn  and  lacerated  structures. 
The  amount  of  this  may  be  so  great  as  to  obliterate  all  the  ordinary 
bony  prominences  and  landmarks.  Blebs  and  bullae  sometimes  form 
over  the  surface  in  the  course  of  a  day  or  two,  and  these  should  be 
carefully  protected  from  infection.  The  discoloration  continues  for 
some  time,  and  may  spread  to  parts  far  removed  from  the  original 
mischief.  This  infiltration  of  the  parts  with  blood  often  leads  to 
considerable  subsequent  thickening,  and  possibly  to  serious  ad- 
hesions and  limitation  of  movement :  this  fact  is  correctly  utilized  as  an 
argument  in  favour  of  the  treatment  of  fractures  by  an  open  operation. 
It  is  unusual  for  suppuration  to  occur  after  a  simple  fracture,  unless 
the  patient  is  very  debilitated  and  with  diminished  germicidal  powers. 

2.  Pveter-natural  mobility  in  the  continuity  of  the  bone  may  be  demon- 
strated by  manipulation,  but  never  unnecessarily.  Impaction  or  non- 
separation  of  the  fragments  prevents  its  occurrence. 

3.  Partial  or  complete  loss  of  fmction  also  follows. 

4.  Crepitus*  can  only  be  felt  when  the  fragments  are  moveable  and 
can  be  brought  into  contact,  but  not  when  there  is  wide  separation  or 
impaction. 

5.  Change  in  shape  of  the  limb  or  deformity  from  displacement 
results  from  three  chief  factors,  viz.,  the  direction  of  the  violence, 
the  weight  of  the  limb,  and  the  contraction  of  muscles,  whilst 
injudicious  movement  or  rough  handling  may  aggravate  it.  It 
is  always  more   marked   in  oblique   than   in   transverse   fractures. 

The  term  Crepitus  is  applied  to  five  different  conditions  which  may  produce 
a  creaking  or  grating  sensation  to  the  examining  hand.  i.  Boiiy  crepitus  results 
from_  the  rubbing  together  of  the  fragments  in  a  fracture,  or  of  the  ends  of  bones 
in  a  joint  when  denuded  of  their  articular  cartilage.  2.  A  softer  variety  of  bony 
crepitus  is  obtained  when  an  epiphysis  is  detached.  3.  An  effusion  of  Mood  into  the 
tissues  gives  rise  to  a  soft  crackling  sensation  on  handling.  4.  Effusivn  into 
(endon  sheaths,  bursse,  and  joints  also  causes  a  soft  crepitant  sensation,  varying 
in  different  cases.  5.  Air  in  the  tissues  causes  surgical  emphysema  and  a 
characteristic  form  of  crepitus. 


470  A  MANUAL  OF  SURGERY 

and  hence  is  usually  greater  in  those  due  to  indirect  violence. 
Various  types  of  displacement  are  described,  viz.:  Angular,  gener- 
ally due  to  the  unequal  action  of  powerful  muscles,  especially  when 
the  line  of  fracture  is  not  far  from  the  end  of  the  shaft,  as  in 
fracture  of  the  upper  third  of  the  thigh ;  lateral,  where  the  displace- 
ment is  merely  to  one  or  the  other  side,  'and  most  common  in 
transverse  fractures ;  longitudinal,  when  one  fragment  overlaps  the 
other  or  is  forcibly  driven  into  it,  causing  shortening  of  the  limb ;  it 
may  also  occur  in  the  form  of  wide  separation  of  the  fragments,  as 
from  contraction  of  the  quadriceps  in  fracture  of  the  patella ;  rotatory, 
when  one  fragment  is  twisted  on  the  other,  as  in  fractures  of  the 
femur,  where  the  weight  of  the  limb  causes  eversion  of  the  lower  end. 
In  flat  bones — e.g.,  the  skull — deformity  may  exist  in  the  shape  of 
depression  or  elevation. 

Radiograpliy  has  proved  of  the  greatest  service  both  in  connection 
with  the  diagnosis  and  the  treatment  of  fractures.  Many  a  case 
which  would  formerly  have  been  called  merely  a  sprain  can  now  be 
demonstrated  to  be  really  a  fracture  (especially  about  the  wrist),  and 
the  constant  use  of  this  procedure  has  revolutionized  our  ideas  as  to 
the  relative  frequency  and  also  as  to  the  nature  of  many  such  lesions. 
The  following  points  must,  however,  be  noted  if  the  practitioner  is 
not  to  be  misled :  In  the  first  place,  an  assured  diagnosis  can  never 
be  made  with  the  screen  alone :  the  limb  must  be  photographed  and 
for  choice  stereoscopically ;  otherwise  the  skiagrams  should  be  taken  in 
two  directions,  antero-posteriorly  and  laterally.  The  importance  of  this 
latter  precaution  is  indicated  by  a  study  of  Figs.  215  and  216,  or 
of  Figs.  247  and  248.  Then  it  must  be  remembered  that  ail  skia- 
grams are  more  or  less  exaggerations,  owing  to  the  proximity  of  the 
tube  to  the  limb,  and  that  a  deformity  which  is  very  obvious  in  the 
skiagram  may  in  reality  be  comparatively  slight.  Moreover,  too,  the 
exact  position  of  the  tube  and  its  angular  relationship  to  the  limb 
must  not  be  neglected,  as  otherwise  misleading  interpretations  may 
be  given  of  the  appearances  presented. 

General  or  Constitutional  Effects. — Shock  is  greater  or  less  according 
to  the  amount  of  violence  and  the  seat  of  injury.  It  varies  from  a 
mere  passing  faintness  to  the  severest  prostration.  If  the  bones  of 
the  head  or  spine  are  injured,  special  symptoms  due  to  concussion  of 
the  brain  or  injury  to  the  spinal  cord  may  also  be  produced. 

Hcemorrhage  is  rarely  sufficient  to  give  rise  to  general  effects  unless 
the  fracture  is  compound,  and  involves  some  important  vessel. 

Fracture  fever  (aseptic  traumatic  fever,  p.  262)  is  met  with  in  the 
majority  of  cases,  commencing  twenty-four  hours  after  the  accident 
and  lasting  two  or  three  days.  As  a  rule,  it  is  not  severe,  the 
temperature  rarely  rising  above  100°  F.  in  uncomplicated  cases.  In 
compound  fractures  where  asepsis  is  not  attained,  any  form  of  wound 
infection  may  result,  and  even  general  septicaemia  or  pyaemia. 

Delirium  tremens  is  a  not  unusual  complication  of  fractures  of  the 
leg  in  debilitated  individuals  or  habitual  drinkers.  The  general 
characters  and  treatment  of  the  disease  are  dealt  with  elsewhere 


myURIES  OF  BONES— FRACTURES  471 

(p.  263).  As  regards  local  treatment,  the  limb  must  be  fixed  by 
splints  or  encased  in  plaster  of  Paris,  and  suspended  in  a  Salter's 
swing  so  as  to  prevent  the  patient  from  moving  the  upper  fragment 
independently  of  the  lower. 

Fat  embolism  results  from  the  absorption  of  broken-up  fat  globules, 
after  any  injury  which  causes  contusion  or  laceration  of  fatty  tissue  ; 
when  this  is  accompanied  by  tension  from  effusion  of  blood,  as  in 
fractures,  this  process  is  more  likely  to  occur.  Usually  the  great 
mass  of  the  fat  is  filtered  off  by  the  lungs  or  eliminated  by  the 
kidneys  (as  can  be'  demonstrated  after  death  by  staining  with  osmic 
acid),  and  no  harm  results.  The  pulmonary  obstruction  may,  how- 
ever, become  so  great  as  to  lead  to  a  fatal  issue  from  dyspncea ; 
whilst  if  the  cerebral  vessels  are  blocked,  syncope,  or  even  coma,  may. 
be  induced.  The  symptoms  are  gradual  in  their  onset,  and  usually 
commence  about  the  third  day,  but  may  not  be  evident  for  a  week. 

The  Union  of  Fractures  is  brought  about  by  a  series  of  changes 
analogous  to  those  which  we  have  already  seen  occur  in  other 
wounds,  except  that  they  do  not  terminate  in  the  formation  of 
cicatricial  tissue,  but  go  on  to  the  further  development  of  bone. 

When  a  fracture  has  occurred,  the  broken  ends  of  the  bone 
are  left  rough,  spiculated,  and  more  or  less  separated  one  from  the 
other;  the  periosteum  is  torn,  but  the  rupture  is  not  always  com- 
plete, a  '  periosteal  bridge '  perhaps  persisting  and  playing  an 
important  part  in  the  reparative  process,  especially  if  the  fracture 
is  not  accurately  set.  The  muscles  and  neighbouring  tissues  are 
lacerated,  and  a  varying  amount  of  blood  is  extravasated,  occupying 
the  interstices  of  the  wound.  In  the  course  of  a  few  hours  after 
the  parts  have  been  immobilized,  the  process  of  repair  is  in- 
augurated by  the  blood-clot  becoming  invaded  by  leucocytes,  and 
after  a  time  it  is  absorbed,  the  haemoglobin  passing  through 
various  stages  of  degeneration,  and  thereby  staining  the  surround- 
ing tissues.  At  the  same  time  there  is  an  exudation  of  plasma 
into  all  the  injured  and  lacerated  soft  parts  around,  and  the  con- 
nective tissue  cells  proliferate  actively.  The  periosteum  becomes 
thickened  and  more  vascular,  and  its  connection  with  the  bone  is 
loosened  for  a  short  distance  on  each  side  of  the  fracture.  The 
blood-clot,  occupying  the  space  beneath  the  loosened  periosteum,  is 
gradually  transformed  into  granulation  tissue,  which  unites  with 
that  derived  from  surrounding  torn  structures  and  from  the  bone 
itself,  and  this  ovoid  mass  binding  the  fractured  ends  together  is 
known  as  the  provisional  or  ensheathing  callus  (Fig.  179). 

The  ossification  of  the  callus  is  the  next  stage  in  the  process.  This 
is  brought  about  by  the  activity  of  the  cells  in  the  deeper  part  of  the 
granulation  tissue,  which  are  derived  from  the  osteoblastic  cells  set 
loose  by  the  injury  and  the  resulting  rarefaction.  These  retain  their 
bone-producing  potentialities,  and  hence  bony  spicules  develop  in 
the  substance  of  the  deeper  parts  of  the  granulation  tissue,  as  also 
from  the  surface  of  the  uncovered  ends  of  the  fragments,  and  from 
the  under  side  of  the  periosteum.     This  latter  membrane  when  it  is 


472  A  MANUAL  OF  SURGERY 

stripped  up  from  the  underlying  bone  draws  with  it  certain  bone 
cells,  accompanying  the  small  vessels  which  pass  from  the  membrane, 
into  the  Haversian  canals,  and  from  these  the  bone  develops.  Ossi- 
fication thus  starts  from  many  foci,  and  the  callus  is  quickly  converted 
into  a  mass  of  bone,  which  is  at  first  soft  and  spongy,  but  after  a  time 
becomes  firm.  When  a  periosteal  bridge  has  been  left,  bone  formation 
commences  on  its  under  surface,  and  not  unfrequently  in  skiagrams 
a  line  of  newly-formed  bone  can  be  seen  passing  from  one  fragment 
to  the  other,  and  evidently  due  to  this  cause. 

The  medulla  becomes  hyperaemic  for  some  distance  from  the  seat 
of  fracture  and  is  transformed  into  granulation  tissue,  which  unites 
with  that  springing  up  from  the  opposite  fractured  surface.  Fine 
spicules  of  bone  gradually  permeate  the  granulation  mass  until  the 
whole  is  ofsified,  constituting  the  internal  callus,  or,  better,  the 
medullary  ping. 

Naturally,  the  compact  bony  tissue  is  the  last  to  engage  in  these 
changes,  and  the  denser  the  bone,  the  longer  they  are  in  being  com- 
pleted. The  fractured  ends  become  hypersemic  and  rarefied,  the 
bone  cells  proliferating,  the  medullary  contents  of  the  Haversian 
canals  increasing  in  amount,  and  the  actual  osseous  substance  being 
absorbed,  until  the  rough  and  spiculated  surface  becomes  smooth 
and  covered  with  granulations.  These  unite  v;ith  the  medullary 
plug,  of  which  they  may  indeed  be  looked  on  as  an  extension,  and 
finally  give  rise  to  the  annular  bond  of  union  between  the  two  layers 
of  compact  bone,  to  which  was  originally  applied  the  name  definitive 
or  permanent  callus. 

It  will  thus  be  obvious  that  the  continuity  of  a  bone  is  restored 
long  before  repair  is  completed,  and  that  it  mainly  depends  on  the 
ossification  of  the  provisional  callus,  the  amount  of  which  is  pro- 
portional to  the  degree  of  mobility  of  the  fragments.  The  newly- 
formed  osseous  tissue  is  at  first  soft  and  spongy,  but  gradually 
becomes  denser ;  at  first  it  is  easily  detachable  from  the  underlying 
bone,  but  later  on  becomes  continuous  with  it.  As  the  so-called 
definitive  callus  becomes  stronger,  the  ensheathing  callus  diminishes, 
and  finally,  if  the  ends  are  in  good  position,  may  vanish  entirely, 
whilst  the  medullary  plug  may  also  be  totally  removed.  Thus 
it  is  possible  for  the  bone,  under  these  circumstances,  to  be 
restored  so  absolutely  as  to  show  no  signs  of  its  having  been 
fractured. 

When  the  ends  of  the  bones  partially  overlap  (Fig.  i8o),  the 
amount  of  ensheathing  callus  is  considerably  increased,  and  fills 
up  all  the  spaces  left  by  the  overlapping  of  the  fragments.  The 
projecting  edges  of  bone  become  rounded  off,  and  the  medullary 
cavities  closed  by  plates  or  plugs.  The  main  bond  of  union  is  the 
ensheathing  mass,  a  considerable  portion  of  which  persists.  Some 
deformity  is  sure  to  remain,  and  it  is  unusual  for  the  medullary 
canal  to  be  restored. 

If  the  fractured  ends  overlap  completely,  but  remain  in  contact 
(Fig.  i8i),  the  union  is  secured  by  a  large  mass  of  ensheathing  callus, 


INJURIES  OF  BONES— FRACTURES 


473 


whilst  the  medullary  cavity  of  each  fragment  is  closed  by  a  plate  of 
internal  callus. 

If  the  fractured  ends  overlap  and  are  kept  from  contact  by  the 
interposition  of  muscular  tissue,  union  rarely  takes  place,  and  an 
ununited  fracture  results.  The  same  occurs  if  the  fragments  are 
widely  separated,  as  in  the  patella. 

Where  comminution  has  occurred,  the  splintered  fragments  are 
matted  together  by  an  abundant  formation  of  granulation  tissue, 
which  is  subsequently  transformed  into  callus. 

The  soft  tissues  around — mtiscle^,  tend?>rfs,  etc. — are  repaired  in 
the  usual  way,  but,  owing  to  the  infiltration  of  the  parts  with  blood 


Fig.  179.  Fig.   180.  Fig.  181. 

Diagrams  to  represent  Union  of  Fractures  :  Fig.  179,  when  the  Ends 
ARE  in  Close  Apposition  ;  Fig.  j8o,  when  the  Ends  are  only  Partially 
Apposed;  and  Fig.  181,  when  the  Fractured  Surfaces  are  not  in 
Contact  at  all. 


and  their  laceration,  the  muscles  become  matted  together  and  often 
lose  their  power  of  independent  movement ;  tendons  may  become 
adherent  to  their  sheaths  and  surrounding  structures ;  nerves  and 
veins  may  be  compressed  in  the  cicatricial  tissue,  so  that  the 
functional  result  may  be  most  disappointing. 

The  removal  of  the  clot  and  the  formation  of  granulation  tissue 
usually  take  about  a  week  or  ten  days,  and  new  bone  formation 
commences  about  the  end  of  the  first  week.  By  the  fourth  or  sixth 
week,  according  to  the  size  and  vascularity  of  the  bone  and  the 
recuperative  power  of  the  individual,  the  fracture  will  be  consolidated, 
but  in  the  lower  limb  it  is  often  eight  weeks  before  the  patient  can 
bear  any  weight  upon  it.  Months  may,  however,  pass  before  the  fina' 
stage  of  complete  repair  is  attained. 

In  conclusion,  one  must  allude  to  the  fact  that  a  sarcoma  sometimes 
develops  at  the  site  of  fracture  within  a  comparatively  short  time  of 
the  accident. 

The  Treatment  of  a  simple  fracture  is  always  to  be  considered  as 
a  task  of  some  difficulty,  inasmuch  as  it  involves  not  only  the  union 
of  the  bony  fragments,  but  also  the  complete  restoration  of  the  limb 
to  functional  utility,  and  that  without  deformity  or  unnecessary  delay. 


474  A  MANUAL  OF  SURGERY 

First  Aid. — In  moving  the  patient  from  the  spot  where  the  accident 
happened,  it  is  necessary  to  secure  the  Hmb  temporarily  in  as  good  a 
position  as  possible ;  splints  have  often  to  be  improvised  from  sticks, 
umbrellas,  newspapers,  and  so  forth.  In  a  railway  accident  the 
splintered  debris  of  the  carriages  may  be  employed  for  this  purpose,  and 
the  upholstery  of  the  seats  as  padding.  A  broken  leg  may  also  be  firmly 
tied  to  the  other  limb,  which  is  thus  converted  into  a  temporary  splint. 

The  Local  Treatment  consists,  first,  in  setting  the  limb,  i.e.,  in 
reducing  the  deformity,  and  replacing  the  fractured  ends  in  a  normal 
position  ;  then  in  fixing  the  fragments  and  limb  so  as  to  prevent  a 
recurrence  of  the  deformity  ;  and,  finally,  in  using  such  further  means 
as  massage  and  manipulation  in  order  to  secure  the  ultimate  functional 
usefulness  of  the  limb. 

Reduction  of  a  fracture  is  usually  accomplished  by  a  combination  of 
traction  or  extension  applied  to  the  lower  segment  of  the  limb,  with 
manipulation  of  the  fractured  ends,  counter-extension  being  at  the 
same  time  maintained  by  an  assistant.  In  some  cases  it  is  necessary 
to  relax  particular  muscles  in  order  to  facilitate  reduction ;  thus,  in 
the  leg,  the  calf  muscles  may  be  relaxed  by  flexing  the  knee,  or  even 
by  division  of  the  tendo  Achillis.  Rotation  must  also  be  corrected, 
and  shortening  reduced  to  a  minimum.  It  is  important  that  the  other 
limb  should  be  uncovered  to  serve  as  a  standard  of  comparison. 

The  manipulation  is  painful,  and  so  much  muscular  spasm  is  often 
elicited  by  it  that  the  setting  of  the  fracture  becomes  almost  impossible 
without  an  anaesthetic.  Reduction  should  alwaj^s  be  accomplished 
as  early  as  possible,  so  as  to  anticipate  the  stiffness  and  infiltration 
which  soon  develop  in  the  affected  parts.  At  the  same  time  it  may  be 
wise  to  delay  a  few  hours,  so  as  not  to  give  an  anaesthetic  on  a  full 
stomach,  or  without  the  previous  administration  of  an  enema  ;  but  if 
practicable,  a  fracture  should  never  be  left  unreduced  for  more  than 
twelve  hours. 

The  Fixation  of  the  fracture  in  a  good  position  is  provided  for  by 
the  application  of  suitable  splints  made  of  wood,  leather,  zinc,  poro- 
plastic,  etc.,  according  to  the  requisites  of  the  case.  If  of  wood,  zinc, 
or  tin,  they  are  usually  made  according  to  some  general  pattern,  and 
fitted  to  the  patient  by  means  of  pads.  If  formed  of  leather  or  poro- 
plastic,  they  can  be  shaped  so  as  to  meet  any  peculiarities  of  the  part. 
A  paper  pattern  is  first  fitted  to  the  opposite  limb,  and  the  splint  is 
then  cut  to  the  desired  shape ;  it  is  softened  by  immersion  in  hot  or 
cold  water,  moulded  to  the  part,  and  allowed  to  dry.  Where  leather 
is  employed,  the  addition  of  a  little  vinegar  to  the  water  assists  in 
rendering  it  soft  and  supple.  The  edges  and  corners  are  finally 
rounded,  and  the  interior  padded  with  wool  or  lint.  In  fractures  of 
the  shafts  of  long  bones  the  joints  both  above  and  below  the  site  of 
fracture  should,  as  far  as  possible,  be  immobilized,  and  the  splints 
must  be  sufficiently  large  to  encase  the  part  firmly,  or  if  flat,  to  pro- 
ject a  little  beyond  it,  so  that  the  limb  may  be  fixed  by  the  splint,  and 
not  the  splint  by  the  limb.  In  all  cases  careful  attention  must  be 
given  to  the  padding  so  as  to  prevent  irritation  or  sloughing  of  the 


INJURIES  OF  BONES— FRACTURES  475 

skin.  In  out-patient  practice,  where  the  patients  are  not  too  careful 
as  to  personal  cleanliness,  it  is  advisable  to  pad  the  splint  with  some 
antiseptic  material,  such  as  boracic  lint,  in  order  to  prevent  the 
development  of  vermin ;  but  it  is  a  wise  precaution  to  shave  and 
purify  the  limb  in  all  cases,  and  to  dust  it  over  with  boric  acid  and 
starch.  When  blebs  or  blisters  have  developed,  a  dry  aseptic  dress- 
ing should  first  be  applied.  The  splints  may  often  with  advantage 
be  first  fixed  to  the  limb  by  one  or  two  turns  of  strapping,  and  then 
secured  by  ordinary  calico  bandages  ;  these  must  not  be  applied  too 
tightly  at  first,  since  the  swelling  of  the  limb  not  unfrequently  in- 
creases afterwards,  and  undue  constriction  resulting  in  gangrene 
might  ensue.  Moreover,  a  limb  ensheathed  in  bandage  must  never 
be  flexed,  but  the  flexion  should  always  be  made  first ;  if  this  is  not 
attended  to,  the  bandage  may  cut  into  the  soft  tissues,  and  by  com- 
pression of  the  vessels  cause  gangrene.  It  is  sometimes  advisable  to 
bandage  the  whole  of  the  limb  from  the  fingers  or  toes  upwards,  so  as 
to  prevent  cedema  from  the  pressure  of  the  apparatus  obstructing  the 
venous  return.  The  patient  should  always  be  seen  on  the  day  following 
the  application  of  the  splints,  and  the  condition  of  the  fingers  or  toes 
carefully  examined ;  if  they  look  at  all  blue,  or  feel  numb  and  cold, 
the  bandages  must  be  slightly  relaxed. 

It  is  also  desirable  that  a  skiagram  be  taken  after  the  application 
of  the  splints,  so  that  the  actual  position  of  the  fragments  can  be 
estimated.  If  it  is  found  to  be  unsatisfactory,  a  further  attempt 
should  be  made  to  improve  it,  and  failing  that  the  question  of  opera- 
tion should  be  raised. 

Various  forms  of  Fixed  Apparatus  are  used  in  the  treatment  of 
fractures,  especially  in  children.  The  materials  most  commonly 
employed  are  starch,  water-glass,  and  plaster  of  Paris. 

The  stavch  bandage  is  utilized  only  in  cases  where  great  strength 
and  rigidity  are  not  required.  The  limb  is  carefully  padded  with 
cotton  wool,  and  over  this  are  applied  thin  strips  of  cardboard  soaked 
in  starch  so  as  to  fit  the  limb.  These  are  firmly  secured  by  a  bandage, 
the  meshes  of  which  are  well  impregnated  with  a  starch  solution,  and 
over  all  may  be  placed  another  bandage,  the  under  surface  of  which 
is  also  rubbed  with  starch.  When  this  dries,  it  produces  a  firm  mass, 
sufficient  to  immobilize  the  limb.  Should  it  become  loose  it  can  easily  be 
readjusted  by  slitting  up  and  paring  away  a  portion  on  one  or  both  sides. 

The  water-glass  bandage  is  applied  by  first  swathing  the  limb  with  a 
padding  of  cotton  wool,  or  bandaging  it  with  boracic  lint ;  around  this 
a  coarse  canvas  bandage  is  applied,  soaked  in  a  solution  of  silicate  of 
soda  of  the  consistency  of  treacle  ;  several  thicknesses  of  the  bandage 
are  required  in  order  to  give  it  the  necessary  strength.  This  material 
is  light,  easily  applied,  and  makes  very  little  mess,  but  is  slow  in 
drying,  taking  fully  twenty-four  hours  to  become  firm. 

Plaster  of  Paris,  though  rather  messy  and  increasing  considerably 
the  weight  of  the  limb,  is  one  of  the  best  means  of  securing  prolonged 
immobilization,  {a)  The  dried  plaster  may  be  rubbed  into  a  coarse 
canvas  bandage,  which  prior  to  use  is  soaked  for  a  few  minutes  in 


475  A  MANUAL  OF  SURGERY 

cold  water,  to  which  a  httle  salt  or  alum  is  added  in  order  to 
hasten  its  setting ;  it  is  then  wound  round  the  limb,  which  has  been 
previously  enswathed  in  boric  lint  or  wool,  and  on  the  exterior  of  this 
fresh  plaster  of  the  consistency  of  cream  is  applied.  To  make  this 
cream  of  the  right  strength  the  dried  powder  is  cast  in  spoonfuls 
into  a  bowl  of  cold  water,  or  a  weak  solution  of  alum,  until  it  no 
longer  sinks  immediately,  but  remains  floating  on  the  surface.  The 
mixture  is  then  stirred  with  an  iron  spoon,  and  is  ready  for  use. 
When  the  casing  is  sufficiently  thick,  the  outer  surface  is  smoothed 
down  with  wet  hands,  or  a  strip  of  wet  bandage  ;  the  date  may  be 
advisably  marked  on  it,  and  the  part  is  slung  up  to  dry.  A  Gigli 
saw,  smothered  with  vaseline,  may  be  incorporated  in  the  dressing 
beneath  the  plaster,  if  it  is  desired  to  remove  it  early  for  the  sake  of 
massage,  etc.  ;  by  this  means  it  is  easily  cut  into  two  pieces,  which 
can  be  re-applied  daily  after  the  rubbing. 

{h)  Ordinary  house-flannel  forms  the  basis  of  various  methods  of 
applying  plaster — e.g.,  Croft's,  the  Bavarian,  etc.  In  the  former,  the 
limb,  protected  by  boric  lint  or  wool,  has  applied  to  one  side  of  it  one 
or  two  thicknesses  of  flannel,  suitably  cut  to  shape,  soaked  in  plaster, 
and  with  perhaps  a  little  extra  plaster  rubbed  in ;  it  is  fixed  to  the 
limb  by  a  muslin  bandage.  When  this  is  dry,  a  similar  splint  is  placed 
on  the  other  side  of  the  limb,  and  again  bandaged  on.  Division  of 
the  bandage  down  the  front  permits  the  removal  of  the  appliance, 
the  bandage  over  the  junction  of  the  two  portions  behind  serving  as  a 
hinge.  If  necessary,  thin  strips  of  wood  or  tin  may  be  incorporated 
in  any  of  these  arrangements,  so  as  to  add  to  their  strength. 

Early  immobilization  by  means  of  plaster  of  Paris,  reinforced  by 
strips  of  wood  or  tin,  has  been  advocated  by  certain  authorities, 
constituting  the  so-called  ambulatory  treatment,  and  so  much  confidence 
have  they  in  it  that  even  fractures  of  the  femur  are  dealt  with  in  this 
way  within  a  few  days  of  the  accident,  and  the  patient  allowed  to 
walk  about. 

A  most  valuable  adjuvant  in  the  treatment  of  fractures  is  Massage, 
advocated  so  forcibly  by  Lucas-Championni^re,  whilst  in  some  cases 
Early  Mobilization  is  also  desirable.  It  has  long  been  recognised  that 
after  a  fracture  the  limb  remains  for  some  considerable  period  weak 
and  stiff,  owing  partly  to  atrophy  of  muscles,  partly  to  cicatricial 
adhesions  between  various  divided  structures,  and  in  part  to  contrac- 
tion of  ligaments  in  neighbouring  joints,  and  that  these  disabihties 
increase  in  direct  ratio  to  the  length  of  time  that  the  limb  is  kept  at 
rest.  It  is  the  object  of  massage  to  prevent  or  obviate  these  dis- 
abilities. In  a  fracture  with  displacement  through  the  shaft  of  a  long 
bone,  the  part  is  immobilized  by  sphnts  for  a  sufficient  time  to  ensure 
the  non-recurrence  of  the  displacement  (say,  two  or  three  weeks  for 
most  bones,  a  little  longer  for  the  femur).  Massage  is  then  commenced, 
and  is  conducted  methodically  day  by  day,  the  sphnts  being  removed 
for  the  purpose  and  re-applied  subsequently  ;  neighbouring  joints  will 
also  be  rubbed,  and  gentle  passive  movements  undertaken.  Possibly 
some  pain  may  be  noticed  at  first,  but  it  soon  disappears,  and  the 


IN  JURIES  OF  BONES— FRACTURES  477 

patient  experiences  a  sense  of  comfort.  Repair  is  hastened,  but  of 
course  the  patient  must  not  put  any  strain  on  the  bone  until  it  is  quite 
consoHdated.  In  fractures  near  joints  or  through  the  articular  ends 
of  bones,  it  is  sometimes  possible  to  discard  splints  entirely,  or  at  any 
rate  to  use  them  only  for  a  short  time,  steadying  the  part  by  some 
simple  contrivance,  such  as  a  sling  or  strapping  ;  massage  is  com- 
menced within  a  few  days  and  regularly  persisted  in.  This  method 
of  treatment  is  specially  apphcable  to  such  injuries  as  fracture  of  the 
anatomical  neck  of  the  humerus,  the  simpler  varieties  of  Colles's  or 
Pott's  fracture,  and  for  some  fracture-dislocations  in  the  neighbour- 
hood of  the  elbow.  At  the  same  time  it  is  necessary  to  point  out 
that  active  movements  should  not  be  encouraged  too  early  in  cases 
where  powerful  muscles  acting  on  one  of  the  fragments  might  over- 
come the  resistance  of  the  callus  and  reproduce  the  deformity. 

The  increasing  success  of  modern  aseptic  surgery  has  given  con- 
siderable impetus  to  the  Early  Operative  Treatment  of  fractures  in 
order  to  secure  complete  fixation  and  the  restoration  of  function  in  as 
short  a  space  of  time  as  possible.  At  first  this  plan  was  only  utilized 
for  such  bones  as  the  patella  or  olecranon,  but  at  the  present  day 
there  is  no  valid  reason  for  refusing  operation  in  suitable  cases.  The 
excellent  results  following  operation  in  compound  fractures,  as  com- 
pared with  those  gained  by  the  treatment  of  simple  fractures  by 
prolonged  immobilization,  emphasize  this  statement.  It  is  often 
impossible  to  co-apt  accurately  the  fragments  apart  from  operation, 
whilst  the  infiltration  of  the  soft  tissues  with  blood  leads  to  much 
fibrosis  and  the  formation  of  many  adhesions  ;  moreover,  the  more 
lengthy  immobilization  results  in  greater  atrophy  of  muscles  and  stiff- 
ness of  joints,  and  hence  the  commercial  value  of  a  working  man  after 
a  fracture  of  the  thigh  or  leg  is  very  considerably  depreciated,  owing 
partly  to  persistent  deformity,  partly  to  the  joints  being  stiff,  whilst 
the  period  of  convalescence  is  reckoned  by  months  rather  than  weeks. 
Should  such  a  case  be  operated  on,  the  blood  being  removed,  and  the 
end  of  the  bones  freed  from  intervening  tissues  and  securely  united 
by  wires,  screws,  or  pegs,  convalescence  may  be  anticipated  in  a 
comparatively  short  time ;  the  bone  retains  its  normal  length  ;  early 
massage  of  the  muscles  and  joints  above  and  below  becomes  practic- 
able, owing  to  the  fixity  of  the  limb,  and  thus  atrophy  on  the  one 
hand,  and  stiffness  on  the  other,  are  avoided. 

The  actual  selection  of  cases  for  operation  must  necessarily  vary 
with  the  views  of  the  particular  surgeon  as  to  the  justifiability  of 
the  procedure,  but  most  surgeons  agree  that  the  following  cases  certainly 
demand  operation :  i.  Fractures  of  small  bones  or  of  processes  which 
are  not  easily  retained  in  position  by  mechanical  appliances,  and 
where  healing  apart  from  operation  is  slow  and  often  defective — e.g., 
in  the  patella,  olecranon,  etc.  2.  Fractures  involving  joints,  where 
fragments  are  displaced,  as  when  the  condyles  of  the  femur  or 
humerus  are  detached.  3.  Fractures  of  the  shafts  of  long  bones 
which  are  oblique  or  spiral,  with  much  longitudinal  displacement, 
and  perhaps  overlapping,  and  with  the  sharp  ends  of  the  fragments 


478 


A  MANUAL  OF  SURGERY 


impacted  in  muscular  or  other  tissues.  Effective  reduction  in  such 
cases  is  often  difficult  even  with  the  tissues  laid  open,  and  is  practi- 
cally impossible  apart  from  operation. 

As  to  the  technique,  the  incision  to  expose  the  bone  should  be 
extensive,  so  as  to  give  plenty  of  room  and  allow  exit  to  as  much 
of  the  extravasated  blood  as  possible.  The  ends  of  the  fragments 
are  then  cleared,  brought  into  correct  position  with  as  little  handling 
as  possible,  and  held  by  suitable  forceps,  whilst  arrangemehts  are 
made  for  fixing  them.  Various  contrivances  are  available,  and  it  is 
not  always  easy  to  determine  which  to  employ.  Sometimes  it  suffices 
to  hold  the  fragments  together  by  silver  wire  of  appropriate  thick- 
ness— e.g.,  for  the  patella  (Fig.  245),  or  for  some  oblique  fractures 
of  the  shafts  of  long  bones  (Fig.  182).  When  the  fracture  extends 
through  masses  of  cancellous  tissue,  it  may  be  possible  to  fix  the  frag- 


FiG.  182. — Fixation  of  Oijliqde 
Fractdre  by  Silver  Wire  Loop 
traversing  the  wliolu  thick- 
NESS OF  THE  Bone. 


Fig.  183. —Lane's  Plate  applied 
for  Transverse  Fracture  with 
Diagrammatic  Longitudinal  Sec- 
tion. 


ments  by  nails,  screws  (Fig.  239)  or  ivory  pegs  driven  into  them. 
Lane's  plates  are  perhaps  the  best  to  employ  for  fractures  of  the  shafts 
of  long  bones  (Fig.  183)  ;  to  be  effective  two  screws  should  be  intro- 
duced both  above  and  below  the  line  of  fracture.  In  a  few  instances 
collars  to  encircle  the  bone  and  steady  the  fragments  may  be  useful. 
Complications  arising  during  Treatment. — (i)  If  an  elderly  patient 
is  kept  in  bed  for  any  length  of  time  in  the  recumbent  posture, 
hypostatic  pneumonia  is  likely  to  ensue.  It  occurs  most  commonly 
after  intracapsular  fractures  of  the  cervix  femoris,  and  non-union 
often  results,  since  the  patients  must  be  allowed  to  get  about  on 
crutches  at  an  early  date,  the  limb  fixed  by  a  suitable  splint. 
(2)  Bedsores  (p.  in)  are  very  liable  to  supervene  in  old  people  with 
fractures  which  need  treatment  in  the  recumbent  posture.  (3)  Crutch 
palsy  is  the  result  of  compression  of  the  brachial  nerves  between  the 


INJURIES  OF  BONES— FRACTURES  479 

bead  of  the  humerus  and  the  pad  of  a  crutch.  It  may  affect  all  the 
nerves  of  the  upper  extremity,  or  may  pick  out  any  one  of  them,, 
and  then  most  commonly  the  musculo-spiral.  It  can  usually  be 
prevented  by  the  use  of  spring-padded  crutches  with  cross-pieces 
for  the  hands,  so  as  to  allow  the  patient  partially  to  relieve  the 
axillary  pressure  by  supporting  the  weight  of  the  body  by  means  of 
the  arms.  When  it  has  occurred,  the  use  of  crutches  must  be 
discontinued,  and  faradism  and  massage  employed  to  the  affected 
muscles.  (4)  Occasionally  a  peculiar  induration  occurs  in  the 
muscles  in  the  neighbourhood  of  a  fracture,  resulting  in  a  rapidly 
developed  shortening.  It  is  usually  seen  in  children  following 
fractures  of  the  forearm  or  lower  end  of  the  humerus,  the  flexor 
muscles  being  involved,  and  manifests  itself  by  the  fingers  becoming 
flexed  and  clawed,  and  by  hyper-extension  of  the  wrist.  The  de- 
formity of  the  fingers  disappears  on  flexing  the  wrist,  demonstrating 
thereby  that  no  adhesions  of  tendons  to  sheaths  are  present.  It 
is  recognised  from  the  results  of  a  nerve  lesion  by  the  absence  of 
sensory  or  trophic  phenomena.  This  so-called  Volhnann''s  IschcBmic 
contraction  has  been  attributed  to  splint  pressure  upon  the  muscles  of 
the  forearm,  but  it  has  also  been  observed  when  splints  have  not 
been  employed ;  probably  it  is  due  to  a  necrobiosis  of  the  muscular 
tissue  due  to  deprivation  of  blood  resulting  from  tight  bandaging, 
and  this  is  followed  by  a  spreading  myositis  fibrosa.  Treatment 
consists  in  exposing  and  lengthening  the  contracted  tendons,  if 
massage  fails,  or  in  shortening  the  bone  or  bones  of  the  limb.  The 
outlook  is,  however,  not  very  promising.  Another  muscular  com- 
plication consists  in  a  deposit  of  bony  tissue  therein,  a  result  of  a 
myositis  ossificans  (p.  416).  (5)  Gangrene  may  arise  from  fractures  in 
a  variety  of  ways  :  (i.)  From  the  immediate  effects  of  the  injury,  either 
by  its  direct  action  on  the  tissues,  or  by  causing  arterial  thrombosis 
in  a  limb  with  atheromatous  vessels,  or  from  rupture  of  the  artery 
with  consequent  venous  thrombosis,  owing  to  the  pressure  of  the 
extravasation ;  (ii.)  by  the  supervention  of  spreading  gangrene 
in  a  compound  fracture  ;  (iii.)  from  errors  in  the  course  of  treatment, 
as  by  bandaging  the  limb  too  tightly,  so  as  to  constrict  the  vessels  ;  or 
by  the  bandage  becoming  unduly  tight,  owing  to  the  subsequent 
swelling  of  the  limb  ;  or  by  flexing  a  joint  after  bandaging  it,  the 
bandage  cutting  into  the  soft  tissues  ;  or  by  the  localized  pressure  of 
a  splint  which  has  been  insufficiently  padded.  Moist  gangrene  is  the 
type  met  with  in  all  cases,  except  when  the  limb  has  been  previously 
drained  of  its  fluids  by  an  atheromatous  condition  of  its  vessels. 
(For  rules  of  treatment,  see  Chapter  VI.) 

Compound  Fractures. 

A  compound  fracture  is  one  in  which  there  is  a  communication 
between  the  external  air  and  the  site  of  injury.  It  is  produced  by 
direct  or  indirect  violence,  and  may  be  associated  with  any  of  the 
complications  or  modifications  met  with  in  simple  fractures.     The 


480  A  MANUAL  OF  StlRGERV 

bones  may  be  but  little  displaced,  or  may  protrude  through  the 
opening  in  the  skin,  and  then  be  bruised  or  comminuted,  and  even 
contaminated  with  dirt  or  mud. 

The  chief  dangers  of  compound  fractures  are,  firstly,  Iminovrhage, 
the  blood,  instead  of  collecting  within  the  tisssues  of  the  limb,  escaping 
externally  if  a  sufficient  opening  is  present ;  otherwise  subcutaneous 
extravasation  occurs,  as  in  a  simple  fracture  ;  and,  secondly,  the 
advent  of  infection.  The  latter  is  the  more  important,  and  may  lead 
to  the  most  serious  consequences.  Portions  of  muscle  and  periosteum, 
which  in  a  simple  fracture  would  be  absorbed  or  incorporated  in  the 
callus,  become  infected,  and  may  slough.  Small  isolated  fragments 
of  bone  are  almost  certain  to  necrose  if  suppuration  ensues,  whilst 
acute  osteo- myelitis  may  occur,  leading  to  extensive  necrosis,  and 
even  endangering  the  patient's  life  by  pyaemia.  Joints  may  be 
infected,  and  acute  suppurative  arthritis  result ;  and  secondary 
haemorrhage  may  follow  an  infective  peri-arteritis.  Such  results  are 
more  likely  to  follow  when  the  external  wound  is  small  and  insufficient 
provision  has  been  made  for  drainage. 

The  Method  of  Union  of  a  compound  fracture  is  much  the  same 
as  that  occurring  in  simple  fractures.  If  the  wound  can  be  rendered 
aseptic,  it  may  be  closed  by  suture,  and  if  it  heals  by  first  intention 
the  fracture  is  converted  into  a  simple  one,  and  repaired  accordingly. 
If,  however,  suppuration  occurs,  it  is  probably  attended  wath  a 
greater  or  less  amount  of  necrosis,  and  possibly  diffuse  inflammation 
and  sloughing  of  the  soft  parts ;  the  wound  will  therefore  remain 
open  for  a  time,  varying  with  the  severity  of  the  local  phenomena. 
Healing  occurs  by  granulation,  which  extends  from  below  upwards, 
and  inasmuch  as  the  deepest  part  of  this  granulation  tissue  is  derived 
from  bone  and  contains  osteoblastic  elements,  it  will  be  transformed 
into  callus,  and  finally  into  true  osseous  tissue.  Repair  is  obviously 
much  slower  under  these  circumstances  than  in  a  simple  fracture. 

The  Constitutional  Symptoms  following  compound  fractures  are 
often  more  marked  than  in  simple  cases.  Even  where  sepsis  is  pre- 
vented by  efficient  treatment,  sorhe  amount  of  aseptic  traumatic  fever 
is  certain  to  supervene  for  a  few  days,  whilst,  if  infection  occurs, 
there  is  a  period  of  marked  febrile  disturbance  for  a  week  or  ten  days, 
similar  to  that  which  is  seen  in  all  septic  lacerated  wounds. 

In  the  Treatment  of  compound  fractures,  the  main  object  is  to 
render  the  wound  aseptic  and  to  give  efficient  exit  to  the  discharges. 
For  this  purpose  the  patient  should  in  all  cases  be  anaesthetized,  the 
limb  shaved  and  thoroughly  purified,  and  the  wound  enlarged  and 
thoroughly  washed  out  with  some  reliable  antiseptic.  It  may  be 
advisable  to  excise  torn  and  dirty  fragments  of  skin,  muscle,  and 
tendon,  especially  when  dirt  has  been  ground  into  them.  Loose 
fragments  of  bone  are  removed,  and  portions  denuded  of  their  perios- 
teum may  be  taken  away  lest  necrosis  should  ensue ;  where  fragments 
retain  any  considerable  connection  with  the  soft  parts,  they  may  be 
left  without  fear.  When  a  sharp  end  of  one  of  the  fragments  is  pro- 
truding  through   a   small   opening  in  the   skin,    it    is    first    purified 


INJURIES  OF  BONES— FRACTURES  481 

thoroughly  before  attempting  its  reduction,  and  then  replaced,  after 
enlarging  the  wound  in  the  skin,  or  a  portion  is  sawn  off.  Haemor^ 
rhage  is  dealt  with  in  the  usual  way,  and  the  fragments  are  placed 
as  nearly  as  possible  in  their  normal  position.  If  the  fragments  can 
be  brought  accurately  into  position,  it  is  well  to  fix  them  by  some 
mechanical  appliance ;  but  where  the  ends  of  the  bone  are  much 
comminuted,  the  small  portions  must  be  arranged  in  position  as  well 
as  possible,  and  no  attempt  made  to  wire  them.  A  good-sized 
drainage-tube  is  inserted,  and,  if  need  be,  counter-openings  are 
made  ;  the  external  wound  is  closed  or  not  according  to  circumstances 
and  dressed,  and  suitable  splints  are  then  applied.  Under  such  a 
regime  the  majority  of  cases  do  well.  Immoveable  apparatus  may 
be  used  after  a  time,  windows  being  left  in  the  plaster  casing  to  allow 
wounds  to  be  dressed. 

In  compound  fractures  which  have  been  attended  with  complica- 
tions directed  to  vessels,  nerves,  and  neighbouring  soft  parts  or  joints, 
the  prognosis  and  course  of  the  case  may  be  considerably  modified  ; 
treatment  suitable  to  each  of  these  conditions  must  be  adopted. 

The  question  of  Amputation  will  necessarily  be  raised  in  the  more 
serious  cases  ;  but  it  is  unnecessary  to  add  anything  here  to  what  has 
been  already  stated  (p.  237). 

Complicated  Fractures. 

1.  Comminution  of  one  or  both  fragments  is  due  to  excessive 
violence,  or  perhaps  to  exceptional  brittleness  of  the  bones.  As  long 
as  the  skin  remains  unbroken,  sound  union  is  usually  obtained, 
though  with  an  increased  amount  of  callus.  Occasionally  comminu- 
tion may  be  a  cause  of  non-union,  a  small  detached  portion  of  dense 
compact  tissue  being  wedged  cross-wise  between  the  fragments, 
especially  in  the  case  of  the  tibia  or  femur.  In  a  compound  fracture 
necrosis  of  the  fragments  may  result  from  the  admission  of  sepsis. 

2.  Implication  of  a  Joint. — When  the  fracture  extends  through  the 
articular  cartilage,  the  joint  becomes  distended  with  blood  and 
synovial  fluid,  but  this  is  subsequently  absorbed,  and  the  fissure  in 
the  cartilage  closed  by  plastic  lymph  which  develops  into  scar  tissue. 
If  the  fragments  are  in  perfect  apposition,  no  harm  results,  although 
the  joint  remains  stiff  for  a  little  while.  If,  however,  the  apposition 
is  imperfect,  adhesions  of  a  more  serious  type  develop,  and  consider- 
able limitation  of  movement  results.  It  is  thus  comprehensible  that 
one  of  the  chief  indications  for  the  operative  treatment  of  fractures 
is  when  they  involve  joints.  In  elderly  people  injuries  of  this  type 
may  result  in  a  traumatic  arthritis  with  changes  akin  to  those  of 
osteo-arthritis,  and  particularly  when  the  shoulder  or  hip  are  involved. 
The  patient  complains  of  great  pain,  and  the  development  of  osteo- 
phytes causes  limitation  of  movement. 

3.  The  same  violence  that  causes  the  fracture  may  at  the  same 
time  produce  a  Dislocation  in  a  neighbouring  joint,  and  particularly 
in  connection  with  the  elbow  and  shoulder.  Treatment  should  always 
be  undertaken  as  soon  as  possible,  except,  perhaps,  in  the  old  and 

3^ 


482  A  MANUAL  OF  SURGERY 

feeble,  or  in  those  who  have  sustained  serious  concomitant  injuries, 
and  its  object  must  be  not  only  to  restore  the  continuity  of  the  bone, 
but  also  to  reduce  the  dislocation.  Should  the  fracture  involve  or  be 
close  to  the  articular  end  of  the  bone,  an  attempt  should  be  made  to 
reduce  the  deformity  by  manipulation  under  an  anaesthetic  ;  but  if 
there  is  any  doubt  as  to  success  of  this  procedure,  or  if  it  recurs  after 
apparent  reduction,  then  open  operation  should  be  undertaken  if  the 
conditions  as  to  surgical  cleanliness  permit.  It  is  quite  an  arguable 
question  whether  it  is  not  wiser  to  operate  always  on  these  cases, 
removing  blood-clot,  reducing  the  dislocation,  and  fixing  the  frac- 
ture when  possible ;  in  some  instances  when  the  displaced  arti- 
cular fragment  is  small,  it  may  be  better  to  remove  it  entirely. 
When  the  fracture  is  farther  away  from  the  joint,  it  is  sometimes 
possible  to  command  the  fragments  by  a  careful  application  of  splints, 
and  then  the  limb  may  be  manipulated  in  the  usual  way  and  the  dis- 
location reduced  under  an  angesthetic.  Failing  this,  the  surgeon  may 
either  fix  the  fracture  by  operation  and  repeat  the  attempt  to  reduce 
the  dislocation,  or  he  may  open  the  joint  and  perform  an  open  reduc- 
tion. The  exact  method  adopted  must  necessarily  vary  with  the 
particular  condition  present.  Should  immediate  treatment,  for  any  of 
the  reasons  given  above,  be  prohibited,  the  limb  should  be  fixed  in 
splints  so  as  to  allow  union  of  the  fracture,  and  at  a  later  date  the 
unreduced  dislocation  should  be  treated. 

4.  The  Main  Artery  may  be  compressed,  contused,  punctured,  or 
ruptured.  Compression  is  often  only  temporary,  and  is  relieved  by 
setting  the  fracture.  Thrombosis  may  follow,  but  if  the  peripheral 
vessels  are  healthy  no  harm  results  unless  the  vein  is  also  implicated, 
and  then  moist  gangrene  will  probably  ensue.  If  the  terminal  vessels 
are  calcareous  and  rigid,  dry  gangrene  of  the  senile  type  may  super- 
vene. Such  untoward  results  are,  of  course,  more  likely  to  develop 
if  the  pressure  on  the  vessel  is  not  relieved.  Puncture  or  rupture  of 
the  artery  is  likely  to  lead  to  widespread  extravasation  and  be 
followed  by  thrombosis,  or  if  less  severe,  the  development  of  a  trau- 
matic aneurism.  The  nutrition  of  the  limb  may  suffer  when  the 
extravasation  is  extensive,  and  even  if  the  vitality  of  the  limb  is  not 
impaired,  yet  considerable  stiffness  may  result  from  the  organization 
of  the  blood  in  the  tissues.  Treatment  necessarily  varies  in  different 
cases.  Compression  must  be  relieved  at  the  earliest  possible  moment 
by  the  reduction  of  the  fracture,  and  the  circulation  of  the  limb  is 
subsequently  watched  carefully  for  some  days.  If  the  main  trunk  is 
punctured  or  ruptured,  the  ideal  practice  is  to  cut  down  in  every  case, 
remove  clots,  and  tie  above  and  below  the  injury  in  the  vessel ;  but, 
owing  to  the  difficulty  sometimes  experienced  in  securing  aseptic 
conditions,  it  is  not  always  advisable  to  do  so,  since  the  lacerated 
Sssues  are  very  prone  to  infection.  Under  such  circumstances  the 
main  artery  may  be  compressed  or  tied  above  the  fracture,  but  only 
when  the  distal  circulation  has  been  re-established ;  in  the  absence  of 
this  condition,  gangrene  would  be  certain  to  ensue.  If  neither  of  the 
above-mentioned  expedients   can  be  adopted,  an  expectant  plan  of 


INJURIES  OF  BONES— FRACTURES  483 

treatment  must  be  followed.  The  limb  is  thoroughly  purified, 
wrapped  in  aseptic  wool,  placed  on  appropriate  splints,  and  slightly 
elevated.  Should  gangrene  supervene,  amputation  is  the  only 
resource ;  it  need  not  be  undertaken  for  a  few  days  if  the  limb  is 
aseptic,  so  as  to  allow  a  distinct  line  of  separation  to  form ;  but  if 
septic,  early  removal  through  or  above  the  line  of  fracture  is 
essential. 

5.  Laceration  of  Veins  results  in  extravasation  of  blood,  which  is 
not  so  extensive  as  when  an  artery  is  wounded,  since  thrombosis 
occurs  more  easily  ;  the  distal  part  of  the  limb  may  become  congested 
and  oedematous,  and  this  may  constitute  an  additional  element  pre- 
disposing to  gangrene.  Simple  compression  of  the  veins  produces 
oedema,  which,  even  in  favourable  cases,  may  persist  for  some  time, 
needing  for  its  removal  firm  bandaging,  massage,  and  cold  douching. 

6.  The  Nerves  of  a  limb  may  be  injured  at  two  different  periods. 
(a)  Immediate  injury  is  due  to  laceration  or  rupture,  either  of  the 
whole  trunk,  or,  as  is  more  common,  of  the  nerve  fibrillae,  without 
loss  of  continuity  of  the  sheath.  Paralytic  and  anaesthetic  phenomena 
follow,  but  are  usually  recovered  from,  (b)  Secondary  symptoms 
result  from  inclusion  and  compression  of  the  nerve  in  the  callus,  or 
from  injudicious  splint  pressure.  Irritative  symptoms  in  the  shape 
of  neuralgia  and  muscular  spasms  are  first  manifested,  followed  by 
paralysis  and  anaesthesia.  This  usually  occurs  about  three  or  four 
weeks  after  the  accident,  and  may  disappear  in  a  month  or  two,  or 
persist.  Treatment  is  always  for  a  time  of  the  expectant  type,  even 
when  the  paralysis  is  immediate,  since  total  rupture  of  a  nerve  is 
rare,  and  restoration  of  function  the  rule  rather  than  the  exception. 
When,  however,  the  symptoms  persist,  the  parts  must  be  laid  open, 
the  nerve  freed  from  adhesions,  or  exuberant  callus  removed,  and 
such  measures  taken  as  will  best  secure  the  nerve  from  further  com- 
pression. 

Ununited  Fractures. 

Three  varieties  of  ununited  fracture  have  been  described:  (i)  Abso- 
lute non-union  is  said  to  be  present  when  no  attempt  at  repair  is  made. 
This  rarely  occurs  except  when  some  definite  bone  disease  exists, 
such  as  sarcoma  or  osteo-malacia,  or  when  in  a  very  debilitated 
patient  there  has  been  no  attempt  to  fix  the  limb.  (2)  Fibrous  Union 
consists  in  the  development  of  a  more  or  less  firm  mass  of  connective 
tissue  as  the  bond  of  union  between  the  ends  of  the  bones,  which  are 
either  rounded  off  and  closed  by  a  thin  plate  of  bone  or  cartilage,  or 
are  sometimes  atrophic  and  pointed.  (3)  A  false  joint,  or  pseud  arthrosis, 
is  a  condition  in  which  the  ends  of  the  fragments  are  covered  either 
by  bone  or  cartilage,  and  more  or  less  altered  in  shape,  so  as  to 
form  a  shallow  ball-and-socket  joint,  the  capsule  being  represented 
by  the  surrounding  fibrous  tissue,  and  the  synovial  cavity  by  an 
adventitious  bursa,  which  results  from  the  friction  of  the  two  ends 
(Fig.  184). 

The  most  common  situations  for  ununited  fractures  are  projecting 


484 


A  MANUAL  OF  SURGERY 


processes  of  bone  to  which  powerful  muscles  are  attached,  such  as 
the  patella,  olecranon,  coracoid  process,  posterior  half  of  the  os  calcis, 
etc. ;  whilst  in  long  bones  the  middle  of  the  shaft  of  the  humerus  and 
the  upper  and  lower  thirds  of  the  femur  are  the  favourite  sites. 

Causes.  —  (i)  Want  of  apposition  of  the  bony  ends,  owing  to 
muscular  action — e.g.,  in  the  patella,  when  the  two  fragments  are 
widely  separated,  or  in  the  femur,  where  they  may  overlap;  (2)  the 
interposition  of  muscular  or  aponeurotic  tissue,  or  detached  frag- 
ments of  compact  bone ;  (3)  want  of  rest,  one  of  the  most  common 
causes,  as  in  the  middle  of  the  shaft  of  the  humerus,  where,  unless 
the  elbow  is  well  supported,  complete  immobility  cannot  be  obtained, 

and  non-union  is  likely  to 
result ;  (4)  defective  blood- 
supply  to  one  or  both  frag- 
ments, as  by  injury  to  the 
nutrient  artery,  or  as  in 
intra  -  capsular  fracture  of 
the  cervix  femoris,  where 
the  only  source  of  supply 
to  the  upper  fragment  is  a 
small  twig  derived  from 
the  obturator  artery  running 
along  the  ligamentum  teres  ; 
(5)  local  affections  of  the 
bone,  such  as  malignant 
tumours,  or  the  undue  pres- 
sure of  pads  upon  the  newly- 
formed  callus  ;  (6)  general 
bone  disease,  as  osteo-ma- 
lacia  ;  and  (7)  general  con- 
stitutional weakness  or  de- 
bility, sometimes  due  to 
definite  diseases,  such  as 
scurvy  or  severe  syphilis, 
sometimes  to  general 
asthenia  or  alcoholism.  It 
has  been  proved  that  senility,  pregnancy,  and  the  cancerous  cachexia 
do  not,  as  used  formerly  to  be  stated,  predispose  to  this  condition. 

The  Signs  of  an  ununited  fracture  are  usually  obvious,  mobility 
between  the  fragments  being  easily  obtained  in  some  directions, 
though  perhaps  not  in  all ;  of  course  crepitus  is  absent. 

The  Prognosis  is  good  if  suitable  treatment  is  adopted,  and  the 
local  conditions  do  not  prohibit  reunion.  In  children,  however,  the 
condition  is  often  maintained  even  after  operation,  and,  in  fact,  may 
be  aggravated  by  it,  the  ends  of  the  bone  becoming  atrophic,  rounded, 
and  covered  by  cartilage ;  in  such  the  final  resource  is  not 
unfrequently  amputation. 

The  Treatment  of  ununited  fractures  is  now  conducted  on  perfectly 
definite  lines,     (i)   If  in  good  position,  the  parts  are  refixed,  and 


Fig.  184. — Ununited  Fracture  with  False 
Joint.  (From  College  of  Surgeons' 
Museum.) 


INJURIES  OF  BONES— FRACTURES 


485 


end    of 

usually 
ping    of 


a  course  of  passive  venous  congestion  (Bier's  treatment)  carried  out. 
An  elastic  bandage  \s  applied  to  the  limb  above  the  fracture  with 
sufficient  tightness  i:c  constrict  the  veins  for  three  or  four  hours  daily. 
Excellent  results  often  follow.  It  may  also  be  advisable  to  adopt 
means  to  improve  the  general  health,  as  by  a  stay  at  the  seaside  and 
the  administration  of  tonics.  (2)  Failing  this,  operative  measures 
must  be  undertaken.  If  the  bone  is  tolerably  superficial,  and  the  ends 
not  very  far  apart,  they  should  be  exposed,  sawn  into  shape,  fitted 
together  (preferably  by  a  dove-tailing  process),  and  secured  by  stout 
silver  wire,  plates,  screws,  or  pegs.  _ 

If,  however,  the  bones  are  deeply 
placed,  so  that  it  is  difficult  to 
expose  the  ends  and  fit  them 
together,  it  may  be  wiser  to  leave 
them  in  their  bad  position,  and  fix 
them  by  the  insertion  of  screws 
or  ivory  pegs.     Thus,  in  the  upper 

the    femur    non-union    is 

associated     with    overlap- 

the  ends  of  the  bone  to 
a  considerable  extent.  To  expose 
and  fit  these  together  would 
necessitate  a  very  extensive  dis- 
section ;  it  may  be  desirable  in 
such  cases  merely  to  cut  down  in 
front  upon  the  upper  anterior 
fragment,  drill  two  holes  in  differ- 
ent directions  through  both  frag- 
ments, and  into  these  insert  suitable 
pegs  or  screws.  Two  holes  should 
always  be  employed,  to  prevent 
slipping  of  the  fragments  during  the  Fir,.  185.  —  Vicious  Union  with 
necessary  manipulations;  whilst  Marked  Deformity  aPter  Frag- 
J   -ii    •  AC       j-u      ■  ture  OF  Femur.    (King's  College 

one  drill  is  removed  for  the  mser-      hospital  Museum.) 
tion   of   the   peg,    the   other    holds 

the  bone  steady.  As  a  rule  the  pegs  may  be  allowed  to  remain 
permanently,  but  occasionally  they  become  loose  in  three  or  four 
weeks,  and  need  removal.  Their  presence  causes  the  formation  of 
a  large,  amount  of  callus,  and  by  this  means  the  fracture  is  con- 
solidated. 

Vicious  Union  (Fig.  185)  of  fractures  results  either  from  imperfect 
adjustment  of  the  ends  of  the  bone,  or  from  the  parts  not  being  kept 
at  rest,  and  hence  becoming  subsequently  displaced.  Various  kinds 
of  deformity  and  disfigurement,  accompanied  or  not  by  loss  of 
function,  may  result  from  this  accident,  and  if  these  are  serious, 
means  must  be  taken  to  remedy  matters.  If  observed  early,  it  is  not 
difficult  to  readjust  the  parts  by  simple  pressure  under  an  anaesthetic, 
if  necessary,  refracturing  the  bone ;  but  this  should  only  be  under* 
taken  whilst  the  callus  is  -soft — i.e.,  within  two  or  three  weeks  of  the 


486  A  MANUAL  OF  SURGERY 

accident.  Some  surgeons  apply  this  method  of  osteoclasia  even  when 
consohdation  has  been  accomphshed,  using  for  the  purpose  powerful 
levers  and  clamps ;  but  such  treatment  is  undesirable,  since  it  is 
difficult  to  gauge  accurately  the  amount  of  damage  concurrently 
inflicted  on  the  soft  parts.  The  open  method  is  certainly  preferable, 
cutting  down  on  the  bone,  redividing  it,  removing  redundant  callus, 
and  fixing  the  fragments  by  silver  wire,  pegs,  or  screws. 

Disunited  Fracture  is  the  term  applied  to  a  rare  condition,  in  which 
a  fracture  which  had  been  firmly  united  becomes  separated  again. 
It  is  only  met  with  when  the  individual  develops  some  extremely 
debilitating  disease,  such  as  scurvy,  and  may  be  recovered  from  under 
suitable  treatment  directed  to  the  cause,  and  by  fixation  of  the 
parts. 

Special  Fractures. 

Bones  of  the  Face. — The  Nasal  bones  are  broken  as  a  result  of  direct 
violence — by  the  fist,  a  cricket-ball,  stick,  etc.  The  fracture  is  generally 
transverse,  and  situated  just  above  their  free  margins;  occasionally, 
when  greater  force  is  used,  it  occurs  close  to  the  root  of  the  nose,  and 
may  then  be  associated  with  fracture  of  the  frontal  bone  or  base  of 
the  skull.  In  young  people  the  cartilages  alone  may  be  separated. 
There  is  usually  considerable  deformity  from  depression  or  lateral 
displacement  of  the  fragments,  although  it  may  at  first  be  masked 
by  the  amount  of  bruising.  Severe  epistaxis,  surgical  emphysema, 
and  cerebral  symptoms,  are  sometimes  met  with  as  complications. 
The  fracture  very  readily  becomes  consolidated,  and  the  deformity 
is  thus  often  irremediably  fixed,  unless  its  presence  is  determined 
at  once,  and  suitable  treatment,  adopted.  The  Septum  is  some- 
times broken  and  depressed,  in  association  with  or  apart  from  the 
above  injury.  Lateral  displacement  occurs,  causing  unilateral  nasal 
obstruction  and  some  amount  of  obvious  deformity.  The  Treatment 
of  these  cases  consists  in  immediate  replacement  of  the  bones, 
advisably  under  an  anaesthetic  ;  this  may  be  accomplished  by  the 
pressure  of  some  blunt  instrument,  such  as  a  pair  of  padded  dressing- 
forceps,  the  blades  of  which  are  introduced  within  the  nostril.  A 
pad  of  lint  or  gauze  soaked  in  carbolized  oil  is  then  inserted  to 
maintain  the  position,  and  a  gutta-percha  or  zinc  splint  moulded  to 
fit  the  bridge.  This  dressing  should  be  changed  every  twenty-four 
hours,  and  the  nose  irrigated.  In  old -standing  cases,  where  there  is 
much  depression,  but  little  can  be  done  by  operation,  but  sub- 
cutaneous injections  of  paraffin  may  improve  the  appearance  (see 
Chapter  XXVIII.).  Lateral  displacement  can  usually  be  remedied 
by  mechanical  appliances  or  operation. 

The  Lachrymal  bone  has  been  broken  by  direct  violence,  the  frac- 
ture usually  extending  from  the  nasal  bone  to  the  lateral  mass  of  the 
ethmoid.  Interference  with  the  flow  of  tears  and  surgical  emphy- 
sema are  the  two  most  marked  symptoms. 

The  Malar  bone  is  but  rarely  broken  without  the  other  bones  of  the 
face  being  involved;-  fracture  is  almost  always  associated  with  damage 


INJURIES  OF  BONES— FRACTURES  487 

to  the  anterior  wall  of  the  antrum  and  considerable  depression  of  the 
fragments.  An  attempt  should  be  made  to  replace  the  parts  by 
pressure  from  within  the  mouth. 

The  Zygoma  is  fractured  by  direct  violence  applied  from  without ; 
the  broken  portion  may  be  depressed  below  the  surface,  but  vertical 
displacement  is  limited  by  the  attachment  of  the  masseter  below  and 
of  the  temporal  fascia  above.  '  Reposition,  either  by  manipulation 
from  within  the  mouth,  or  even  by  operation,  is  essential  in  order  to 
prevent  interference  with  the  subsequent  mobility  of  the  jaw.  Perhaps 
the  simplest  plan  to  adopt  is  to  encircle  the  zygoma  subcutaneously 
with  a  loop  of  silver  wire  and  drag  it  up  to  its  natural  level. 

The  Superior  Maxilla  is  invariably  broken  as  a  result  of  direct 
injury,  such  as  a  gunshot  wound  or  a  blow;  it  is  almost  always  com- 
pound, and  often  bilateral.  The  alveolar  portion  is  either  partially 
or  entirely  detached,  or  a  transverse  fissure,  extending  as  far  as  the 
pterygoid  processes  on  each  side,  may  render  the  whole  palate  and 
lower  part  of  the  facial  skeleton  moveable.  More  frequently  all  the 
bones  of  the  face  are  smashed  and  comminuted,  severe  haemorrhage 
sometimes  resulting  from  wounds  of  the  terminal  branches  of  the 
internal  maxillary  artery.  Treatment  consists  in  merely  keeping  the 
patient  quiet  and  applying  cooling  lotions ;  union  occurs  with  great 
readiness,  but  is  sometimes  associated  with  suppuration  and  necrosis. 
The  patient  must  be  fed  by  a  tube,  and  a  carefully-fitted  dental  plate 
should  be  applied  to  a  broken  alveolus. 

The  Inferior  Maxilla  is  usually  fractured  by  direct  violence,  but 
occasionally  by  force  applied  indirectly,  as  when  a  carriage  passes 
over  the  bone,  laterally  compressing  the  two  sides,  and  leading  to  a 
fracture  in  the  middle  line.  Most  frequently  the  lesion  is  a  little 
in  front  of  the  mental  foramen  (Fig.  186),  this  being  a  weak  spot 
at  the  junction  of  two  strong  parts,  viz.,  the  symphysis  menti,  and 
the  alveolar  process  carrying  the  molar  teeth ;  the  bone  is  further 
weakened  by  the  long  narrow  alveolus  which  lodges  the  canine  tooth. 
This  fracture  is  sometimes  bilateral  when  great  violence  has  been 
applied  to  the  symphysis.  A  solution  of  continuity  sometimes  occurs 
close  to  the  angle  behind  the  molar  teeth,  whilst  the  coronoid  process 
and  condyle  have  occasionally  been  broken,  the  former  only  as  a  result 
of  great  force— ^.^.,  a  gunshot  wound — -the  latter  from  either  direct 
or  indirect  violence. 

The  Signs  of  fracture  are  very  evident  if  the  lesion  is  situated 
anteriorly ;  but  when  behind  the  teeth,  diagnosis  may  be  much  more 
difficult.  The  usual  variety  is  almost  always  compound,  owing  to 
the  firm  attachment  of  the  muco-periosteum  to  the  alveolar  border. 
Laceration  of  the  gums,  the  blood-stained  saliva  soon  becoming  foetid, 
the  irregularity  in  the  line  of  the  teeth,  and  the  easily  elicited  crepitus, 
all  constitute  a  typical  picture.  There  is  often  considerable  pain, 
owing  mainly  to  the  tearing  of  the  mucous  membrane,  but  possibly 
due  to  implication  of  the  inferior  dental  nerve.  The  main  trunk, 
however,  generally  escapes,  owing  to  the  position  of  the  fracture  in 
front  of  the  mental  foramen,  whilst  in  those  behind  there  is  but  little 


4^8  A  MANUAL  OP  SUHGERV 

displacement.  Smart  haemorrhage  sometimes  occurs  from  laceration 
of  the  accompanying  artery.  The  posterior  fragment  is  usually  raised, 
whilst  the  anterior  portion  is  depressed  by  the  action  of  the  hyoid 
muscles,  and  may  override  the  other,  owing  to  the  direction  of  the 
fracture,  the  anterior  fragment  including  more  of  the  outer  surface  of 
the  bone  than  the  posterior.  The  direction  of  the  displacement  is 
reversed  in  some  cases.  When  situated  at  the  angle  or  in  the  vertical 
ramus,  there  is  such  equal  muscular  support  on  the  two  sides  that  but 
little  displacement  results.  When  the  fracture  passes  through  the  neck 
of  the  condyle,  that  process  is  drawn  forwards  and  inwards  by  the 
external  pterygoid,  whilst  the  body  of  the  bone  is  freely  moveable 
antero-posteriorly,  and  displaced  towards  the  fractured  side.  When 
the  coronoid  process  is  detached,  it  is  dragged  upwards  by  the  temporal 
tendon,  but  no  great  displacement  can  occur,  owing  to  the  extensive 
attachment  of  the  tendinous  fibres. 


Fig.   i86. — Lower  Jaw,  indicating  the 
Most  Common  Sites  of  Fracture. 


Fig.  187. — Application  o? 
Four-Tailed  Bandage  for 
Fracture  of  Lower  Jaw. 


In  those  cases  of  fracture  which  are  compound  (and  this  includes 
the  great  majority),  septic  inflammation  of  the  ends  of  the  bone  often 
ensues,  leading  to  localized  necrosis,  and  sometimes  to  septic 
pneumonia,  or  even  to  general  pyaemia.  An  abscess  sometimes 
develops,  and  points  in  the  submaxillary  region. 

The  Treatment  of  a  fractured  mandible  is  frequently  a  troublesome 
matter,  owing  partly  to  the  septic  element,  and  partly  to  the  diffi- 
culty of  fixing  the  jaw  without  interfering  with  the  patient's  nutrition ; 
hence  the  co-operation  of  a  skilled  dentist  should  always  be  secured. 
Teeth  loosened  by  the  injury  will  probably  require  removal,  and  at 
the  same  time  it  is  wise  to  extract  septic  teeth  or  roots,  so  as  to  be 
able  to  keep  the  mouth  in  a  more  cleanly  condition. 

I.  As  a  temporary  measure,  and  indeed  as  a  permanent  appliance 
in  simple  cases  without  much  displacement  of  the  fragments  and 
where  dental  assistance  is  not  to  hand,  all  that  is  needed  is  an  efficient 


mjURIES  OF  BONES— FRACTURES  489 

four-tailed  bandage.  This  is  made  by  taking  a  piece  of  calico  4  inches 
wide  and  i  yard  in  length,  and  splitting  each  end  into  two,  leaving 
about  8  inches  undivided,  in  the  centre  of  which  a  small  longitudinal 
cut  is  made  for  the  insertion  of  the  chin.  The  two  lower  tails  are 
then  drawn  up  and  tied  over  the  vertex,  whilst  the  two  upper  ends 
are  secured  behind  the  occiput,  and  then,  to  prevent  slipping,  are 
knotted  to  the  ends  of  the  former  (Fig.  187).  The  bandage  is 
maintained  firmly  in  position  for  three  weeks,  the  patient  being  fed 
through  a  tube  passed  between  the  teeth  or  through  the  gap  behind 
the  last  molar,  and  all  movement  of  the  jaw  prohibited.  The  mouth 
should  be  frequently  washed  out  with  some  antiseptic  lotion.  Union 
is  usually  secured  in  five  weeks. 

2.  If  patients  are  unruly,  or  if  the  above  method  fails  to  maintain 
the  fragments  in  position,  a  moulded  poroplastic  or  leather  splint 
may  be  applied,  made  in  the  shape  indicated  in  Fig.  188,  the  upper 
portion,  which  should  reach  to  the  posterior  border  of  the  vertical 
ramus,  being  folded  back,  and  the  lower  portion  drawn  up  around 


Fig.  188. — Leather  Splint 
FOR  Lower  Jaw. 


Fig.  1S9. — Leather  Splint 

APPLIED. 


the  bone.     It  is  lined  with  lint,  and  secured  by  bandages  or  tapes 
passed  through  holes,  and  tied  as  shown  in  Fig.  189, 

3.  Where  there  is  much  displacement,  the  fragments  must  be  fixed. 
Wire  sutures  passed  around  or  between  adjacent  teeth  and  tied  are 
distinctly  objectionable,  causing  the  teeth  to  become  loose  and  perhaps 
diseased.  Hammond's  wire  splint  is  the  best  apparatus  to  employ.  It 
consists  of  a  firm  wire  collar  or  framework  (Fig.  190),  which  encircles 
the  whole  series  of  teeth  in  the  lower  jaw.  It  is  accurately  fitted  by 
a  dentist,  firstly,  to  a  cast  of  the  jaw,  subsequently  to  the  jaw  itself, 
and  is  fixed  by  several  wires  passing  from  one  half  to  the  other 
between  the  teeth. 

4.  In  cases  where  a  Hammond's  splint  fails  in  remedying  the  dis- 


49° 


A  MANUAL  OF  SURGERY 


placement,  or  where  the  teeth  are  defective,  a  Kingsley's  apparatus 
(Fig.  191)  may  be  used  with  advantage.  It  consists  of  a  vulcanite 
splint  fitted  over  the  teeth  or  alveolar  process  of  the  mandible,  and 
extending  for  a  sufficient  distance  on  each  side  of  the  fracture  to 
steady  the  fragments.  To  the  front  of  this  are  attached  curved 
metal  bars,  which  extend  sideways  from  the  angles  of  the  mouth 
over  the  cheeks.  It  is  kept  in  position  by  passing  a  bandage  over 
the  bars  and  under  the  chin  (Fig.  192),  and  secures  thereby  excel- 
lent immobilization  of  the  fragments,  even  when  the  mouth  is 
opened. 

5.  Wiring  of  the  fragments  together  may  be  required  in  a  few  cases. 
The  wires  must  be  passed  either  through  the  bone  below  the  teeth — 
a  task  not  easy  to  accomplish  without  an  external  wound — or  through 

the  empty  alveoli  of  neigh- 
bouring teeth,  which  are 
extracted  for  the  purpose. 
When  septic  inflamma- 
tion occurs  of  such  severity 
as  to  lead  to  necrosis,  it  is 
best  to  delay  all  operative 
treatment  until  the  seques- 
trum has  been  detached, 
and  the  parts  are  more 
healthy,  the  patient's 
mouth  in  the  meantime 
being  frequently  cleansed 
with  antiseptic  lotions. 
Wiring  of  the  fragments 
may  then,  if  necessary,  be 
undertaken  with  good  hope 
of  success. 

Fracture  of  the  Hyoid 
Bone  is  uncommon,  arising  usually  from  direct  violence,  such  as  a 
forcible  grasp  or  the  constriction  of  the  neck  in  hanging.  Either 
the  body  may  be  broken,  or  one  of  the  cornua  separated.  The 
symptoms  produced  are  :  Pain  on  attempting  to  move  the  tongue, 
jaw,  or  neck  ;  a  husky  voice ;  and  deformity,  which  can  sometimes 
be  detected  from  without.  Occasionally  the  mucous  membrane  is 
perforated,  and  bleeding  into  the  pharynx  may  occur,  whilst  oedema 
of  the  glottis  may  supervene.  The  fragments  should  be  approxi- 
mated as  well  as  possible  by  manipulation  between  one  finger  in  the 
mouth  and  the  hand  outside,  and  the  neck  then  fixed  by  a  poroplastic 
collar. 

Fracture  of  the  Ribs  may  arise  in  two  distinct  \vays :  (i)  By  direct 
violence,  as  by  blows  or  stabs,  the  fragments  being  driven  inwards, 
and  damage  to  the  underlying  pleura,  lungs,  liver,  or  diaphragm,  being 
very  likely  to  occur ;  or  (2j  much  more  frequently  by  indirect  violence, 
as  when  the  chest  is  compressed  between  a  cart-wheel  and  the  ground. 


Fig.  190. — Hammond's  Splint  for 
Fracture  of  Lower  Jaw. 


INJURIES  OF  BONES— FRACTURES 


491 


or  between  a  wall  and  the  back  of  a  waggon.  The  ends  of  the  ribs 
are  then  approximated  beyond  the  limits  of  natural  elasticity,  and 
they  give  way  at  the  most  convex  part — i.e.,  near  the  angle.  The 
viscera  may  be  contused,  but  less  often  than  in  the  former  class, 
although  haemothorax  from  rupture  of  the  parietal  pleura  is  not  un- 
common. One  or  several  ribs  may  be  broken,  but  the  displacement  is 
rarely  marked,  except  in  cases  due  to  direct  violence,  where  several 
ribs  have  been  '  staved  in.'  The  fifth  to  the  eighth  ribs  are  those 
usually  injured,  being  more  prominent  and  fixed  at  both  ends  ;  the  first 
and  second  ribs  are  so  well  protected  by  the  clavicle  as  to  be  seldom 
broken  by  direct  injury,  although  great  violence  from  above  downwards 
to  the  outer  end  of  the  clavicle  may  lead  to  such  an  accident ;  the  lower 
ribs  often  escape  on  account  of  their  greater  mobility.     Elderly  women 


Fig.  191. 
Kingsley's  Splint  for  Fracture 
OF  Lower  Jaw. 


Fig.  192, 
Kingsley's  Splint 

APPLIED. 


and  persons  suffering  from  general  paralysis  of  the  insane  are  specially 
prone  to  this  fracture. 

The  Symptoms  are  tolerably  obvious,  viz.,  a  sensation  of  something 
snapping  or  giving  way,  a  sharp  localized  catching  pain  at  the  site  of 
the  injury,  increased  on  deep  breathing  and  coughing,  and  possibly 
some  local  extravasation  and  swelHng.  Pain  is  elicited  by  a  local 
examination,  and  also  by  conjoined  pressure  upon  the  sternum  and 
spinal  column,  whilst  the  fracture  may  be  evident  on  palpation,  or 
crepitus  detected  when  the  patient  coughs  or  on  auscultation.  When 
several  ribs  are  driven  in,  a  marked  depression  results,  but  if  a  single 
bone  is  broken  in  a  fat  individual,  the  diagnosis  may  be  extremely 


492  A  MANUAL  OF  SURGERY 

obscure.     For  the  clinical  history  of  the  pulmonary  or  pleural  com- 
plications, see  Chapter  XXXII. 

Treatment. — The  affected  side  should  be  firmly  strapped  with  broad 
strips  of  adhesive  plaster,  so  as  to  limit  its  movements.  The  strips, 
i|^  to  2  inches  wide,  should  extend  beyond  the  middle  line,  both  front 

and  back,  and  are  applied  from  below 

,^^  upwards,  whilst  the  chest  is  in  a  state  of 

^^  forcible  expiration,   each  strip  overlap- 

,  '  ping  the  preceding  one  and  crossing  the 

<  direction  of  the  ribs  (Fig.  193).     A  firm 

I  %x^        woollen  bandage  should  then  be  applied 

•   I  I  ^^    over  all.     If  the  ends  of  the  bone  are 

»  '— — '^  "  ~   /  driven  inwards,  strapping  can  rarely  be 

I  '--^'    ^  7  borne,  as  it  tends  still  further  to  irritate 

p  y^———~       ~~''  or  compress  the  lung.     Under  such  cir- 

O  U— — — r  cumstances  all  constriction  of  the  chest 

B  k -^  must  be  avoided,  the  patient  being  con- 

^m   '  fined  to  bed  with  a  sandbag  between  the 

^%,  shoulders,  and   the  arm   bound   to   the 

m\\t.     .      -  -s*^  side.    When  the  lower  ribs  are  broken. 

Fig.  193.— Method  of  Strap-   tight  applications  are  generally  contra- 

piNG  Broken  Ribs.  indicated,  since  the  diaphragm  is  likely 

to  be  irritated,  and  troublesome  hiccough 

may  result.     Ribs  unite  readily,  but  with  a  considerable  amount  of 

callus,  owing  to  the  mobility  of  the  fragments. 

Separation  of  a  Costal  Cartilage  sometimes  occurs,  giving  rise  to  the 
same  symptoms  and  requiring  the  same  treatment  as  a  broken  rib. 
Occasionally  the  cartilage  itself  may  be  fractured.  In  each  case  the 
resulting  bond  of  union  is  osseous. 

Fracture  of  the  Sternum  is  almost  always  due  to  direct  violence. 
The  line  of  fracture  is  usually  transverse,  the  bone  giving  way  either 
between  the  manubrium  and  gladiolus  or  a  little  belov/  this  level. 
The  fragments  may  remain  in  situ  or  the  upper  portion  be  displaced 
backwards,  the  deformity  in  such  cases  being  very  evident,  and  great 
dyspnoea  resulting.  As  a  late  effect,  aneurism  of  the  arch  of  the 
aorta  may  occur.  Treatment. — The  patient  should  be  kept  in  bed 
with  a  pillow  between  the  shoulders,  and  the  chest  strapped  as  for 
fractured  ribs.  If  the  patient  cannot  bear  this  position,  he  should  be 
allowed  to  sit  up  with  the  body  leaning  forwards.  Reposition  can 
sometimes  be  effected  by  manipulation,  combined  with  extension  of 
the  spine. 

Fractures  of  the  Upper  Extremity. 

Fracture  of  the  Clavicle. — No  bone  in  the  body,  with  the  exception 
of  the  radius,  is  broken  more  frequently  than  the  clavicle ;  this  is  due 
to  its  exposed  position  and  its  buttress-like  action  in  keeping  out  the 
point  of  the  shoulder,  so  that  every  shock  to  the  arm  is  transmitted 
through  it  to  the  trunk.     Hence,  although  sometimes  broken  by  direct 


INJURIES  OF  BONES— FRACTURES 


493 


-^x-^ 


Fig.  194. — Fractdre  of  Clavicle 

THROUGH  Greater  Convexity. 
Sterno-mastoid  ;  2,  subclavius ;  3,  pec- 
toralis   minor;    4,    pectoralis     major; 
5,  latissimus  dorsi. 


violence,  fracture  is  usually  due  to  force  directed  to  the  hand  or 
shoulder,  such  as  a  fall  from  a  horse.  It  is  more  common  in  men 
than  in  women,  and  in  children  is 
often  of  a  greenstick  nature.  The 
bone  may  yield  in  four  different 
situations,  viz. : 

1.  At  the  Sternal  End,  an  un- 
usual occurrence,  due  to  direct  or 
indirect  violence.  The  displace- 
ment varies  with  the  line  of  frac- 
ture ;  if  transverse,  it  is  slight ; 
but  if  oblique,  and  this  is  most 
usual,  the  outer  fragment  is  drawn 
downwards  and  forwards  as  in 
the  next  variety,  though  to  a  less 
degree. 

2.  Through  the  Greater  Con- 
vexity, the  commonest  situation. 
The  bone  yields  about  its  centre, 
or  a  little  external  to  it,  and  the 
line  of  fracture  is  slightly  oblique, 
running  from  before  backwards 
and  inwards.  The  displacement 
is  quite  characteristic,  and  is 
present  in  any  fracture  situated 

between  the  rhomboid -ligament  on  the  inner  side  and  the  coraco- 
clavicular  ligaments  on  the  outer,  being  less  marked,  however, 
when  the  fracture  is  nearer  the  extremities  than  in  the  centre 
of  this  space.  The  patient  gives  a  history  of  injury  and  severe 
pain,  supports  the  elbow  v/ith  the  other  hand,  the  head  being  bent 
over  to  the  affected  side  to  relax  the  muscles  of  the  neck,  and 
the  arm  is  powerless.  The  point  of  the  shoulder  is  less  prominent 
than  usual,  being  approximated  to  the  middle  line,  and  on  a  lowei 
level  than  the  other,  whilst  a+  the  seat  of  fracture  the  inner  fragment 
projects.  This  deformity  is  accounted  for  by  a  displacement  of  the 
whole  outer  fragment  downwards,  forwards,  and  inwards  (Fig.  194) ; 
the  outer  end  being,  however,  more  displaced  than  the  inner.  This 
is  mainly  due  to  the  weight  of  the  arm  acting  upon  the  outer  fragment 
when  the  buttress-like  action  of  the  bone  is  gone ;  muscular  action 
has  but  little  effect.  The  position  of  the  inner  fragment  is  probably 
but  little  altered,  since  it  is  held  in  place  by  the  rhomboid  ligament , 
the  apparent  projection  of  its  outer  end  is  due  rather  to  the  depression 
of  its  outer  fragment  than  to  elevation  of  the  inner  by  the  sterno- 
mastoid. 

3.  Between  the  Coraco-clavicular  Ligaments,  usually  arising  from 
direct  violence,  and  with  but  little  displacement,  owing  to  the  tension 
of  the  ligaments  and  to  the  fact  that  the  periosteum  is  not  torn  across. 
The  signs  of  local  trauma  and  crepitus  are,  however,  present,  though 
not  very  obvious. 


494 


A  MANUAL  OF  SURGERY 


4.  At  the  Acromial  End,  external  to  the  trapezoid  ligament,  and, 
again,  generally  produced  by  direct  violence.  The  inner  fragment 
retains  its  position  unaltered,  but  the  outer  fragment  is  dragged  down 
by  the  weight  of  the  arm,  and  forwards  by  the  action  of  the  muscles, 
so  that  it  lies  at  right  angles  to  the  rest  of  the  bone. 

Complications  arise  most  frequently  in  cases  produced  by  direct 
violence.  The  subclavian  vein  may  be  injured,  or  the  brachial  plexus ; 
and  even  the  dome  of  the  pleura  and  the  subjacent  lung  have  been 
wounded.  Gangrene  of  the  arm  has  resulted  from  obstruction  to  the 
vessels.     Great  violence  has  resulted  in  fracture  of  the  first  rib. 

Treatment. — Where  there  is  little  or  no  displacement,  all  that  is 
needed  is  to  immobilize  the  arm  in  a  sling  and  to  keep  the  patient  quiet. 

For  fractures  with  displacement  many  different  plans  of  treatment 
have  been  adopted.  In  order  to  replace  the  fragments,  the  surgeon 
should  stand  behind  the  patient,  who  is  seated,  with  his  knee  between 
the  scapulae ;  traction  is  then  made  upon  the  shoulders,  and  the  point 
of  the  acromion  is  drawn  upwards  and  backwards.  To  maintain  the 
fractured  ends  in  apposition  the  following  methods  have  •  been  re- 
commended :  [a)  The  simplest,  which  can  always  be  applied  in 
emergency  cases,  is  that  known  as  the  three- handkerchief  plan.  Two 
large  handkerchiefs,  folded  double  and  rolled  into  bands,  are  placed 
vertically,  one  over  each  shoulder  and  under  each  axilla ;  each  is 
lightly  knotted  behind,  and  the  ends  firmly  tied  to  the  opposite 
handkerchief  across  the  middle  line.  By  this  means  the  point  of  the 
shoulder  is  kept  outwards  and  backwards.  The  third  handkerchief 
is  now  folded  crosswise  and  used  as  a  sling  to  support  the  elbow, 
which  is  drawn  well  forwards,  the  hand  being  placed  over  the  sound 
clavicle.  If  this  apparatus  is  employed  permanently,  the  knots  must 
be  examined  every  few  days,  especially  at  first,  as  the  handkerchiefs 
always  stretch  a  little  and  require  occasional  tightening,  (b)  Sayre^s 
method  is  very  useful,  especially  in  treating  children.  A  long  strip  of 
adhesive  plaster,  3^  inches  wide  or  less,  according  to  the  size  of  the 
patient,  is  passed  round  the  arm  a  little  below  the  axilla,  as  a  loop, 
with  the  sticky  side  out,  and  then  around  the  body  with  the  adhesive 
side  inwards,  the  arm  being  drawn  well  back,  and  the  loop  and  ends 
secured  by  stitches  (Fig.  195).  If  this  has  been  applied  firmly,  it 
may  now  be  used  as  a  fulcrum,  so  that  as  the  elbow  is  drawn 
forwards,  the  point  of  the  shoulder  is  directed  backwards  and  out- 
wards, and  thus  the  main  deformity  is  overcome.  Another  strip  of 
a  similar  width  is  applied  over  the  elbow  (a  small  hole  being  cut  to 
receive  the  point  of  the  olecranon),  and  by  this  means  the  elbow  is 
raised  and  drawn  forwards  (Fig.  196)  so  that  the  hand  can  be  placed 
on  the  opposite  shoulder,  and  the  desired  position  is  thus  maintained. 
In  children  more  than  one  strip  of  plaster  will  be  needed  in  order  to 
secure  the  arm,  whilst  an  additional  bandage  is  also  useful.  Excellent 
results  follow  this  plan  of  treatment,  {c)  In  ladies,  where  even  the 
slightest  deformity  is  undesirable,  it  is  better  to  confine  them  to  bed 
for  three  weeks ;  the  head  is  kept  low  without  a  pillow,  and  a  sandbag 
placed  between  the  scapulae,  the  arm  being  bandaged  to  the  side. 


INJURIES  OF  BONES— FRACTURES 


495 


Union  is  probably  attained  in  four  weeks,  but  the  movements  of 
the  arm  should  be  restricted  for  some  time  longer.  A  considerable 
amount  of  callus  is  usually  formed,  and  there  is  very  likely  to  be 
some  slight  persistent  deformity. 

Fractures  of  the  Scapula. — i.  The  Acromion  Process  may  be  broken 
by  direct  violence  applied  to  the  point  of  the  shoulder.  The  arm 
hangs  powerless,  supported  by  the  other  hand,  and  the  shoulder  is 
flattened.  The  irregularity  of  the  bone  can  be  readily  detected,  and 
crepitus  can  be  elicited  by  raising  the  elbow  and  rotating  the  arm. 
Occasionally  the  tip  alone  is  detached,  and  then  the  above  signs 
will  not  be  present.  Treatment  consists  in  raising  the  elbow,  and 
bandaging  the  arm  to  the  side. 

2.  The  Coracoid  Process  is  rarely  fractured,  and  then  only  by  direct 
violence.    There  is  but  little  displacement,  on  account  of  the  powerful 


Figs.  195  and  196.— Sayre's  Method  of  Strapping  for  Fractured  Clavicle, 

ligaments  attached  to  it,  and  all  the  treatment  needed  is  to  raise  the 
elbow  by  a  sling  and  keep  the  arm  to  the  side. 

3.  The  Body  of  the  scapula  is  broken  as  a  result  of  considerable 
direct  violence,  which  is  often  primarily  received  by  the  spine. 
There  is  but  little  displacement  when  the  fracture  is  comminuted  or 
transverse  just  below  the  spine.  A  longitudinal  fracture  may,  how- 
ever, result  in  the  inner  or  vertebral  fragment  being  drawn  upwards 
and  outwards  in  front  of  the  axillary  portion  by  the  serratus  magnus 
and  levator  anguli  scapulae.  The  diagnosis  is  sometimes  difficult 
owing  to  the  presence  of  a  large  haeniatoma,  but  can  usually  be  made  by 
grasping  the  bone  firmly,  and  moving  one  fragment  on  the  other; 
crepitus  may  thus  be  obtained.  Treatment  consists  in  bandaging  the 
arm  to  the  side,  and  possibly  applying  strapping  to  support  the 
fragments. 

4.  Fracture  of  the  Neck  is  usually  due  to  great  violence  directed  to 
the  shoulder,  but  is  uncommon.  A  portion  of  the  articular  surface  is 
broken  off  and  displaced  downwards  in  some  few  cases  of  dislocated 


496 


A  MANUAL  OF  SURGERY 


run 


shoulder  (Fig.  197,  A);  or  the  fracture  has  been  known  to 
through  the  anatomical  neck  (Fig.  197.  B),  either  condition  causing 
some  flattening  of  the  shoulder,  slight  lengthening  of  the  arm  and 
displacement  downwards  of  the  head  of  the  humerus,  so  that  the- 
appearance  somewhat  resembles  that  of  a  dislocation.  Treatment,— 
The  arm  must  be  kept  to  the  side  and  raised.  .     ,  ^r    , 

More  commonly,  however,  the  fracture  involves  the  Surgical  Neck 
VFiff  IQ7  Q,  extending  from  the  suprascapular  notch  above  to  just 
^     &•    ^"     ^'  °  below  the  origin  of  the  triceps 

muscle,  so  that  the  detached 
fragment  includes  the  cora- 
coid  process.  Flattening  of 
the  shoulder  results,  with 
prominence  of  the  acromion, 
lengthening  of  the  arm  as 
measured  from  the  acromion 
to  the  external  condyle,  and 
crepitus  on  raising  and  ro- 
tating the  limb.  Treatment. 
— The  bone  is  replaced  by 
pressure  in  the  axilla,  if 
necessary  under  chloroform, 
and  fixed  by  an  axillary  pad 
or  a  n -shaped  leather  splint, 
whilst  the  arm  is  kept  to  the 
side. 

Fractures  of  the  Upper  End 
of  the  Humerus. — i.  Of  the 
Anatomical  Neck,  the  so- 
called  '  Intracapsular  Frac- 
ture '  (Fig.  199).  This  is 
usually  due  to  blows  or  falls 
on  the  shoulder,  less  com- 
monly to  indirect  violence. 
The  shoulder  becomes  greatly 
swollen  from  effusion  of  blood, 
making  a  satisfactory  exam- 
ination almost  impossible  for 
some  days ;  pain  on  movement  is  severe,  but  crepitus  may  perhaps 
be  felt  on  rotating  the  arm ;  there  is  usually  about  half  an  inch  of 
shortening.  In  most  cases  the  upper  fragment  is  not  totally  detached, 
but  remains  connected  with  the  rest  of  the  bone  by  a  few  shreds  of 
capsule,  and  thus  necrosis  is  prevented.  Should  impaction  occur, 
the  small  upper  fragment  is  driven  into  the  lower,  and  marked 
deformity  of  the  head  of  the  bone  results,  which  can  be  detected 
occasionally  by  palpation  from  the  axilla.  If  the  articular  surface  is 
completely  detached,  it  is  often  rotated  on  its  own  axis,  and  even 
dislocated  into  the  axilla.  Examination  must  be  conducted  with 
great  care  lest  impaction  be  disturbed,  or  any  capsular  attachments 


FiCx   197. — Fractures  of  the  Neck  of  the 
Scapula. 

A ,  Through  the  glenoid  fossa ;  B,  through 
the  anatomical  neck ;  C,  through  the 
surgical  neck. 


INJURIES  OF  WNES—PRACtURES 


49? 


broken  through ;  the  routine  use  of  skiagraphy  in  all  serious  lesions 
of  the  shoulder  renders  such  manipulation  less  necessary  than 
formerly.  Repair  takes  place  mainly  from  the  lower  end,  and, 
ov/ing  to  the  difficulty  of  apposing  and  immobilizing  the  fragments, 
a  considerable  mass  of  callus  is  usually  formed.  Treatment. — When 
there  is  but  little  'displacement,  nothing  more  is  required  than  to 
raise  the  elbow  and  keep  the  arm  to  the  side  by  a  suitable  bandage, 
though  a  comfortable  sense  of  support  is  given  by  placing  a  pad  in 
the  axilla.  Massage  is  commenced  early — about  the  fourth  or  fifth 
day — and  passive  movements  a  few  days  later.  In  the  more  serious 
cases  a  pad  or  H -shaped  splint  is  placed 
in  the  axilla,  and  retained  in  position 
by  a  soft  bandage  or  handkerchief  pass- 
ing over  the  top  of  the  shoulder,  and 
tied  under  the  opposite  axilla ;  this 
assists  in  raising  the  arm,  which  is 
also  supported  by  an  elbow -sling. 
Finally,  a  comfortable  poroplastic  or 
leather  cap  is  fitted  over  the  shoulder 
and  buckled  on.  Union  generally 
occurs  in  about  six  weeks,  but  often 
results  in  great  stiffness,  unless  mas- 
sage and  manipulation  are  suitably 
employed ;  they  must  commence,  how- 
ever, a  little  later  than  in  the  simpler 
cases  mentioned  above.  At  first  the 
splints,  etc.,  are  restored  to  position 
after  the  daily  rubbing,  but  are  gradu- 
ally discarded,  so  that  by  the  end  of  ^"^-  ^98.-Fracture  of  Sur- 
, ,   -^  1  i.1  •  1  GiCAL  Neck  of  Humerus, 

three  weeks  or  so  the  arm  is  merely  c  c  i  i    •      r  t^    ,    •    ■ 

supported  by  a  sling.  ^'  S^bscapulans  ;  L.D. .  lat:ss:mus 

If  dislocation  of  the  small  fragment 
has  occurred,  or  if  skiagraphy  indicates 
that  it  has  been  rotated  or  seriously  displaced,  the  surgeon  may 
advisably  raise  the  question  of  operation,  with  a  view  to  removing 
the  fragment  entirely. 

2.  Fracture  of  the  Surgical  Neck,  the  '  Extracapsular  Fracture  ' 
(Fig.  20i).  The  bone  yields  in  this  case  below  the  muscles  attached 
to  the  tuberosities,  but  above  the  insertions  into  the  bicipital  groove 
and  its  margins  of  the  latissimus  dorsi,  pectoralis  major,  and  teres 
major  (Fig.  198).  It  results  from  violence  applied  directly  below 
the  point  of  the  shoulder,  or  from  falls  on  the  hand  or  elbow,  and 
is  usually  more  or  less  transverse.  The  displacement  of  the  upper 
fragment  varies  somewhat,  and  is  probably  never  very  great;  the 
lower  fragment  is  drawn  inwards  by  the  muscles  attached  to  the 
bicipital  groove,  and  upwards  by  the  deltoid,  coraco-brachialis,  biceps, 
and  triceps  (Fig.  198).  The  appearance  of  the  patient  is  sufficiently 
characteristic  ;  the  head  of  the  bone  is  still  in  the  glenoid  cavity,  so 
that  there  is  no  loss  of  the  fulness  of  the  shoulder  (Fig.  199,  C), 

32 


laris  : 
dorsi ;  i),    deltoid  ; 
toralis  major. 


P.M.,    pec- 


498 


A  MANUAL  OF  SURGERf 


although  there  is  a  depression  just  below,  unless  it  is  obliterated  by 
the  extensive  hajmorrhagic  effusion.  The  elbow  is  directed  away 
from  the  side,  and  the  axis  of  the  lower  fragment  is  upwards  and 
inwards.     Crepitus  can  be  obtained  by  extending  and  rotating  the 

\  \ 


Fig.    199. — Outlines  of  Shoulder. 
A,  Normal  shoulder;  B,  dislocation  of  shoulder;  C,  fracture  of  surgical  neck 

of  humerus. 


arm,  which  is  shortened  an  inch  or  more.  This  fracture  is  often  very 
painful  from  pressure  of  the  upper  end  of  the  lower  fragment  against 
the  brachial  nerves.  If  impaction  occurs,  the  signs  are  much  less 
evident,  and,  indeed,  may  be  very  equivocal ;  the  lower  fragment  is 
usually  driven  into  the  upper,  and  only  slight  shortening  or  displace- 
ment may  be  present. 

Complications. — The  axillary  vessels  may  be  seriously  damaged,  or 
more  commonly  some  of  the  nerves  sustain  injury,  especially  the 
circumflex,  which  winds  round  the  neck  of  the  bone  close  to  the  site 
of  the  fracture. 

Treatment. — Immobilization  of  the  fragments  is  absolutely  neces- 
sary in  this  fracture.  It  may  be  secured  by  the  application  of  an 
axillary  pad  and  a  shoulder-cap,  whilst  the  arm  is  kept  to  the  side, 
and  the  hand  supported  by  a  sling.  The  elbow  should  be  allowed  to 
hang  to  overcome  the  shortening.  Middeldorpf's  triangle  (Fig.  203) 
may  be  used  with  advantage  in  this  fracture.  When  the  fracture  is 
oblique  and  the  fragments  overlap,  retention  in  a  good  position  is 
difficult  unless  the  patient  is  willing  to  go  to  bed  and  allow  weight 
extension  to  be  made  from  the  elbow  for  a  week  or  two.  Firm  union 
usually  results  in  four  and  a  half  to  six  weeks,  but  with  the  formation 
of  a  good  deal  of  callus ;  massage  and  passive  manipulations  should 
be  daily  employed  from  the  third  week  onwards,  the  apparatus  being 
taken  off  for  the  purpose  and  re-applied,  if  necessary. 

3.  Separation   of  the   Upper  Epiphysis  occurs  up  to  the  age   of 


<;   IB 


1      iM 


INJURIES  OF  BONES— FRACTURES  501 

eighteen  to  twenty  years,  and  involves  the  head  and  both  the  tuberosi- 
ties. The  upper  end  of  the  shaft  is  somewhat  conical  in  shape,  the 
apex  of  the  cone  fittihg  into  a  depression  in  the  middle  of  the  epiphysis 
(Fig.  202).  The  lesion  usually  folloAvs  the  line  of  the  cartilage  ;  but 
the  displacement  is  often  incomplete, partly  from  the  conical  projection 
hitching  against  the  inner  edge  ot  the  epiphysis  (a  doubtful  occur- 
rence), but  mainly  from  the  persistence  of  a  well-marked  periosteal 
sleeve  or  bridge  on  the  outer  and  posterior  side.  The  shaft  usually 
travels  forwards,  its  upper  end  projecting  so  as  to  be  felt  or  even  seen 
beneath  the  skin  an  inch  or  more  below  the  coracoid  process ;  occa- 
sionally a  well-marked  inward  displacement  is  superadded,  so  that  the 
condition  somewhat  resembles  a  subcoracoid  dislocation.  The  presence 
of  the  head  of  the  bone  in  the  glenoid  cavity  should  prevent  this  mistake, 
whilst  the  softness  of  the  crepitus  distinguishes  it  from  a  fracture. 


Fig.  202. — Separation  of  the  Upper  Epiphysis  of  the  Humerus. 

Treatment. — It  is  most  important  to  reduce  this  displacement,  since 
otherwise  interference  with  the  growth  of  the  limb  is  almost  certain  to 
ensue.  This  may  be  effected  by  traction  upon  the  arm  under  an 
anaesthetic,  assisted  perhaps  by  slight  rotary  movements  or  abduction  ; 
but  should  these  manoeuvres  not  be  successful,  operation  should  be 
undertaken  to  restore  the  parts  to  their  correct  position.  After 
reduction  the  limb  is  treated  as  for  a  fracture  of  the  neck.  Should 
union  occur  in  the  displaced  position,  considerable  limitation  of 
movement  results  from  the  projecting  edge  of  the  diaphysis  ;  this 
may  be  improved  by  cutting  down  and  chiselling  it  away. 

4.  The  Great  Tuberosity  is  occasionally  torn  off  as  a  result  of  direct 
or  muscular  violence,  or  as  a  complication  of  fracture  through  the  neck. 
If  the  whole  tuberosity  is  separated,  there  is  marked  deformity,  result- 
ing in  a  great  increase  in  the  breadth  of  the  shoulder.  The  fragment 
is  displaced  upwards  and  backwards  by  the  unopposed  action  of  the 


502  A  MANUAL  OF  SURGERY 

supra-  and  infra-spinatus,  whilst  the  shaft  of  the  humerus  is  drawn 
forwards  and  partially  dislocated  (or  subluxated)  by  the  subscapularis 
and  other  muscles.  A  distinct  sulcus  is  felt  between  the  two  bony 
masses,  and  if  they  can  be  brought  together,  crepitus  is  obtained.  ' 
Treatment. — There  can  be  no  question  that  when  displacement  has 
occurred,  the  most  efficacious  plan  is  to  cut  down  on  the  fragment 
and  fix  it  in  position  by  wire,  screw,  or  peg.  Excellent  results  follow, 
if  asepsis  is  maintained.  Failing  operative  treatment,  the  patient 
must  be  kept  in  bed,  with  the  arm  elevated  and  extended,  sup- 
ported by  pillows — a  most  uncomfortable  position — until  union  has 
occurred. 

5.  Fracture  of  tlie  Upper  End  of  the  Humerus  combined  with.  Dis- 
location of  the  head  of  the  bone  is  not  a  very  common  accident. 
The  fracture  is  usually  more  or  less  oblique,  and  passes  through  the 
greater  tuberosity  or  involves  the  surgical  neck. 

It  is  usually  produced  by  severe  direct  violence,  such  as  by  a 
person  pitching  with  great  force  on  the  shoulder.  The  head  of 
the  bone  is  first  forced  into  the  axilla  through  a  rent  in  the  capsule, 
the  tendons  attached  to  the  tuberosities  being  stretched  or  torn,  and, 
secondly,  the  violence  being  unexpended,  fracture  of  the  neck  of  the 
bone  follows.  Unless  seen  early,  haemorrhage  and  serous  effusion 
make  diagnosis  difficult,  and  from  time  immemorial  mistakes  have 
occurred  in  diagnosis  and  treatment.  Stereoscopic  skiagraphy 
should,  where  practicable,  be  used  as  soon  as  possible.  At  the  same 
time  the  tension  of  the  deltoid  and  the  absence  of  the  head  from  the 
glenoid  cavity  and  its  presence  elsewhere  should  suffice  to  guide  the 
surgeon  to  a  correct  opinion.  If  unreduced,  the  displaced  head  of 
the  bone  may  remain  loose,  or  union  may  occur  with  much  deformity 
and  the  production  of  many  adhesions,  which  may  involve  the  vessels 
and  nerves,  and  lead  to  serious  after-trouble  in  the  limb. 

Treatment.* — The  reduction  of  the  dislocation  is  a  matter  of  con- 
siderable difficulty,  but  the  head  of  the  bone  should,  if  possible,  be 
manipulated  back  through  the  rent  in  the  capsule  without  delay,  whilst 
steady  traction  is  made  upon  the  shaft  of  the  limb  either  downwards 
or  at  right  angles  to  the  trunk.  This  reposition  can  hardly  be  hoped 
for  apart  from  complete  anaesthesia.  If  successful,  the  fracture  is. 
treated  in  the  usual  way,  suitable  apparatus  to  maintain  end-to-end 
apposition  of  the  fragments  being  applied.  If,  however,  reposition 
is  not  effected,  operative  measures  should  be  undertaken.  The 
parts  are  laid  open  from  the  front,  the  head  of  the  bone  is  replaced, 
and  the  fracture  wired  or  screwed  into  accurate  end-to-end  union. 
Failing  that,  and  especially  if  any  loose  fragments  due  to  breaking 
up  the  globular  head  exist,  they  should  be  excised.  McBurney 
has  devised  a  special  hook,  which  can  be  introduced  through  a 
hole  in  the  bone  so  as  to  exercise  traction  to  facilitate  the  open 

*  For  an  interesting  series  of  skiagrams  of  tiiis  condition,  see  an  article  by 
Robert  Jones,  British  Medical  Journal,  June  16,  1906.  The  subject  is  also  ably 
dealt  with  in  Bransby  Cooper's  (1842)  edition  of  Sir  Astley  Cooper's  treatise  on 
'  Dislocations  and  Fractures  of  the  Joints.' 


INJURIES  OF  BONES— FRACTURES 


503 


reduction  of  the  dislocation  or  the  division  of  Hgaments  if  excision 

jis;;$equired. 

^>1  Fractures  of  the  Shaft  of  the  Humerus  may  arise  from  any  form  of 
violence,  whether  direct  or  indirect,  and  even  from  muscular  violence, 
as,  e.g.,  in  throvi^ing  a  cricket  ball.  The  signs  of  the  injury  are  very 
obvious,  and  most  typical.  The  displacement  depends  largely  on  the 
position  of  the  fracture.  If  it  occurs  above  the  insertion  of  the  deltoid, 
but  below  that  of  the  muscles  inserted  into  or  around  the  bicipital 
groove,  the  upper  fragment  is  drawn  inwards,  and  the  lower  upwards 
and  outwards.  If,  however,  it  is  below  the  deltoid,  the  upper  fragment 
is  drawn  outwards,  and  the  lower  upwards  and  inwards.  As  the  line 
of  fracture  approaches  the  elbow,  the  displacement  tends  to  become 


Fig.  203. — Middeldorpf's  Triangle  for  Fractured  Humerus, 
For  the  sake  of  clearness,  the  bandages,  etc.,  have  been  represented  as  much 
smaller  than  would  be  the  case  in  the  living  subject  ;  a  Gooch  splint  may 
also  with  advantage  be  applied  to  the  fore-arm. 

more  antero-posterior  than  lateral,  owing  to  the  change  in  shape  of  the 
bone.  The  most  common  complication  is  injury  to  the  musculo-spiral 
nerve  which  winds  round  the  shaft  close  to  its  centre. 

Treatment. — An  internal  angular  splint  reaching  from  the  axilla  to 
the  wrist  must  be  applied,  together  with  three  small  lateral  splints  to 
fix  the  fragments,  or  a  piece  of  Gooch  or  kettle-holder  splint ;  the 
limb  is  kept  to  the  side  in  the  sling.  Union  is  usually  complete  in 
five  weeks. 

Some  authorities  recommend  the  use  of  four  short  lateral  splints, 
the  outer  one  of  which  is  prolonged  upwards  to  constitute  a  shoulder- 
cap,  and  downwards  as  an  external  angular _  splint.  The  fore-arm 
is  kept  midway  between  pronation  and  supination ;  and  the  hand 
points  directly  forwards,  so  as  not  to  rotate  the  lower  fragment. 


504    ■  A  MANUAL  OF  SURGERY 

A  useful  appliance  for  all  fractures  of  the  Humerus  is  the  Middel- 
dorpf  triangle  (Fig.  203).  It  is  carefully  padded  so  that  the  angles 
and  edges  are  protected,  and  applied  so  that  its  base  is  in  con- 
tact with  the  body-wall  and  its  obtuse-angled  apex  in  the  elbow. 
It  is  fixed  by  a  strap  or  bandage  passed  from  the  axillary  angle  over 
the  same  shoulder  and  under,  the  opposite  axilla,  as  also  by  a  sheet  or 
bandage  round  the  trunk.  Pieces  of  Gooch  splinting  can  be  applied 
to  the  arm,  thus  completely  immobilizing  the  humerus,  and  the  fore- 
arm is  also  fixed.  The  fingers  are  left  free,  or  if  there  is  any  swelling 
they  are  bandaged.  This  apparatus  is  even  more  efficacious  when  the 
patient  is  standing  than  when  he  is  recumbent. 

It  is  not  at  all  uncommon  to  meet  wuth  an  ununited  fracture  of  the 
shaft  of  this  bone  ;  this  is  probably  due,  not  to  any  anatomical  reasons, 
but  simply  to  the  fact  that  the  necessity  for  fixing  and  supporting  the 
elbow-joint  has  not  been  appreciated,  the  fore-arm  being  allowed  to 
hang  loose  on  the  false  plea  of  tending  to  diminish  the  shortening. 

Fractures  of  the  Lower  End  of  the  Humerus. — In  dealing  with  any 
injury  in  the  vicinity  of  the  elbow,  it  is  absolutely  essential  that  the 
relative  position  of  the  bony  points,  which  can  there  be  felt,  should 
be  accurately  established,  and  a  comparison  made  with  those  of  the 
opposite  side.  Normally  four  bony  prominences  can  be  detected, 
viz.,  the  two  condyles,  the  olecranon,  and  the  head  of  the  radius. 
The  relation  of  the  olecranon  to  the  condyles  varies  w-ith  the  position 
of  the  elbow.  If  the  fore-arm  is  extended,  the  tip  of  the  olecranon 
just  touches  the  intercondyloid  line,  but  is  placed  nearer  the  inner 
than  the  outer  condyle,  whilst  in  flexion  of  the  fore-arm  it  lies  below 
that  line.  The  head  of  the  radius  in  all  positions  of  the  arm  is 
immediately  below  the  outer  condyle,  and  can  be  felt  rotating  beneath 
a  dimple  in  the  skin  which  appears  at  that  spot.  When  the  forearm  is 
flexed  to  a  right  angle,  the  tip  of  the  olecranon  is  a  little  in  front  ot 
the  posterior  surface  of  the  arm,  so  that  a  ruler  placed  along  thai 
surface  misses  the  olecranon ;  this  is  a  useful  guide  in  ascertaining 
if  the  bones  of  the  fore-arm  have  been  displaced  backwards  or  for- 
wards, together  with  or  apart  from  the  loAver  end  of  the  humerus. 

Anottaer  important  feature  depends  on  the  fact  that  the  axis  of  the 
fore-arm  does  not  correspond  with  that  of  the  arm,  the  former  being 
in  a  position  of  slight  abduction  (about  15°),  constituting  what  is 
known  as  the  '  carrying  angle '  (Fig.  204,  A).  Lateral  deviation 
following  fractures  in  the  neighbourhood  of  the  elbow  results  in 
modifications  of  this  angle,  and  if  these  are  allowed  to  persist, 
conditions  of  cubitus  varus  or  valgus  (Fig.  204,  B,  C)  ensue,  which 
much  interefere  with  the  utility  of  the  limb. 

I.  Transverse  Supracondyloid  Fracture,  involving  the  shaft  about 
I  or  2  inches  above  the  joint,  is  due  either  to  a  fall  on  the  hand  with 
■  the  arm  bent,  when  the  lower  fragment  is  usually  displaced  back- 
wards, or  much  less  commonly  to  a  fall  on  or  violence  directed  to  the 
point  of  the  elbow,  when  the  displacement  is  either  forwards  or  back- 
wards. When  the  lower  fragment  is  displaced  backwards,  it  is  also 
drawn  up  by  the  action  of  the  triceps  upon  the  olecranon,  a  certain 


INJURIES  OF  BONES— FRACTURES 


505 


imount  of  angular  as  well  as  vertical  deformity  being  thus  produced ; 
when  displaced  forwards,  apparent  lengthening  of  the  fore-arm 
results,  with  a  loss  of  prominence  of  the  olecranon.  The  former  of 
these  conditions  is  likely  to  be  mistaken  for  a  dislocation  of  both 
bones  backwards  at  the  elbow  {cf.  Fig.  205,  A  and  B),  but  may  be 
recognised  by  the  following  facts :  (o)  The  relative  position  of  the 
bony  points  at  the  elbow  is  unimpaired  ;  in  a  dislocation  they  are 
necessarily  disturbed,  {b)  The  length  of  the  arm  measured  from  the 
deltoid  tubercle  which  can  be  easily  felt  at  the  back  of  the  acromion 
to  the  outer  condyle  is  diminished  in  a  fracture,  but  remains  unaltered 
in  a  dislocation.  On  the  other  hand,  the  length  of  the  fore-arm,  as 
measured  from  the  external  condyle  to  the  styloid  process  of  the 
radius,   is  shortened  in  a  dislocation,  but  remains   unaltered   in  a 


Fig.  204.— Outlines  of  Upper  Extremity  to  show  A,  Normal  Carrying 
Angle  (a  =  i5°);  B,  Cubitus  Varus;  C,  Cubitus  Valgus. 

fracture,  (c)  The  forward  projection  of  the  lower  end  of  the  upper 
fragment  is  felt  above  the  crease  of  the  joint,  whilst  in  a  dislocation 
it  corresponds  with  it.  {d)  The  deformity  is  easily  reduced  with 
crepitus,  but  readily  reappears  ;  in  a  dislocation  the  bones  are  replaced 
with  difficulty,  but  after  replacement  they  usually  remain  in  position. 
Lateral  deviation  sometimes  occurs,  and  the  restoration  of  the  normal 
'  carrying  angle  '  must  always  be  aimed  at.  It  may  be  difficult  and 
at  times  almost  impossible  to  recognise  this  condition  at  once,  apart 
from  skiagraphy,  owing  to  the  amount  of  swelling  and  ecchymosis 
present ;  the  application  of  a  cooling  lotion  for*  a  few  days  will  so 
reduce  this  as  to  permit  a  thorough  examination,  but  the  delay  may 
be  fraught  with  serious  consequences,  and  in  all  doubtful  cases 
skiagraphy  must  be  employed  at  once. 

Much  care  is  needed  in  the  Treatment  of  these  cases  in  order  to 


5o6 


A  MANUAL  OF  SURGERY 


prevent  ankjdosis  or  deformity,  and  the  stereotyped  application  of  an 
internal  angular  splint  is  by  no  means  sufficient.  To  correct  the 
backward  deformity  the  elbow  must  be  flexed  as  far  as  possible,  and 
traction  made  upon  the  fore-arm,  which  is  placed  in  a  position  of  full 
supination.  A  carefully-moulded  gutter-shaped  posterior  splint  is 
then  applied  reaching  well  above  and  below  the  elbow,  and  a  shorrer 
anterior  splint  reaching  down  to  the  bend  of  the  joint ;  or  the  limb 
may  be  fixed  in  the  flexed  position  by  plaster  of  Paris  applied  as 
for  a  Croft's  splint  (p.476).  In  these  fractures  the  elbow-joint  is 
not  as  a  rule  involved,  and  therefore  passive  movement  is  not  com- 
menced too  early  for  fear  of  deformity,  owing  to  yielding  of  the  callus. 
At  the  same  time,  it  must  not  be  delayed  too  long,  as  if  the  olecranon 
and  coronoid  fossae  are  involved,  they  become  filled  by  callus,  and 


Fig.   205. — Fracture  of  Lower  End  of  Humerus  (B)  compared  with  Dis- 
location OF  Radius  and  Ulna  Backwards  at  Elbow  (A^      (Tillmanns.) 

if  this  is  allowed  to  consolidate,  the  movements  of  the  arm  will  be  sub- 
sequently limited.  In  displacements  of  the  lower  fragment  forwards 
an  anterior  angular  splint  should  be  employed,  and  possibly  a  short 
posterior  one  in  addition. 

2.  Separation  of  the  Lower  Epiphysis  of  the  Humerus  is  a  very 
common  accident  in  children.  At  birth  and  for  some  years  afterwards 
the  epiphysis  consists  of  a  single  mass  of  cartilage,  including  the  two 
condyles  as  well  as  the  articular  surface,  and  these  are  all  involved  in 
any  separation,  together  possibly  with  a  fragment  of  the  diaphysis 
(Fig.  206).  As,  however,  growth  and  ossification  proceed,  the  shaft 
encroaches  rapidly  upon  the  inner  portion  of  the  epiphysis,  so  that  the 
epiyhyseal  line  becomes  almost  rectangular  (Fig.  206,  B),  the  internal 
condyle  being  isolated  from  the  rest  of  the  epiphysis.     As  a  result  of 


INJURIES  OF  BONES— FRACTURES 


507 


this,  separation  of  the  epiphysis  after  puberty  does  not  include  the 
internal  condyle  ;  the  accident  at  this  period  is  situated  relatively 
much  nearer  the  joint  than  in  infants,  and  consequently  is  more  likely 
to  be  followed  by  impairment  of  movement.  The  displacement  is 
generally  backwards  (Fig.  209),  with  some  amount  of  lateral  dis- 
placement or  deviation  (Fig.  210).  Treatment. — Reduction  can 
usually  be  accomplished  by  flexion,  and  the  application  of  antero- 
posterior splints  may  suffice  to  maintain  the  fragment  in  position  ; 


Fig.  206. — A  and  B,  Lower  End 
OF  THE  Humerus  at  Three 
Years  and  Fifteen  Years  of 
Age.  (Semi  diagrammatic  ; 
after  Quain's  'Anatomy.') 

In  A  there  is  only  one  centre  of 
ossification;  in  B  all  the  centres 
in  the  lower  epiphysis  have 
joined  together  with  the  excep- 
tion of  that  for  the  internal 
condyle. 


Fig.  207. — Separation  of  the 
Lower  Epiphysis  of  the  Humerus 
IN  AN  Infant  under  Three  Years. 
(Museum  of  Royal  College  of 
Surgeons.) 

A,  Epiphysis,  including  both  con- 
dyles ;  B,  small  portion  of  the 
diaphysis  detached  with  epiphysis  ; 
C,  diaphysis;  D,  loose  periosteal 
bridge. 


but  it  is  an  open  question  whether  it  is  not  wiser,  at  any  rate  in  small 
children,  to  avoid  splints  and  trust  to  full  and  complete  flexion  alone, 
the  hand  being  bandaged  down  to  the  shoulder  on  the  same  side. 
Passive  movements  should  commence  from  about  the  eighth  day. 
Should  there  be  much  effusion  of  blood,  an  incision  on  each  side 
through  the  periosteum  is  desirable,  so  as  to  remove  the  blood  and 
enable  the  epiphysis  to  be  manipulated  into  position.  As  a  rule  full 
flexion   suffices  to  retain   it  in  situ,  and  nails  and  screws  are  not 


So8 


A  MANUAL  OF  SURGERY 


required.  Should  union  occur  without  effective  reposition,  much 
impairment  of  movement  may  result ;  growth  may  be  hindered,  and 
a  condition  of  cubitus  varus,  or  less  often  of  valgus,  may  ensue. 

3.  Fracture  of  the  Condyles  usually  results  from  direct  injury, 
though  the  outer  is  sometimes  broken  by  indirect  violence,  such  as  a 
fall  on  the  hand,  since  the  laxity  of  the  elbow-joint  on  this  side  allows 
considerable  mobility  between  the  radial  head  and  the  capitellum  of 
the  humerus.  Fracture  of  the  external  condyle  (Fig.  211)  always 
involves  the  elbow-joint,  and  is  more  common  than  that  of  the  inner. 
The  line  of  fracture  runs  from  the  condyloid  ridge  downwards  and 
inwards  so  as  to  separate  the  capitellum,  or  even  encroach  upon  the 
trochlear  surface.  The  fragment  is  rotated  forwards,  and  can  be  felt 
to  move  independently  with  crepitus,  which  may  also  be  produced  by 
rotation  of  the  hand  and  radius.  The  accident  is  associated  with 
much  pain  and  ecchymosis.     Fracture  of  the  internal  condyle  may 

be  intra-  or  extra-capsular.  The  extra-articular 
variety  (Fig.  208)  consists  of  a  mere  displace- 
ment of  the  tip  of  the  condyle  (or  epicondyle), 
and  in  young  people  is  probably  a  separation 
of  the  epiphysis,  which  remains  distinct  from 
the  shaft  till  the  age  of  eighteen  or  nineteen 
years.  The  small  fragment  is  drawn  a  little 
downwards  by  the  muscles  attached  to  it,  and 
the  fracture  is  readily  detected  by  the  usual 
signs  ;  it  may  be  associated  with  injury  of 
the  ulnar  nerve.  The  intra-articnlar  form  is 
the  more  common,  and  extends  from  the 
condyloid  ridge  to  the  trochlear  surface,  im- 
plicating the  coronoid  and  olecranon  fossae. 
The  fragment  is  displaced  a  little  upwards 
and  backwards,  the  ulna  usually  accompany- 
ing it,  so  that  on  extending  the  elbow  the 
olecranon  appears  unduly  prominent,  the 
lower  end  of  the  humerus  projects  anteriorly, 
and  the  fore-arm  is  slightly  adducted  (cubitus  varus).  The  ulnar 
nerve  may  also  be  injured  in  this  case. 

Treatment. — Flexion  of  the  fore-arm  will  sometimes  suffice  to 
restore  the  fragment  to  its  normal  position  ;  but  this  must  be  demon- 
strated by  radiography.  The  limb  under  such  circumstances  is  placed 
in  an  angular  splint,  and  massage  and  passive  movements  are  started 
early.  Failing  reposition  by  flexion,  operation  must  be  undertaken, 
and  the  fragment  secured  in  position  by  wire  or  screw  (Fig.  212). 

4.  T-  or  Y-shaped  Fracture  usually  occurs  as  the  result  of  direct 
injury.  A  fissure  extends  into  the  joint  between  the  condyles,  and 
may  bifurcate  above  so  as  to  detach  partially  or  completely  the  two 
condyles,  or  it  may  be  connected  with  a  transverse  supracondyloid 
fissure,  constituting  the  T-shaped  variety.  If  the  fragments  are  not 
totally  detached,  there  will  be  much  bruising  and  pain,  but  no  crepitus ; 
but  if  the  fragments  are  separated,  the  condyles  will  move  on  each 


Fig. 

OF 


208,  —  Fractures 
Internal  Con- 
dyle AND  Epicondyle 
OF  Humerus.     (Till- 

MANNS.) 


Fig.  209. — Separation  of  Lower  Epiphysis  and  a  Portion  of  the  Diaphysis  in  a  Child 

OF  Twelve  Years. 

The  skiagram  is  taken  from  the  side.  The  displacement  is  backwards.  The  dark  black  spots 
represent  tin-tacks  in  the  wooden  splint  on  which  the  arm  was  resting.  In  this  case 
reduction  was  affected  after  incision  had  been  made  on  each  side  through  the  periosteum 
to  let  out  the  blood-clot,  which  is  indicated  by  the  dark  area  around  the  end  of  the  bone. 


Fig.  210. — Separation  of  the  Lower  Epiphysis  of  the  Humerus,  with  Displacement 
Outwards,  in  a  Young  Person  a  little  over  the  Age  of  Puberty. 

The  outer  condyle  has  been  broken  off,  as  well  as  the  epiphysis,  and  displaced  upwards  and 
outwards ;  above  this  fragment  is  seen  a  shadow  caused  by  the  stripping  up  of  the  peri- 
osteum.   .The  ulna  and  radius  accompany  the  lower  epiphysis  of  the  humerus  outwards. 


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INJURIES  OF  BONES— FRACTURES  513 

other  with  crepitus,  and  the  elbow  will  be  widened  with  much 
deformity.  In  these  cases  the  joint  is  very  likely  to  become  stiff, 
owing  not  only  to  adhesions  within,  but  also  to  the  filling  up  of  the 
fossEe  in  the  lower  end  of  the  humerus  with  callus.  Excess  of  violence 
leads  to  comminution,  and  luxation  of  the  bones  of  the  fore  arm  may 
also  occur.  A  marked  feature  of  these  cases  is  the  rapidity  with 
which  swelling  supervenes,  owing  to  haemorrhage  into  and  around 
the  joint,  rendering  accurate  diagnosis  difficult  apart  from  skiagraphy. 
Treatment. — In  the  majority  of  cases  operation  holds  out  the  only 
prospect  of  giving  a  good  result.  After  thorough  and  effective  puri- 
fication, incisions  are  made  over  and  above  each  condyle  ;  blood  and 
loose  spicules  of  bone  are  removed ;  the  condyles  apposed  and  secured 
to  each  other  by  screws  or  pegs,  and  then  united  to  the  shaft ;  or 
possibly  each  condyle  may  be  separately  screwed  or  pegged  to  the 
shaft.  The  wound  is  closed  with  or  without  drainage,  according  to 
circumstances,  and  passive  movements  are  commenced  early.  If  for 
any  reason  operation  is  not  resorted  to,  the  fragments  are  manipulated 
into  as  good  a  position  as  possible  after  the  swelling  has  disappeared, 
antero-posterior  angular  splints  are  applied,  and  passive  motion  and 
massage  started  early.  When  badly  comminuted,  excision  of  the 
broken  end  and  all  the  fragments  may  be  the  wisest  course  to  adopt. 

Fractures  of  the  Ulna. — i.  The  Olecranon  is  frequently  broken  by 
direct  violence,  the  patient  falling  on  the  bent  elbow,  but  occasionally 
by  muscular  action.  The  line  of  fracture  usually  runs  through  the 
base  of  the  process  at  its  attachment  to  the  shaft,  and  is  for  the  most 
part  transverse.  Should  the  tendinous  and  periosteal  coverings  of 
the  bone  remain  intact,  there  is  but  little  separation ;  but  if  the 
fracture  is  complete,  the  detached  fragment  is  drawn  up  by  the 
triceps  and  tilted  backwards  (Fig.  213),  whilst  the  bones  of  the  fore- 
arm are  subluxated  forwards.  Great  swelling  in  and  around  the 
joint  comes  on  early ;  on  examination,  the  detached  fragment  can  be 
readily  distinguished,  and  between  it  and  the  shaft  a  sulcus,  which 
increases  on  flexing  and  diminishes  on  extending  the  fore-arm.  If 
the  fragments  are  not  brought  accurately  into  apposition,  fibrous 
union  occurs,  and  although  the  new  cicatricial  tissue  may  stretch 
considerably,  a  useful  elbow  sometimes  results  ;  in  some  cases  the 
fragment  is  drawn  up  and  fixed  to  the  humerus,  and  a  false  joint  is 
developed  below  it.  If,  however,  the  fragments  are  brought  in 
contact,  bony  union  follows,  though  even  then  some  impairment 
of  function  may  result  from  the  formation  of  adhesions.  In  all  cases 
the  ulnar  nerve  is  exposed  to  injury,  though  it  is  rarely  affected. 

Treatment. — The  most  satisfactory  plan  consists  in  laying  the 
parts  open,  freeing  the  joint  of  blood-clot,  removing  shreds  of  tendon 
which  may  be  placed  between  the  fragments,  and  then  wiring  them 
together,  the  wire  just  extending  down  to  the  articular  cartilage 
(Fig.  214).  The  same  precautions  and  after-treatment  must  be 
followed  as  in  dealing  with  the  patella  ;  passive  movements  may 
usually  be  started  in  ten  days,  and  active  after  a  fortnight.  A 
similar  plan  should  be  adopted  in  all  compound  cases,  and  in  those 

33 


514  A  MANUAL  OF  SURGERY 

where  loose  fibrous  union  has  occurred  with  a  resulting  weak  and 
relaxed  elbow  ;  in  the  latter  instance  the  new  fibrous  tissue  must  be 
entirely  dissected  away  and  the  bony  surfaces  freshened.  If  an  opera- 
tion is  not  undertaken,  the  arm  should  be  kept  extended  by  applying 
a  plaster  of  Paris  or  moulded  leather  splint  on  the  anterior  aspect, 
the  fragment  being  draAvn  into  position  as  well  as  possible  by  means 
of  a  pad  and  figure-of-8  bandage.  Gentle  passive  movement  and 
massage  should  commence  at  the  end  of  a  fortnight. 

2.  The  Coronoid  Process  is  so  deeply  placed  and  so  well  protected 
that  fractures  must  necessarily  be  very  imcommon,  except  as  an 
accompaniment  of  dislocation  of  the  ulna  backwards.  The  signs 
relied  on  in  making  a  diagnosis  are  that  reduction  of  the  dislocation 
is  easier  than  usual  and  associated  with  crepitus,  and  that  the 
deformity  is  likely  to  recur.  The  Treatment  consists  in  apposing 
the  bony  surfaces,  if  possible,  by  flexing  the  fore-arm.  Bony  union 
is,  however,  less  important  than  a  freely  moveable  elbow,  and  there- 
fore passive  movement  is  commenced  early. 

3.  The  Shaft  of  the  Ulna  is  often  fractured  by  itself  as  a  result  of 
direct  violence,  to  which  its  exposed  position  renders  it  peculiarly 
liable.  Fracture  also  occurs  as  a  complication  of  several  of  the 
forms  of  dislocation  of  the  radius  alone.  The  superficial  position 
of  the  posterior  border  renders  examination  of  the  bone  easy;  if 
displacement  or  a  breach  of  substance  occurs,  it  is  readily  de- 
tected, but  when  merely  a  fissure  exists,  it  is  not  so  easy  to  make 
out.  The  constant  pain  referred  to  one  spot,  the  slight  mobility, 
and  possibly  crepitus,  indicate  the  character  of  the  lesion.  No 
longitudinal  displacement  can  occur  if  the  radius  remains  intact, 
and  under  such  circumstances  the  only  deformity  consists  in  a  slight 
drawing  forwards  of  the  upper  fragment  by  the  brachialis  anticus, 
whilst  the  lower  fragment  is  approximated  to  the  radius  by  the 
pronator  quadratus.  Treatment.  —  The  arm  is  placed  midway 
between  pronation  and  supination,  the  deformity  corrected,  and  the 
limb  kept  at  rest  between  anterior  and  posterior  splints,  or  in  plaster 
of  Paris. 

4.  The  Styloid  Process  may  be  detached  by  direct  violence,  or  as 
a  complication  of  fracture  of  the  lower  end  of  the  radius.  The  dis- 
placement may  be  considerable  and  very  evident,  being  governed  by 
the  direction  of  the  violence.  Treatment  consists  in  replacing  the 
fragment  by  manipulation,  and  fixing  it  by  adhesive  plaster ;  an 
anterior  splint  is  applied  with  the  hand  adducted.  Fibrous  union 
usually  results. 

Fractures  of  the  Radius. — i.  The  Head  of  the  Radius  may  be 
broken  alone,  but  more  usually  such  an  accident  is  associated  w-ith 
other  injuries  to  the  elbow,  as,  for  instance,  fracture  of  the  outer 
condyle  or  some  form  of  dislocation.  The  line  of  fracture  may  be 
transverse  or  vertical,  and  the  displacement  is  slight  if  the  orbicular 
ligament  remains  intact.  In  complete  separation  the  head  is  im- 
moveable, and  crepitus  is  produced  when  the  arm  is  rotated ;  bony 
union  usually  follows,  with  more  or  less  impairment  of  function,  but 


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INJURIES  OF  BONES— FRACTURES  517 

sometimes  the  head,  or  a  portion  of  it,  remains  detached  as  a  loose 
body  in  the  joint.  Treatment. — Skiagraphy  will  indicate  the  exact 
nature  of  the  injury,  and  as  a  rule  removal  of  the  loose  fragment  and 
of  the  remainder  of  the  head,  if  it  be  small,  is  the  best  plan  to  adopt. 
The  incision  is  of  course  a  posterior  one.  The  limb  is  subsequently 
kept  at  rest  for  a  short  time  midway  between  pronation  and  supina- 
tion, and  early  passive  movement  instituted.  Excision  of  the  head 
may  also  be  required  in  old-standing  cases  for  limitation  of  movement, 
due  to  excessive  formation  of  callus. 

2.  The  Neck,  i.e.,  the  portion  between  the  orbicular  ligament  and 
the  biceps  tuberosity,  is  occasionally  broken.  The  lower  fragment 
is  drawn  upwards  and  forwards  by  the  biceps,  causing  a  bony  pro- 
jection on  the  front  of  the  elbow,  especially  evident  on  attempting 
to  flex  the  joint,  whilst  the  fore-arm  is  pronated  with  loss  of  the 
power  of  rotation,  and  the  head  of  the  bone  does  not  accompany  the 
shaft  on  rotating  it  passively.  Treatment. — -The  arm  is  flexed  to 
relax  the  biceps  and  supinated,  and  the  limb  placed  on  a  posterior 
angular  splint,  with  a  pad  over  the  front  of  the  lower  fragment. 
Passive  movement  should  not  be  commenced  too  early,  as  the  lesion 
is  extra-articular,  and  the  biceps  may  produce  permanent  deformity  if 
allowed  to  act  upon  unconsolidated  callus. 

3.  The  Shaft  of  the  radius  is  not  unfrequently  broken  by  direct 
violence  or  more  rarely  by  falls  on  the  palm  ;  the  latter  accident, 
however,  rarely  causes  fracture  except  at  the  lower  end.  A  Chauffeur's 
fracture  of  this  bone  has  also  been  described.  It  involves  the  lower 
end  of  the  radius,  and  results  from  a  jerk  backwards  of  the  starting 
handle  of  the  car  due  to  premature  ignition.  The  lesion  is  placed  a 
little  above  the  level  of  an  ordinary  Colles's  fracture,  and  sometimes 
well-marked  displacement  is  present.  There  is  usually  little  difficulty 
in  diagnosing  a  fractured  radius ;  the  chief  signs  are  localized  pain 
and  loss  of  power  of  active  rotation,  whilst  passive  rotary  movements 
are  accompanied  by  crepitus,  the  head  of  the  bone  and  upper  frag- 
ment remaining  immobile  below  the  outer  condyle,  unless  impaction 
is  present. 

The  displacement  is  somewhat  characteristic.  If  the  fracture  is 
situated  above  the  insertion  of  the  pronator  teres,  the  upper  fragment  is 
flexed  and  fully  supinated  by  the  action  of  the  biceps  and  supinator 
brevis,  whilst  the  lower  fragment  is  drawn  towards  the  ulna  and  fully 
pronated  by  the  unopposed  action  of  the  two  pronator  muscles. 
Treatment. — -Inasmuch  as  it  is  scarcely  possible  to  command  the 
small  upper  fragment,  the  lower  must  be  brought  into  apposition  with 
it  by  fully  supinating  the  fore-arm  and  hand  after  flexing  the  elbow, 
and  applying  a  posterior  splint,  the  patient  being  preferably  kept  in 
bed  for  a  time  and  the  arm  laid  on  pillows.  It  may  afterwards  be 
supported  in  a  hollow  leather  splint  carried  across  the  body,  and  with 
the  palm  directed  upwards. 

When  the  fracture  is  placed  below  the  insertion  of  the  pronator  teres, 
the  upper  fragment  is  drawn  forwards  by  the  action  of  the  biceps, 
and  inwards  by  the  pronator,  assuming  a  position  midway  between 


5iS  A  MANUAL  OF  SURGERY 

pronation  and  supination ;  the  lower  fragment  may  be  slightly  ap- 
proximated to  the  ulna  by  the  direct  action  of  the  pronator  quadratus  ; 
the  hand  is  fully  pronated  looking  downwards.  Union  to  the  ulna  by 
callus  thrown  across  the  interosseous  space  is  not  unlikely  to  occur. 
Treatment. — The  arm  is  placed  midway  between  pronation  and  supina- 
tion, and  the  hand  fully  adducted.  The  fragments  are  manipulated 
into  position,  and  splints  applied  back  and  front.  It  is  wise  to  place 
a  good  pad  under  the  palmar  splint  over  the  site  of  fracture  so  as  to 
repress  the  tendency  to  anterior  displacement  of  the  fragments ;  a 
Gordon's  splint  is  useful  in  this  direction. 

4.  The  Lower  End  of  the  Radius  is  broken  with  extreme  frequency, 
constituting  what  is  known  as  Colles's  Fracture.  This  injury  occurs 
most  commonly  in  women  of  advanced  years,  although  it  may  happen 
at  any  age  or  to  either  sex.  It  is  almost  invariably  due  to  falls  upon 
the  outstretched  palm,  when  the  hand  is  completely  pronated  and 
extended.  The  line  of  fracture  is  placed  about  i  inch  from  the  wrist, 
though  rather  under  than  over  this.  It  is  usually  transverse  from 
side  to  side,  but  is  oblique  in  an  antero-posterior  direction,  sloping 
from  above  downwards  and  forwards,  so  that  the  fracture  is  nearer 
the  wrist-joint  in  front  than  it  is  behind  (Fig.  221). 

The  displacement  is  somewhat  complicated,  (a)  The  lower  frag- 
ment is  carried  backwards  and  a  little  upwards,  owing  to  the 
direction  of  the  violence,  viz.,  a  fall  on  the  outstretched  hand,  the 
radius  being  compressed  between  the  ground  and  the  weight  of  the 
body,  and  yielding  at  what  is  evidently  a  weak  spot ;  this  deformity  ■ 
is  maintained  by  the  radial  extensor  muscles  of  the  wrist,  and  often  by 
impaction  of  the  fragments.  (b)  From  the  fact  that  the  main 
violence  is  received  on  the  thenar  eminence,  the  outer  side  of  the 
lower  fragment  is  displaced  more  than  the  inner,  which  remains  fixed 
to  the  ulna  by  the  strong  inferior  radio-ulnar  ligaments.  This  posi- 
tion is  in  part  kept  up  by  the  extensors  of  the  thumb  and  the 
supinator  longus,  but  mainly  by  impaction  of  the  fragments.  The 
hand  and  carpus  always  follow  the  lower  fragment,  and  hence  the 
former  is  abducted,  causing  the  styloid  process  of  the  ulna  to  become 
unduly  prominent,  and  lower  than  that  of  the  radius,  whereas  it  is 
normally  placed  on  a  slightly  higher  level.  In  bad  cases  the  styloid 
process  of  the  ulna  is  actually  torn  off,  or  the  internal  lateial  liga- 
ment ruptured,  allowing  displacement  outwards  of  the  whole  hand. 
(c)  The  lower  fragment  is  also  rotated  around  a  transverse  axis,  so 
that  the  lower  articular  surface  looks  backwards  as  well  as  down- 
wards, a  displacement  due  to  the  fact  that  in  falling  the  force  is 
directed,  through  the  carpus,  more  to  the  posterior  than  to  the 
anterior  aspect  of  the  bone,  (d)  The  upper  fragment  is  pronated  and 
approximated  to  the  ulna  by  the  pronator  quadratus  muscle.  The 
deformity  produced  by  the  fracture  is  therefore  very  characteristic. 
The  hand  is  in  a  position  of  radial  abduction,  and  usually  pronated, 
with  the  fingers  somewhat  flexed  (dinner-fork  deformity).  Three 
abnormal  osseous  projections  are  present :  (i.)  The  styloid  process  or 
head  of  the  ulna  is  very  marked,  owing  to  the  radial  abduction  of  the 


INJURIES  OF  BONES— FRACTURES  521 

hand  (Fig.  218) ;  (ii.)  on  the  back  of  the  wrist  is  a  prominence  which 
terminates  abruptly  above,  caused  by  the  projection  of  the  lower 
fragment  (Fig.  217);  and  (iii.)  corresponding  to  this  dorsal  projection 
there  is  a  well-marked  depression  on  the  palmar  surface,  and  above 
it  a  less  sharply  defined  swelling,  which  gradually  shelves  into  the 
fore-arm,  due  to  the  upper  fragment.  Pronation  and  supination  are 
lost,  and,  as  a  rule,  there  is  neither  crepitus  nor  preternatural  mobility, 
owing  to  impaction  of  the  fragments.  An  important  diagnostic  point 
is  the  relative  position  of  the  two  styloid  processes ;  normally,  that 
of  the  radius  is  below  that  of  the  ulna,  but  m  cases  of  fracture  it  is 
on  a  level  with  or  above  it. 


Fig.   217. — CoLLEs's  Fracture:  Fig.  218.  — Colles's  Fracture: 

Lateral  View.  Palmar  View. 

As  already  stated,  the  fracture  is  commonly  impacted,  the  upper 
fragment  being  firmly  driven  into  the  cancellous  tissue  of  the  lower 
end  ;  excess  of  violence  may,  however,  disimpact,  but  often  at  the 
expense  of  comminution  of  the  lower  fragment.  Union  is  effected 
without  difficulty,  but  the  patient  should  always  be  warned  at  an 
early  date  to  expect  some  deformity  about  the  wrist,  as  well  as  con- 
siderable impairment  in  the  subsequent  mobility  of  the  fingers  and 
hand,  owing  partly  to  adhesions  in  the  joint,  partly  to  blood  trickling 
down  the  tendon  sheaths  and  fixing  the  tendons. 

Treatment. — To  reduce  the  deformity,  extension  and  manipulation 
are  both  needed.  The  patient,  if  not  under  an  anaesthetic,  should  be 
seated  on  a  chair,  and  the  surgeon,  standing  in  front,  should  grasp 
the  hand  firmly,  using  the  right  hand  for  fractures  on  the  right  side, 
and  the  left  for  those  on  that  side.  Counter-extension  is  made  from 
the  flexed  elbow,  and  the  hand  is  then  forcibly  extended  and  adducted  ; 
disimpaction  is  thus  brought  about,  and  a  little  manipulation  enables 
the  fragments  to  be  moulded  into  position. 

Many  plans  have  been  adopted  in  the  application  of  splints  for  this 
fracture :  (i)  A  piece  of  Gooch  splint  is  perhaps  the  most  simple  and 
efficacious.  It  is  shaped  so  as  to  cover  the  radius  front  and  back  as 
far  as  the  middle  line  of  the  arm,  and  extends  nearly  from  the  elbow 
to  the  front  and  back  of  the  knuckles  of  the  index  and  middle  fingers  : 
its  lower  end  is  hollowed  out  in  a  horseshoe  manner,  so  as  not  to 
reach  beyond  the  end  of  the  metacarpal  bone  of  the  thumb.  This 
is  well  padded  and  firmly  bandaged  on  ;  it  grasps  the  radius  and 
steadies  the  hand  in  a  position  of  adduction,  without  in  any  way 
interfering   with    the   movements   of    the    fingers.     (2)    Gary's   splii)^ 


Sii 


A  MANUAL  OF  SURGERY 


(Fig.  219)  consists  of  two  shaped  pieces  of  wood  fitting  the  front  and 
back  of  the  radial  side  of  the  fore-arm,  whilst  to  the  palmar  one  is 
attached  an  oblique  rod  to  be  grasped  by  the  fingers,  and  thus  the 
hand  and  wrist  are  maintained  in  a  position  of  adduction,  whilst  the 
fingers  can  be  freely  moved.  (3)  Gordons  splint  is  another  excellent 
contrivance,  which  consists  of  two  pieces.  The  palmar  portion  has 
a  curved  projection  on  its  radial  side,  to  correspond  to  the  site  of 
the  fracture  and  to  the  concavity  of  the  lower  end  of  the  radius  ; 
on  the  ulnar  side  it  is  prolonged,  so  as  to  fit  the  ulnar  border  of 
the  hand.  The  dorsal  splint  is  slightly  curved  at  the  lower  end, 
so  as  to  apply  itself  comfortably  to  the  wrist  when  in  a  position  of 
flexion. 

Union  is  usually  firm  enough  in  a  week  to  permit  the  removal 
of  the  splints,  the  arm  being  kept  in  a  leather  or  guttapercha  sup- 
port for  some  time  longer.  Massage  and  passive  movements  should 
be  employed,  and  the  fingers  left  free  and  exercised  after  the  first 
two  or  three  days. 

if/m/iiiiiiiiiiiiiiui!liilli!<iui'ililirilliiiiinf/li///f//^ 


Fig,  219. — Carr's  Splint  for  Colles's  Fracture  of  Left  Hand. 


5.  Separation  of  the  Lower  Epiphysis  of  the  radius  occurs  in  young 
people  under  twenty,  and  when  it  is  displaced  backwards,  simulates 
somewhat  closely  a  Colles's  fracture.  The  lower  end  of  the  diaphysis 
projects  anteriorly  to  a  much  greater  extent,  and,  indeed,  may  pro- 
trude through  the  skin  of  the  wrist.  The  lower  end  of  the  ulna  may 
be  involved  in  the  accident,  either  the  epiphysis  being  separated,  or 
the  shaft  broken  a  little  above.  This  condition  may  be  mistaken  for 
a  backward  dislocation  of  the  wrist,  but  a  diagnosis  can  be  readily 
made  by  observing  the  relative  position  of  the  styloid  processes  to 
the  carpal  bones.  Lateral  displacement  occurs  in  some  cases 
(Fig.  223).    Treatme-it  is  practically  the  same  as  for  Colles's  fracture. 

Should  arrest  of  growth  result  from  this  accident,  the  hand  retains 
its  connection  with  the  stunted  radius,  but  the  ulna  continues  to 
grow  downwards,  and  its  lower  end  is  found  on  the  inner  and 
posterior  aspect  of  the  carpus,  which  is  pushed  en  bloc  towards  the 
radial  side,  but  without  any  marked  abduction. 

Fracture  of  both  Bones  of  the  Fore-arm  may  result  from  direct 
violence  or  falls  on  the  palm.  Any  part  of  the  bones  may  yield,  but 
the  middle  and  lower  thirds  are  most  frequently  affected  (Fig.  222). 
When  due  to  direct  violence,  both  bones  may  be  broken  at  the  same 


<  < 


^,Q 


h  « 


6  ^ 


Fig.  222.— Fractupk,  of  Both  Bonfs  of  the  Fokti-arm,    with 
Displacement  Outwards. 


Fig.  223. — Skiagram  of  Displacement  of  Lower  Epiphysis  of  Radius 
AND  of  the  Hand  Ootwards, 


INJURIES  OF  BONES— FRACTURES 


527 


level ;  but  if  due  to  a  fall  on  a  palm,  the  ulna  usually  gives  way  at  a 
higher  level  than  the  radius.  The  line  of  fracture  may  be  transverse 
or  oblique,  and  the  displacement  varies  both  with  this  and  with  the 
force  employed.  The  upper  fragments  are  usually  drawn  together 
and  pronated,  whilst  the  lower  end  of  the  radius  is  drawn  up  by  the 
supinator  longus.  In  young  people  a  not  uncommon  result  of  falls 
in  the  football  field  or  at  the  skating-rink  is  a  complete  fracture 
of  the  lower  third  of  the  radius,  and  a  greenstick  fracture  of  the 
ulna.  The  upper  fragment  of  the  radius  is  displaced  forwards  in 
front  of  the  pronator  quadratus,  which  prevents  its  displacement, 
even  by  traction  under  an  anaesthetic.  The  diagnosis  of  these 
fractures  is  very  simple,  since  there  is,  as  a  rule,  obvious  deformity. 
Treatment  consists  in  reduction  by  extension  conjoined  with  manipula- 
tion, and  the  application  of  splints  which  will  prevent  cross-union  of 
the  bones.  If  the  fracture  is  above  the  insertion  of  the  pronator 
teres,  the  arm  must  be  put  up 
in  full  supination,  as  suggested 
for  a  similar  fracture  of  the 
radius  alone  (p,  517),  whilst 
below  that  spot  the  usual  posi- 
tion midway  between  pronation 
and  supination  may  be  allowed. 
Union  is  generally  complete  in 
five  or  six  weeks.  If  the  frag- 
ments are  not  readily  manipu- 
lated into  position,  as  indi- 
cated by  radiography,  operation 
should  be  undertaken  without 
delay,  as  the  lower  ends  of  these 
bones  are  a  rather  favourite 
site  of  election  for  non-union. 

Fractures  of  the  Carpus.  — 
These  may  result  from  direct 
violence  in  the  nature  of  a 
severe  crush,  and  then  several 

of  the  bones  may  be  involved,  and  the  lesion  may  be  compound.  The 
ordinary  treatment  of  such  a  condition  must  be  followed,  and  the 
parts  kept  at  rest  on  a  palmar  splint. 

Skiagraphy  has  demonstrated  that  many  '  sprains  of  the  wrist ' 
from  indirect  violence  are  in  reality  associated  with  fracture  of  a 
carpal  bone,  and  of  these  a  transverse  fracture  through  the  waist  of 
the  scaphoid  (Fig.  224)  is  perhaps  the  most  common.  As  a  rule, 
rest  and  subsequent  massage  are  alone  required  ;  but  occasionally 
movement  is  impaired  by  a  displaced  fragment,  or  painful  weakness 
follows  from  non-union,  and  then  removal  of  the  fragment  or  of  the 
bone  is  necessary. 

Fractures  of  tlie  Metacarpal  Bones  and  Phalanges  are  not  uncommon, 
particularly  in  the  third  and  fourth  fingers,  being  due  to  direct  violence, 
and  hence  usually  transverse.     There  is  generally  but  little  displace- 


FiG.  224. — Fracture  of  the  Waist  of 
THE  Scaphoid  in  a  Patient  supposed 

MERELY  to  HAVE  SPRAINED  HIS  WrIST. 


528  A   MANUAL  OF  SURGERY 

raent,  thouj^^h  occasionally  the  fragments  may  overlap,  whilst  a  certain 
amount  of  localized  swelling  and  tenderness  is  always  noted.     The 

treatment  usually  required  is  immo- 
bilization for  a  short  time,  and  for  the 
phalanges  a  small  zinc  splint  moulded 
along  the  front  of  the  finger  acts  admir- 
ably. Should  the  fragments  overlap, 
operation  may  be  necessary. 

Bennett,  of  Dublin,  has  described  an 
interesting   fracture  of   the  first  meta- 
carpal (stave  of  the  thumb),  which  is  due 
to  indirect  violence,  and  not  very  rare. 
The  line  of  fracture  is  oblique  (Fig.  225), 
separating   the  anterior  portion  of  the 
base,  which  remains  in   situ,  from  the 
Fig.    225.— Skiagram    of    a     rest  of  the  shaft,  which  is  drawn  upwards 
'Stave    of    the    Tiiumh'     and  backwards  by  the  long  extensor  ten- 
Fracture.  dons,  so  as  to  lie  behind  the  trapezium. 

Should  the  displacement  be  overlooked, 
the  bone  unites  in  this  position,  and  the  deformity,  which  persists, 
determines  weakness  and  disability  of  the  thumb.  Treatment. — The 
fracture  is  reduced  by  traction.  A  poroplastic  splint  is  moulded  to 
the  anterior  (palmar)  aspect  of  the  thumb,  reaching  above  the  wrist ; 
it  is  first  fixed  to  the  distal  end  by  strapping,  and  then  bandaged 
above,  so  that  extension  is  continuously  applied. 

Fractures  of  the  Pelvis. 

Fractures  of  the  pelvic  bones  are  almost  always  the  result  of  direct 
injury,  such  as  blows,  gunshot  wounds,  and  railway,  carriage  or  cart 
accidents.  For  convenience  they  may  be  described  under  the  follow- 
ing headings  : 

1.  Fractures  of  the  False  Pelvis. — A  portion  of  the  crista  ilii  may  be 
broken  off,  or  the  anterior  or  posterior  spines  separated,  or  merely  a 
fissure  in  the  bone  produced.  But  little  importance  attaches  to  such 
conditions,  as  the  displacement  can  never  be  great,  although  a  portion 
of  the  crest  may  be  drawn  down  by  the  glutei  muscles,  or  the  an- 
terior superior  spine  displaced  by  the  sartorius ;  in  severer  cases, 
when  the  bones  are  crushed  and  comminuted,  the  true  pelvis  is 
also  likely  to  be  affected,  and  more  serious  consequences  may  then 
arise.  Considerable  pain  is  always  produced  by  these  conditions, 
especially  on  any  vigorous  respiratory  movements.  Union  occurs 
readily  if  the  patient  is  kept  quiet  in  bed  with  the  shoulders  raised, 
and  the  legs  supported  to  relax  the  muscles.  A  flannel  bandage 
round  the  pelvis  gives  comfort  and  support. 

2.  Fracture  of  the  True  Pelvis  is  a  much  more  serious  accident. 
The  line  of  fracture  in  front  usually  runs  into  the  obturator  foramen, 
and  involves  both  the  horizontal  and  descending  rami  of  the  pubes 
or  the  ascending  ramus  of  the  ischium  (Fig.  226).    This  is  frequently 


INJURIES  OF  BONES— FRACTURES 


529 


conjoined  behind  with  a  fracture  in  the  neighbourhood  of  the  sacro- 
iliac synchondrosis  either  on  the  same  or  opposite  side,  but  more 
frequently  the  latter ;  whilst  a  double  fracture,  front  and  back,  may 
also  occur  at  these,  the  weakest,  points.  The  cause  of  the  posterior 
fracture  is  that,  when  the  pelvic  ring  has  yielded  anteriorly  from  the 
violence,  the  continued  strain,  whether  directed  from  the  front  or  from 
the  sides,  must  necessarily  fall  on  the  part  where  the  ilium  is  most 
closely  connected  with  the  sacrum,  and  the  bones  then  give  way 
rather  than  the  unyielding  and  powerful  sacro-iliac  ligaments. 
Probably  the  fracture  involves  the  lateral  mass  of  the  sacrum  rather 
more  frequently  than  the  ihum.  The  Symptoms  are  those  of  severe 
shock  and  pain  in  and  around  the 
pelvis,  especially  on  movements  of 
the  legs  or  on  coughing.  There 
may  be  local  ecchymosis  and 
tenderness  over  the  pubic  ramus, 
as  also  deeply  in  the  iliac  fossa,  and 
the  patient  either  cannot  stand,  or 
feels  as  if  he  were  falling  to  pieces 
on  attempting  to  do  so.  Usually 
there  is  but  little  deformity, 
although  occasionally  displace- 
ment backwards  of  the  innominate 
bone  is  visible,  and  depression  of 
the  pubic  symphysis  or  of  the 
ischial  or  pubic  rami  palpable. 
Crepitus  may  be  elicited  on  grasp- 
ing the  iliac  bones,  and  moving 
them  one  on  the  other  ;  but  such 
a  method  of  investigation  must  be 
very  sparingly  indulged  in. 

The  chief  dangers  from  a  fractured  pelvis  arise  from  the  presence  of 
co-existent  visceral  lesions,  especially  to  the  urethra,  bladder,  or  rectum. 
The  membranous  portion  of  the  urethra  is  torn  by  the  displacement 
of  the  pubic  symphysis,  and  this  is  indicated  by  escape  of  blood 
from  the  meatus.  Every  effort  must  be  made  to  prevent  extravasa- 
tion of  urine,  and  the  patient  warned  against  passing  water,  however 
urgent  the  desire.  Rupture  of  the  bladder  results  in  pelvic  or 
intra-peritoneal  extravasation,  according  to  the  site  of  the  lesion. 
The  rectum  may  be  punctured  by  the  displaced  pubic  rami,  and  on 
examination  per  rectum  the  ends  of  the  bones  may  be  felt.  The 
vagina  and  the  pelvic  vessels  and  nerves  are  less  frequently  injured. 

Treatment. — The  patient  should  be  moved  with  the  greatest  care, 
both  on  account  of  the  shock,  and  also  for  fear  of  producing  or 
increasing  visceral  complications.  He  is  put  to  bed  on  a  firm  divided 
mattress  with  fracture-boards  beneath  it,  and  kept  quiet  until  the 
shock  has  in  measure  passed  off.  A  more  complete  examination 
is  then  made,  if  need  be  under  an  anaesthetic,  and  complications 
dealt  with.     It  is  rarely  desirable  to  attempt  replacement  of   the 

34 


Fig.  226. — Unilateral  Fracture  of 
THE  Pelvis.  (Museum  of  the 
Royal  College  of  Surgeons.) 

The  fracture  runs  through  the  sacrum 
on   the  left   side,   and    through  the 
horizontal  and  descending  rami 
the  pubes. 


of 


530  A  MANUAL  OF  SURGERY 

fragments,  which  gradually  return  to  a  more  or  less  normal  position. 
The  pubes,  however,  may  be  pushed  forwards  by  a  finger  in  the 
rectum  or  vagina.  A  broad  binder  to  steady  the  parts  is  sometimes 
recommended  ;  but  it  is  not  really  necessary,  and  involves  a  good 
deal  of  movement,  which  is  undesirable.  It  is  wise  to  keep  the 
patient's  knees  tied  together,  and  he  should  be  turned  in  bed  with 
the  greatest  care  in  order  to  wash  the  back. 

The  viscera]  complications  will,  of  course,  demand  treatment  as 
described  hereafter,  but  we  would  indicate  here  the  necessity  for 
examining  the  urethra  in  all  cases,  and  drawing  off  the  water  by  a 
catheter.  If  the  urethra  is  torn,  it  may  be  possible  to  pass  a  catheter 
and  tie  it  in  ;  but  failing  this,  a  perineal  incision  must  be  made  in 
order  to  prevent  urinary  infiltration.  If  the  pubic  rami  are  also  felt 
projecting  into  the  rectum,  it  may  be  advisable  to  prolong  the 
perineal  incision  backwards  so  as  to  lay  open  that  viscus  freely, 
thereby  allowing  free  exit  to  faeces  and  discharge,  and  permitting 
of  more  satisfactory  cleansing 

Apart  from  complications  union  may  be  expected  in  about  six 
weeks,  but  the  patient  should  be  kept  in  bed  for  at  least  eight,  and 
even  then  only  allowed  to  get  about  on  crutches,  wearing  a  padded 
belt.  Late  complications  in  the  form  of  abscesses  connected  with 
necrosis  of  the  pubic  rami  or  pelvic  extravasation  may,  of  course, 
arise,  and  prove  fatal  or  delay  convalescence. 

3.  Fracture  of  the  Acetabulum  is  of  two  types:  (i)  The  posterior 
lip  is  broken  off  by  the  head  of  the  femur,  which  is  dislocated  back- 
wards by  the  same  accident  Reduction  is  effected  easily  and  with 
crepitus,  but  the  displacement  usually  recurs,  and  to  prevent  it  prolonged 
and  effective  extension  is  required.  (2)  A  heavy  fall  on  the  trochanter 
may  cause  (a)  a  simple  fissure  extending  into  or  across  the  cavity, 
or  (b)  a  starred  fracture,  possibly  resolving  the  cavity  into  its  three 
constituent  elements,  or  (c)  it  may  even  drive  the  head  of  the  bone 
into  the  pelvis  {central  dislocation  of  the  femur).  A  mere  fissure  of  the 
acetabulum  produces  but  few  symptoms  beyond  a  little  pain  and 
impairment  of  movement ;  but  if  the  head  of  the  bone  is  driven  into 
the  pelvic  cavity,  the  symptoms  are  much  more  serious,  on  account  of 
the  associated  injuries  to  the  viscera  and  the  greater  amount  of  violence 
employed.  The  case  will  resemble  one  of  fractuire  of  the  neck  of  the 
femur,  but  there  is  usually  only  very  slight  mobility,  and  the  head 
may  be  felt  within  the  pelvis  on  rectal  examination.  An  attempt 
should  be  made  to  free  it  by  horizontal  traction  outwards,  and 
manipulation  through  the  rectum  ;  extension  is  then  maintained,  and 
passive  movement  commenced  early. 

4.  Fracture  of  the  Tuber  Ischii  has  been  known  to  occur  from  falls 
in  the  sitting  position.  The  diagnosis  is  often  obscure,  as  the  dis- 
placement is  slight. 

5.  Fracture  of  the  Sacrum  is  always  due  to  direct  violence  of  con- 
siderable severity,  such  as  kicks,  blows,  or  gunshot  wounds.  It  is 
not  unfrequently  comminuted,  and,  from  the  associated  injury  to  the 
lower  sacral  nerves,  may  result  in  loss  of  power  of  the  bladder  and 


INJURIES  OF  BONES— FRACTURES  §31 

rectum.  In  a  transverse  fracture,  the  lower  fragment  is  usually 
displaced  forwards,  and  may  cause  pressure  upon  the  rectum ;  irregu- 
larity in  the  shape  of  the  bone  may  be  detected  from  within  (per 
rectum)  or  from  without.  Treatment. — The  lower  fragment  should 
be  replaced,  if  possible ;  but  considerable  difficulty  may  be  experienced 
in  keeping  it  in  position.  A  well-fitting  pelvic  band,  with  rest  in  bed, 
is  probably  all  that  is  necessary. 

6.  Fractures  of  the  Coccyx  result  from  falls  or  blows,  although  its 
mobility  often  protects  it  from  injury.  Great  pain  is  felt  on  walking, 
or  on  any  movement  which  increases  the  intra-abdominal  pressure, 
such  as  straining,  coughing,  defsecation,  etc.,  since  the  coccygeus 
muscle  forms  part  of  the  pelvic  diaphragm.  A  rectal  examination 
reveals  preternatural  mobility  of  the  lower  fragment,  angular  de- 
formity, and  perhaps  crepitus.  The  Treatment  consists  in  keeping 
the  patient  at  rest  until  union  has  occurred  ;  it  is  impossible  to  apply 
any  apparatus,  and  hence  the  bone  may  unite  at  an  angle,  causing 
pain,  discomfort,  and  difficulty  in  parturition.  Excision  of  the  hone  is 
then  required.  The  patient  lies  semi-prone  with  the  legs  slightly 
flexed,  or  in  the  lithotomy  position,  and  a  longitudi-^aL  'incision  is 
made  in  the  middle  line.  The  apex  and  lateral  margins  of  the  bone 
are  cleared,  and  the  ligamentous  tissues  uniting  it  to  the  sacrum 
divided  by  the  knife  ;  the  bone  is  now  laid  hold  of  by  sequestrum 
forceps,  and  its  remaining  attachments  severed,  due  precautions 
being  taken  not  to  encroach  on  the  rectum..  Two  or  three  stitches 
are  inserted,  and  also  a  drainage-tube  for  a  few  hours ;  the  dressing  is 
secured  in  position  by  a  T-bandage.  The  bowels  should  be  confined 
for  some  days  after  the  operation. 

Falls  upon  the  coccyx,  unaccompanied  by  fracture,  sometimes  give 
rise  to  a  most  severe  and  intractable  type  of  neuralgia,  known  as 
coccydynia,  which  may  quite  prevent  the  patient  from  following  his 
avocations.  It  is  probably  due  to  adhesions  forming  between  the 
posterior  sacral  nerves  and  the  bruised  periosteum.  If  all  the  usual 
sedatives  fail  in  giving  relief,  the  bone  must  be  excised. 


Fractures  of  the  Upper  End  of  the  Femur. 

I .  Fractures  of  the  Neck  of  the  Femur  may  involve  any  portion  of 
this  region,  but  for  clinical  purposes  are  usually  divided  into  those 
near  the  head  and  those  affecting  the  base  near  the  trochanter. 

Fracture  of  the  Cervix  Femoris  near  the  Head  (the  so-called  intra- 
capsular variety,  Fig.  227)  is  most  frequently  met  with  in  persons  of 
advanced  age,  and  especially  in  females.  This  is  explained  by  the 
atrophic  changes  which  take  place  in  the  cervix  femoris  of  elderly 
people.  The  spaces  between  the  bony  cancelli  are  enlarged  and 
loaded  with  soft  fat,  whilst  the  ensheathing  compact  tissue  is  thinned, 
and  the  '  calcar  femorale  '  of  Merkel  {i.e.,  the  process  of  thick  cortical 
substance  running  from  the  lesser  trochanter  to  the  under  part  of  the 
head)  is  atrophied.     The  neck  of  the  bone  is  sometimes  more  hori- 


532 


A  MANUAL  OF  SURGERY 


zontal  than  usual,  and  the  head  sinks  below  its  normal  position. 
Under  such  circumstances,  it  requires  but  little  violence  to  produce 
a  fracture,  the  direction  of  which  varies  according  to  the  force  applied. 
A.S  a  rule,  the  accident  is  due  to  some  slight  stumble  or  fall,  such  as 
slipping  off  the  kerb  or  tripping  upstairs ;  the  bone  yields  in  conse- 
quence, and  the  patient  falls  to  the  ground.  The  line  of  fracture 
may  be  transverse  or  oblique,  and  is  mainly  intracapsular.  Some  of 
the  fibres  reflected  from  the  under  surface  of  the  capsule  to  the  head 
of  the  bone  may  remain  untorn  at  first,  but  later  on  they  may  give  way 
from  inflammatory  softenmg,  injudicious  manipulation,  or  attempts  to 
use  the  limb.  The  fracture  is  not  usually  impacted ;  if,  however, 
this  condition  should  occur,  the  upper  end  of  the  neck  is  driven  into 
the  loose  cancellous  tissue  of  the  head.  The  displacement  is  neces- 
sarily limited  entirely  to  the  lower  fragment,  which  is  drawn  upwards 
by  the  glutei,  recti,  and  hamstring  muscles,  and  rotated  outwards 

and  somewhat  backwards,  so  that  the 
fractured  surface  looks  almost  directly 
forwards. 

The  Method  of  Repair  in  these  cases 
depends  to  a  large  extent  upon  the 
general  condition  of  the  individual. 
If  of  a  healthy  temperament,  and 
without  any  chronic  pulmonary  affec- 
tion, so  that  he  can  be  kept  in  the 
recumbent  posture  for  six  or  eight 
weeks,  bony  union  may  certainly  occur. 
The  main  process  of  repair  takes  place 
from  the  lower  end,  but  little  callus 
being  formed  from  the  head  of  the 
bone,  the  vascular  supply  being  only 
just  sufficient  to  maintain  its  vitality. 
If,  however,  the  patient  is  feeble  and 
weakly,  and  especially  if  the  subject 
of  chronic  bronchitis  and  emphysema, 
the  prognosis  is  by  no  means  good, 
since  hypostatic  pneumonia  and  extensive  bedsores  may  carry  him 
off  during  the  short  stay  in  bed  which  is  alwaj's  necessary  in  order 
to  relieve  the  more  urgent  symptoms  of  pain.  Bony  union  is 
never,  under  these  circumstances,  to  be  expected,  and  a  loose 
fibrous  union,  or  even  a  false  joint,  is  the  best  that  can  be  looked  for, 
the  patient  henceforth  walking  with  the  assistance  of  a  stick  or 
crutch.  Not  unfrequently  the  joint  undergoes  changes  akin  to  those 
of  osteo-arthritis,  and  the  patient  henceforth  suffers  much  pain  and 
discomfort.  Sometimes  the  neck  is  absorbed  and  the  shaft  slips  up 
on  the  dorsum  ilii,  the  weight  of  the  bod}'  being  carried  by  the  outer 
limb  of  the  Y-ligament  of  Bigelow  and  the  obturator  internus  tendon. 
The  prognosis  is,  of  course,  much  improved  by  the  presence  of 
impaction,  and  the  fear  of  breaking  this  down  must  ever  be  in  the 
mind  of  the  examining  surgeon ;  whilst  the  integrity  of  bridges  of 


—  Fracture    of    the 
Femoris    near     the 


INJURIES  OF  BONES— FRACTURES 


533 


periosteum  and  reflected  fibres  from  the  capsule  also  improves  the 
outlook. 

Radiographic  examination  has  shown  that  a  similar  type  of  fracture  of  the  neck 
occurs  in  children  and  young  people.  It  is  not  unfrequently  incomplete,  and 
associated  with  bending  of  the  neck.  The  patient  often  recovers  mobility  of  the 
limb,  and  can  walk  about  after  resting  in  bed  for  a  few  days;  but  the  deformity 
persists,  and,  in  fact,  increases  from  further  yielding  of  the  softened  bone,  so  that 
in  time  a  typical  coxa  vara  results.     A  similar  deformity  follows  a  partial  separa- 


FiG.  228.— Fracture  of  Cervix 
Femoris  near  the  Base. 
(Semi-diagrammatic,  from 
THE  Front.) 


Fig.  229. — Fracture  of  Neck  of 
Femur  near  the  Base,  seen 
from  Behind.  (College  of 
Surgeons'  Museum.) 

The  head  and  neck  are  depressed, 
and  the  trochanter  major  drawn 
slightly  upwards. 


tion  of  the  upper  epiphysis.  A  mistaken  diagnosis  of  tuberculous  coxitis  may 
be  made,  unless  one  clearly  appreciates  the  rapid  appearance  of  the  symptoms 
after  an  injury,  and  the  facts  that  the  trochanter  is  raised,  the  limb  shortened, 
and  the  movements  limited  only  in  particular  directions  or  not  at  all.  If  there  is 
complete  separation,  treatment  is  best  carried  out  by  fixation  with  plaster  of 
Paris  in  an  abducted  position,  and  by  prolonged  freedom  from  the  body- weight 
so  as  to  allow  the  callus  to  harden,  as  by  the  application  of  a  Thomas's  hip-splint! 

Fracture  of  the  Cervix  Femoris  near  the  Trochanter  (the  so-called 
extracapsular  fracture)  always  involves  the  hip-joint,  since  the  capsule 
extends  to  the  shaft  of  the  bone  along  the  anterior  intertrochanteric 
line,  and  leaves  no  portion  of  the  neck  uncovered  in  this  situation. 
The  line  of  fracture  is  placed  in  front,  either  along  the  attachment  of 
the  capsule  (Fig.  228)  or  well  within  it,  and  is  really  only  extra- 
capsular behind  ;  sometimes,  however,  the  shaft  itself  is  considerably 
encroached  on. 

Mechanism. — This  fracture  is  usually  the  result  of  violence  acting 
transversely  upon  the  trochanter  major,  as  from  a  heavy  fall  upon  the 
hip.     The  posterior  part  of  the  neck,  being  weaker  than  the  anterior, 


534  A  MANUAL  OF  SURGERY 

first  gives  way,  being  more  or  less  crushed  and  comminuted  ;  the 
whole  neck  then  yields,  and  the  severed  head  and  neck  are  forcibly 
impacted  into  the  junction  of  the  trochanter  and  shaft.  The  majority 
of  these  cases  are  thus  primarily  impacted,  continuation  of  the  violence 
producing  disimpaction,  coupled  either  with  detachment  of  one  or  both 
trochanters,  or  with  comminution  of  the  great  trochanter  ;  at  least 
three,  and  perhaps  four,  fragments  are  thus  produced  (Fig.  229). 
Disimpaction  may  also  follow  at  a  later  date  from  the  rarefaction 
associated  with  the  early  stages  of  repair  or  from  injudicious 
manipulation. 

The  displacement  is  much  the  same  as  in  the  former  variety ;  the 
upper  fragment  remains  in  the  acetabulum,  whilst  the  lower  is  drawn 
up  and  everted,  only  to  a  greater  extent.  Shortening  may  at  first  be 
slight,  but  is  likely  to  increase  at  the  end  of  a  few  days,  as  a  result  of 
disimpaction  of  the  fragments,  or  from  the  yielding  of  the  reflected 
fibres  of  the  capsule,  or  from  the  tonic  action  of  the  muscles. 

Unio'ri  of  the  fragments  is  much  more  certain  in  this  variety  than  in 
the  intracapsular,  but  it  is  often  accompanied  by  a  considerable 
development  of  callus,  which  may  subsequently  impair  the  movements 
of  the  limb,  whilst  secondary  bending  and  late  increase  of  the 
shortening  may  occur  if  the  patient  walks  too  soon. 

The  Signs  and  Symptoms  of  these  two  fractures  may  well  be  con- 
sidered together,  the  points  of  similarity  and  contrast  being  in  this 
way  more  effectually  emphasized, 

{a)  The  signs  of  local  trauma,  viz.,  pain,  bruising,  and  swelling,  may 
be  present  in  both  ;  but  whilst  slight  in  the  intracapsular  variety,  they 
are  very  marked  in  the  extracapsular.  It  must  not  be  overlooked, 
however,  that  even  in  the  former  the  patient  may  fall  on  the  affected 
hip  after  the  fracture  has  occurred,  and  thus  cause  a  considerable 
amount  of  bruising. 

(&)  Crepitus  is  evident  in  the  unimpacted  forms  of  each ;  but  it  is 
unnecessary  and,  indeed,  extremely  unwise  to  elicit  it  by  forcible 
manipulation,  especially  in  the  intracapsular  variety. 

(c)  Loss  of  power  is  perhaps  more  marked  in  the  extracapsular  form 
than  in  the  intracapsular.  Cases  of  the  latter  in  which  the  patient 
was  able  to  walk  into  hospital  some  days  after  the  accident  are  not 
unknown,  and  are  probably  due  to  impaction. 

(d)  Eversion  is  a  most  characteristic  feature  in  both  varieties,  the 
limb  lying  absolutely  helpless  on  its  outer  side.  This  displacement 
is  accredited  to  the  natural  weight  of  the  limb,  to  the  greater  fragility 
of  the  back  of  the  cervix,  causing  it  to  be  more  comminuted  than  the 
anterior  surface,  and,  lastly,  to  the  greater  power  of  the  external 
rotator  muscles.  Inversion  has  been  met  with  in  a  few  rare  cases,  but 
is  probably  due  to  the  violence  in  the  particular  instance  being 
directed  from  behind  forwards,  and  to  impaction  of  the  fragments. 

(e)  Shortening  is  slight  in  the  early  stage  of  intracapsular,  and  much 
greater  in  the  extracapsular,  fractures.  In  the  latter  case  the  shorten- 
ing usually  attains  its  maximum — viz.,  i^  to  2|,  or  even  3  inches — at 
once  ;  but  such  is  not  always  the  case  in  the  former.     It  is  indicated 


INJURIES  OF  BONES—FRACTURES 


535 


by  displacement  of  the  trochanter  upwards,  due  allowance  being  made 
for  the  position  of  the  Hmb  as  regards  abduction  or  adduction. 

(/)  The  position  of  the  great  trochanter  is  of  the  greatest  importance. 
It  is  raised  above  its  ordinary  level  and  everted ;  it  is  approximated 


Fig.  230.- 


-Nelaton's  Line  and   Bryant's   Measurement  for  ascertaining 
Position  of  Great  Trochanter, 


to  the  middle  line  of  the  body  and  to  the  anterior  superior  iliac  spine, 
and  rotates  in  the  arc  of  a  smaller  circle  than  usual,  the  radius  being 
the  thickness  of  the  trochanter  alone,  instead  of  including  also  the 
length  of  the  neck.  The  demonstration  of  this  position  is  most  im- 
portant, and,  amongst  others,  the  following  tests  are  employed : 

Nelaton's  line  (Fig.  230)  is  one  drawn  from  the  anterior  superior 
spine  to  the  most  prominent  point  of  the  tuber  ischii  (AB),  The 
centre  of  this  (D)  corresponds  to  the  top  of  the  great  trochanter,  if 
the  limb  is  placed  in  the  axis  of  the  body ;  but  if  either  abduction  or 
adduction  is  present,  the  top  is  situated  sHghtly  above  or  below  the 
line.  Definite  elevation  of  the  bone  above  the  line  indicates  shorten- 
ing of  the  limb  due  to  dislocation  backwards,  fracture  of  the  neck,  or 
absorption  of  the  head  and  neck  from,  disease. 

Bryant's  Test  Line  (Fig.  230). — In  this  the  patient  lies  flat  on  a 
horizontal  couch,  and  a  vertical  line  (AC)  is  drawn  from  the  anterior 
superior  spine  ;  a  thin  wooden  rod  held  against  the  side  answers  this 
purpose  admirably.  The  perpendicular  distance  of  the  top  of  the 
great  trochanter  from  the  line  (CD)  is  compared  with  a  similar 
measurement  on  the  opposite  side  ;  definite  shortening  may  thus  be 
discovered.  In  the  normal  adult  this  measurement  is  usually  about 
2|  inches. 

Morris's  hitrochanteric  test  indicates  the  amount  of  inward  displace- 
ment. It  is  conducted  by  measuring  the  distance  between  the  outer 
surfaces  of  the  trochanters  and  the  middle  line  of  the  body  by  means 


536  A  MANUAL  OF  SURGERY 

of  a  rod  graduated  from  the  centre,  along  which  two  pointers  work 
outwards.  Shortening  in  this  direction  will  also  be  observed  in  most 
dislocations  of  the  hip-joint. 

One  other  change  in  the  great  trochanter  may  be  noted  in  the  extra- 
capsular form  of  fracture,  which  can  be  utilized  as  a  useful  diagnostic 
feature  between  it  and  the  intracapsular  variety,  viz.,  the  great 
amount  of  thickening  of  the  process  which  is  always  produced,  owing 
to  the  excessive  development  of  callus.  In  the  intracapsular  variety 
it  is  rarely  fissured  or  injured,  and  therefore  no  thickening  occurs. 

[g)  Lastly,  relaxation  of  the  fascia  between  the  crest  of  the  ilium  and 
the  great  trochanter  (that  is,  of  the  upper  part  of  the  ilio-tibial  band) 
is  given  as  a  characteristic  feature  of  these  fractures. 

Diagnosis. — Simple  tmimpacted  fractures  are  readily  detected,  and 
there  can  be  but  little  difficulty. in  distinguishing  the  two  forms,  either 
from  one  another  or  from  other  injuries.  The  fact  that  an  impacted 
fracture  has  occurred  can  also  be  easily  made  out  as  a  rule,  the  pain, 
eversion,  and  shortening  sufficing  to  indicate  its  existence;  but  it  is 
very  often  difficult  to  say  which  of  the  two  forms  of  fracture  is  present, 
especially  if  the  surgeon  is  not  called  till  late  in  the  case.  The  character 
of  the  accident  and  the  age  of  the  patient  must  be  taken  into  account, 
whilst  the  existence  of  fissuring  or  thickening  of  the  trochanter,  or  an 
excessive  amount  of  shortening,  would  suggest  that  the  lesion  is 
located  near  the  trochanter.  A  severe  contusion  of  the  hip,  which 
may  be  associated  with  marked  eversion,  is  known  from  a  fracture 
by  the  absence  cf  shortening  and  crepitus  ;  there  is  no  displace- 
ment of  the  trochanter,  which  rotates  in  a  normal  manner.  The 
shortening  which  sometimes  follows,  owing  to  subsequent  atrophy 
of  the  neck,  may,  however,  complicate  matters.  In  a  dislocation  the 
head  of  the  bone  can  be  felt  in  an  abnormal  position,  and  hence  no 
difficulty  should  be  experienced  in  its  recognition.  In  chronic  osteo- 
arthritis of  the  hip  with  antecedent  shortening  and  marked  bony 
crepitus,  there  may  be  no  history  of  accident,  and  no  acute  eversion, 
pain,  or  loss  of  power  ;  possibly  the  existence  of  similar  disease  in 
other  joints  may  assist  the  surgeon,  whilst  osteo-arthritis  of  the  hip 
usually  results  in  prominence  of  the  trochanter,  and  not  in  flattening, 
as  occurs  after  fracture.  Moreover,  the  fascia  above  the  trochanter 
is  never  relaxed  in  osteo-arthritis,  always  in  fractures.  It  must  not 
be  forgotten  that,  after  an  intracapsular  fracture,  the  patient  may 
fall,  not  on  the  injured  side,  but  on  the  sound  thigh,  and  cases  have 
been  known  where  the  surgeon's  attention  was  directed  to  the  wrong 
limb  owing  to  the  amount  of  bruising  there  manifested.  Radiography 
may  be  advisably  employed  to  assist  in  making  a  diagnosis,  but  it  is 
wise  to  utilize  a  small  diaphragm  so  as  to  get  concentration  of  action 
and  a  more  defined  shadow  of  the  bones. 

The  Treatment  of  Intracapsular  Fractures  must  depend  in  great 
measure,  as  already  stated,  upon  the  individual.  If  old,  weakly,  and 
with  a  tendency  to  chronic  bronchitis,  long  confinement  to  bed  would 
have  a  most  deleterious,  if  not  fatal,  effect.  In  such  cases  the  limb 
is  put  at  rest  for  a  few  days  between  sandbags,  and  cooling  lotions 


INJURIES  OF  BONES— FRACTURES  537 

applied.  A  Thomas's  splint  or  a  plaster  of  Paris  spica  should  be 
fitted  as  early  as  possible,  and  the  patient  encouraged  to  get  about 
on  crutches. 

In  a  healthy  individual  with  good  physique,  where  bony  union 
maybe  expected  and  the  fracture  is  ^minipacted,  the  patient  is  kept  at 
rest  in  bed  for  six  or  eight  weeks,  with  extension  applied  to  the  limb 
and  a  Liston's  splint. 


///////    1 ^ 


Fig.  231. — Method  of  Cdtting  and  Folding  the  Strapping  in  Applying 

Extension. 


Fig.  232. — Method  of  Arranging  Strapping  on  Stirrup  or  '  Spreader.' 
The  end  A^  is  attached  by  a  safety-pin  to  A,  the  end  of  the  upper  piece  of  strapping 
in  Fig.  231,  and  a  similar  attachment  is  made  on  the  otlier  side  of  the  hmb 
to  the  other  piece  of  strapping. 

Extension  ly  weight  and  pulley  is  required  in  so  many  different  con- 
ditions that  a  description  of  its  method  of  application  is  necessary. 
Two  pieces  of  broad  adhesive  plaster  are  prepared  as  in  Fig.  231  ; 
they  should  reach  from  well  above  the  knee  to  the  malleoli.  The 
upper  ends  are  notched  obliquely  to  make  them  fit  better  to  the  limb, 
whilst  the  lower  are  folded  on  themselves  so  as  to  cover  in  the  adhesive 
surface.  A  stirrup  is  then  prepared  as  in  Fig.  232  ;  adhesive  plaster 
is  fixed  to  a  wooden  spreader,  rather  broader  than  the  ankle,  with  a 
hole  in  its  centre  for  the  passage  of  a  cord.  The  long  strips  are 
applied  on  either  side  of  the  limb,  and  secured  to  it  by  a  woollen  or 
boracic  bandage,  which  should  not  extend  much  below  the  knee. 
The  stirrup  is  then  attached  to  the  strips  by  safety-pins  (A^  to  A) ; 
the  cord  is  passed  over  a  pulley  fixed  to  the  end  of  the  bed,  and  to  it 
is  attached  a  suitable  weight ;  the  weight  employed  varies  in  different 
cases,  but  as  a  rule  not  more  should  be  applied  i-n  fractures  than 
suffices  to  correct  the  shortening.  The  lower  end  of  the  bed  is  raised 
by  placing  the  legs  on  blocks,  so  that  the  weight  of  the  body  may 
act  as  a  counter-extending  force. 

In  America  Btick's  method  of  extension  is  much  employed  and  gives 
great  satisfaction.  It  may  well  be  utilized  in  fractures  of  the  cervix. 
The  above-described  extension  is  employed,  but  in  addition  a  third 
strip  of  plaster,  i  yard  long  and  2  inches  wide,  is  fixed  to  the  back  of 
rhe  calf,  brought  down  below  the  sole  of  the  foot,  and  secured  by  a 


538 


A  MANUAL  OF  SURGERY 


roller  bandage.  A  Volkmann's  sliding  rest  (Fig.  233)  is  then  placed 
under  the  limb,  and  secured  to  it  by  the  loose  end  of  strapping  and  a 
bandage. 

Liston's  long  splint  (Fig.  234)  is  a  useful  and  comfortable  ap- 
pliance, if  rightly  adjusted.  It  should  reach  from  the  axilla  to  about 
6  inches  below  the  ankle,  and  is  fixed  to  the  body  either  by  bandages, 
or  by  two  broad  sheets,  which  first  firmly  envelop  the  splint,  and  are 


%..."-ii4::  'i.:mn 


Fig.   233. — Volkmann's  Sliding  Rest  for  Fractures  of  the  Femur. 

A  points  to   the  junction  of  the   upper  and  lower  pieces  of   strapping,   as  in 

Figs.  231  and  232. 

then  passed  under  and  round  the  trunk  and  lower  extremity  re- 
spectively, and  are  finally  secured  by  pins.  Lateral  movement  or 
rotation  is  prevented  by  slipping  the  lower  end  of  the  splint  into  a 
slot  between  two  '  angle-irons  '  screwed  to  a  substantial  wooden  base, 
which  rests  on  the  bed. 

Treatment  by  means  such  as  this  must  be  maintained  for  at  least 
eight  or  ten  weeks,  and  perhaps  more.  During  this  period  the 
utmost  care  must  be  taken  of  the  back  so  as  to  prevent  bed-sores. 
Subsequently  the  patient  is  fitted  with  a  Thomas's  splint,  or  a  plaster 
of  Paris  spica  applied,  and  crutches  are  ordered  for  another  month 
or  two. 

In  impacted  intracapsular  fractures  no  attempt  should  be  made  to 
separate  the  fragments.  The  patient  is  kept  in  bed  and  a  long  splint 
applied.  A  careful  watch  is  maintained  to  ascertain  if  disimpaction 
has  occurred,  as  then  weight  extension  must  be  employed. 

Treatment  of  Fracture  near  the  Trochanter  is  usually  conducted  on 
very  similar  lines  to  that  of  the  intracapsular  variety. 

In  the  unimpacted  form  extension  is  the  all-important  element.  It 
is  conducted  in  the  usual  way  by  weight  and  pulley  ;  the  weights 
must  be  heavy,  and  sometimes  as  much  as  14  pounds  are  required  ; 
the  strapping  must  reach  well  above  the  knee,  or  the  ligaments  of 
this  articulation  may  suffer.  Rotation  must  be  prevented  by  the  use 
of  Buck's  extension  and  a  Volkmann's  sliding  rest,  or  by  fixing  a 
broad  piece  of  wood  carefully  padded  transversely  behind  the  knee 
by  means  of  a  plaster  of  Paris  bandage.     The  addition  of  a  long 


INJURIES  OF  BONES— FRACTURES 


539 


splint  will  keep  the  body  at  rest,  but  inasmuch  as  it  might  interfere 
with  the  extension,  it  may  be  as  well  to  apply  it  to  the  sound  side. 
At  the  end  of  eight  weeks  the  patient  may  be  allowed  to  get  about 
with  a  Thomas's  splint  and  crutches,  or  a  plaster  spica. 

Impacted  fractures  should  rarely  be  broken  up,  except  in  young  and 
active  people.  In  older  patients  the  l\mb  is  kept  at  rest  for  six 
or  eight  weeks  on  a  long  splint  without  extension. 

Union  occurs  readily  and  by  means  of  bone ;  but  there  is  usually 
a  good  deal  of  deformity  and  subsequent  disability  from  the  develop- 
ment of  bony  outgrowths.  In  order  to  obviate  this,  operation  may 
be  undertaken  in  young  people,  the  fragments  being  secured  by 
screws  or  wires. 


Fig.  234. — Method  of  Application  of  Liston's  Long  Splint  with 
Weight  Extension. 

The  splint  reaches  from  the  axilla  below  the  side  of  the  foot,  and  is  secured  in 

place  by  sheets. 

2.  Fracture  of  the  Great  Trochanter  is  rare,  and  always  due  to 
direct  violence ;  in  the  young  it  occurs  as  an  epiphyseal  lesion.  The 
trochanter,  or  a  portion  of  it,  is  separated  from  the  rest  of  the  bone 
without  any  loss  of  the  continuity  of  the  shaft.  Independent  move- 
ment of  the  fragment  with  crepitus  is  usually  obtainable  ;  and  if  the 
displacement  is  at  all  marked,  an  operation  to  fix  it  should  be 
undertaken. 

3.  Fracture  through  the  Great  Trochanter  {the per-tyochanteric  fracture 
of  Kocher)  closely  resembles  the  extracapsular  fracture,  the  lesion 
running  from  the  inner  and  under  part  of  the  neck  obliquely  upwards 
and  forwards  through  the  base  of  the  trochanter.    The  lower  fragment, 


540 


A   MANUAL  OF  SURGERY 


including  the  lesser  trochanter,  is  drawn  upwards  and  backwards 
towards  the  sciatic  notch,  and  forms  a  projecting  mass  behind,  some- 
what simulating  a  dislocation  ;  the  tip  of  the  trochanter  can,  however, 
be  felt  separately,  not  moving  with  the  shaft.  Such  cases  may  be 
treated  by  extension  w^ith  the  long  splint,  or  perhaps  better  by 
Hodgen's  apparatus. 


Fig.  235, — Kodgen's  Splint  and  its  ^Method  of  Application. 

Hodgen's  splint  (Fig.  235)  consists  of  a  rigid  iron  frame  in  the 
form  of  the  letter  U,  the  outer  and  longer  limb  reaching  from  the 
anterior  superior  spine  to  3  inches  below  the  instep,  and  the  inner 
from  the  adductor  longus  tendon  to  the  same  spot,  where  the  two 
limbs  unite  in  a  cross-bar  3  inches  in  width.  The  sides  taper  with 
the  limb,  and  should  be  f  inch  farther  apart  than  the  diameter  oi 
the  limb  at  any  point.  At  the  upper  end  the  bars  are  united  by  an 
arch  of  the  same  material,  which  should  correspond  to  Poupart's 
ligament ;  one  or  two  similar  arches  are  placed  at  equal  points  lower 
down.     The  splint  is  slightly  bent  at  the  knee. 

Before  applying  the  splint,  an  ordinary  extension  apparatus  is 
attached  to  the  limb.  Strips  of  house-flannel,  about  7  inches  wide, 
are  then  cut  and  arranged  beneath  the  limb  at  right  angles  to  its 
direction,  each  one  overlapping  the  next;  the  length  of  the  strips 
should  be  rather  more  than  the  circumference  of  the  limb  at  the  spot 
to  which  each  is  to  be  applied.  The  splint  is  then  placed  in  position ; 
the  strips  of  flannel  are  raised  in  succession,  a.nd,  being  la.pped  over 
the  bar,  are  pinned  or  stitched  there,  so  that  the  limb  lies  in  a  flannel 
trough,  from  which  only  the  upper  surface  projects.  The  cord  of 
the  extension  appliance  is  then  securely  tied  to  the  lower  end  of  the 
splint.  Two  hooks  are  soldered  to  each  side  of  the  frame,  and  to 
them   are   attached   cords,   which    are    brought    together    over    the 


INJURIES  OF  BONES— FRACTURES  541 

limb;  another  stout  cord  is  tied  to  these,  and  passes  over  a  pulley 
attached  to  a  vertical  post  at  the  end  of  the  bed  ;  it  is  weighted  to  a 
sufficient  extent.  The  limb  when  the  weight  is  applied  should  lie 
free  of  the  bed,  even  to  its  extreme  upper  limit.  It  is  advisable  to 
encircle  the  thigh  in  Gooch  splinting,  a  narrow  piece  in  front  between 
the  bars  and  a  broader  piece  behind.  These  are  well  padded  and 
secured  by  bandages  which  extend  over  the  whole  length  of  the 
apparatus  ;  finally,  starch  is  rubbed  in  so  as  to  fix  it  more  firmly. 
When  correctly  applied,  the  splint  itself  is  pulled  on  by  the  extending 
force  (the  weight),  and  this  is  transmitted  to  the  limb  through  the 
stirrup  end,  which  should  be  taut  '  like  a  harp-string  ' ;  laxity  of  this 
end  indicates  slipping  of  the  splint,  and  necessitates  its  readjustment. 

4.  Separation  of  the  Upper  Epiphysis  of  the  Femur. — The  upper 
cartilaginous  end  of  the  femur  in  infants  includes  not  only  the  head, 
but  also  both  trochanters,  and  there  is  no  case  on  record  of  com- 
plete detachment  of  this  portion.  Ossific  centres  early  appear  for 
each  of  these  three  projections,  and  by  the  rapid  growth  upwards  of 
the  shaft  they  are  separated  from  each  other  by  the  fourth  year,  the 
neck  thus  being  really  constituted  as  an  outgrowth  of  the  shaft.  The 
epiphysis  of  the  head  has  been  completely  detached  in  a  considerable 
number  of  cases,  but  the  accident  is  not  so  common  as  in  the  humerus, 
owing  to  the  protection  given  by  the  depth  of  the  acetabulum.  The 
phenomena  closely  simulate  those  of  an  intracapsular  fracture,  but 
are  less  obvious.  Impairment  of  growth  may  follow,  and  possibly 
the  shape  of  the  head  and  neck  may  be  so  altered  subsequently 
as  to  simulate  the  condition  known  as  coxa  vara.  Treatment  of  the 
lesion  is  by  prolonged  fixation  of  the  limb  in  an  abducted  position. 

Fractures  of  the  Shaft  of  the  Femur  are  extremely  common 
accidents,  in  spite  of  the  apparent  strength  of  the  bone.  Any  part 
may  be  involved,  particularly  the  centre,  whilst  they  occur  at  the 
lower  end  more  frequently  than  at  the  upper.  In  the  latter  situation 
they  are  usually  due  to  indirect  violence,  whilst  at  the  lower  end  they 
generally  result  from  direct  injury ;  either  form  of  violence  may  lead 
to  a  fracture  about  the  middle  of  the  bone,  and  skiagraphy  has  shown 
us  that  spiral  fractures  are  by  no  means  uncommon. 

In  almost  every  case  displacement  occurs,  the  direction  and  amount 
of  which  depend  not  only  on  the  line  of  fracture,  but  also  on  the 
situation.  In  the  upper  third  (Fig.  236),  the  small  upper  fragment 
is  usually  tilted  forwards  by  the  ilio-psoas,  and  abducted  and  everted 
by  the  gluteus  minimus  and  external  rotators ;  whilst  the  lower 
fragment  is  drawn  upwards  and  to  the  inner  side  of  the  upper  by  the 
hamstring  and  adductor  muscles,  marked  eversion  also  resulting, 
partly  from  the  weight  of  the  foot,  and  partly  from  the  action  of  the 
adductors  ;  but  such  a  complicated  displacement  is  not  always  present. 

In  the  middle  third,  if  due  to  indirect  violence,  the  line  of  fracture 
usually  slants  from  above  downwards  and  backwards,  causing  a 
simple  overriding  of  the  fragments  or  an  angular  deformity.  The 
lower  fragment  is  drawn  upw^ards  and  inwards,  either  in  front  of 
or  behind  the  upper  fragment,  and  is  usually  everted.     The  upper 


S42 


A  MANUAL  OF  SURGERY 


fragment  is  sometimes  tilted  forwards.  If  due  to  direct  violence, 
the  fracture  is  more  or  less  transverse,  often  comminuted,  and  any 
form  of  displacement  may  then  occur. 

In  the  lower  third  the  fractures  which  arise  from  direct  force  are 
transverse ;  the  lower  fragment  may  then  be  tilted  backwards  by  th-^i 
gastrocnemii  muscles  (Fig.  237),  and  compress  or  rupture  the  popliteal 
vessels,  perhaps  causing  gangrene.  Oblique  or  spiral  fractures  from 
indirect  violence,  sloping  from  above  downwards  and  forwards,  are 
also  met  with ;  the  upper  fragment  is  driven  into  the  substance  of  the 
quadriceps  muscle  and  may  become  fixed  in  it,  projecting  immediately 
beneath  the  skin,  whilst  the  lower  fragment  is  drawn  up  behind.     If 


Fig.  236.  —  Fracture  of  Upper 
Third  of  Femur,  showing  Dis- 
placement OF  Bone.  (After 
Gray's  '  Anatomy.') 

I,  Ilio-psoas  tendon ;  2,  rectus ;  3, 
adductors;  4,  biceps. 


Fig.  237.  —  Fracture  of  Lower 
Third  of  Femur,  showing  Dis- 
placement OF  Lower  Fragment 
Backwards.  (After  Gray's 
'  Anatomy.') 

I,  Rectus;  2,  biceps;  3,  semi-mem- 
branosus  and  semi-tendinosus  ;  4, 
gastrocnemius. 


such  a  case  is  left  unreduced,  non-union  is  likely  to  ensue ;  the  knee- 
joint  is  generally  penetrated  by  the  lower  end  of  the  upper  fragment. 
Treatment.— In  the  upper  third,  where  the  upper  fragment  is  often 
too  short  to  be  controlled  by  any  splint,  reduction  of  the  deformity  is 
accomplished  by  flexing  the  thigh,  and  making  extension  from  the 
knee,  the  lower  fragment  being  thus  brought  into  the  same  axis  as 
the  upper.  Manipulation  will  usually  correct  any  lateral  displace- 
ment. The  limb  must  be  confined  in  this  position  by  some  form  of 
inclined  plane,  such  as  a  Macintyre's  splint,  with  a  long  thigh-piece, 


INJURIES  OF  BONES— FRACTURES 


543 


and  with  small  straight  wooden  splints  or  a  piece  of  Gooch's  splinting 
fixed,  if  necessary,  to  the  front  and  outer  sides  of  the  limb,  over  the 
seat  of  fracture.  The  splint  is  slung  at  the  knee,  the  foot-piece 
being  fixed  to  blocks  of  wood,  a  little  lower  than  the  level  of  the  knee. 
If  these  precautions  are  not  taken,  an  ununited  fracture,  with  the 
upper  fragment  in  front  of  the  lower,  is  likely  to  occur.  Hodgen's 
apparatus  also  answers  admirably  in  these  cases,  but  in  healthy 
patients  treatment  by  operation  is  certainly  desirable. 

In  the  middle  third  of  the  thigh,  where  the  upper  fragment  can  be 
controlled  by  splints,  shortening  is  prevented  by  extension  (p.     537), 


Fig.   23S.— Bryant's  Method  of  Extexsiok  for  Treatmext  of  Fracture 

OF  THE  Femur  in  Small  Children. 

The  right  leg  is  fractured  and  has  the  weight  attached  to  it  ;  the  left  leg  is 

merely  tied  up  to  keep  it  vertical  and  out  of  the  way. 

the  thigh  being  surrounded  by  pieces  of  Gooch's  splinting,  which 
grasp  the  muscles  and  keep  the  parts  at  rest.  The  limb  is  then 
placed  between  sandbags,  or  secured  on  a  Liston's  splint.  A  half- 
box  splint  {i.e.,  a  long  splint  with  a  back-piece)  may  be  successfully 
employed  in  many  of  these  cases,  the  limb  being  firmly  bandaged  to 
the  appliance.  Where  the  fracture  is  oblique  or  spiral,  and  especially 
if  there  is  any  tendency  to  overlap,  Hodgen's  apparatus  may  be 
utilized,  or  operation  undertaken. 

In  the  lower  third,  when  the  lower  fragment  is  tilted  backwards, 
a  Macintyre's  splint,  Avith  a  long  thigh-piece  and  the  knee  well  flexed, 
may  sometimes  be  employed,  together  with  a  short  anterior  thigh- 


541 


A   MANUAL  OF  SURGERY 


piece  of  Gooch's  splinting ;  but  in  the  oblique  type,  if  the  upper 
fragment  has  penetrated  the  quadriceps,  operation  alone  holds  out 
any  prospect  of  bringing  the  parts  into  apposition,  the  muscular 
fibres  being  divided  to  allow  the  projecting  end  of  the  bone  to  be 
replaced,  and  fixed  by  screws  or  wire.  In  other  cases  the  ordinary 
long  splint  or  Hodgen's  will  be  required. 

In  children,  Bryant's  plan  of  treatment  (Fig.  238)  is  excellent ;  it 
consists  in  slinging  the  limb  from  a  crossbar  at  right  angles  to  the 
body,  with  or  without  a  back-splint,  reaching  from  the  heel  to  the 
nates,  and  short  lateral  splints,  thus  obtaining  extension  by  utilizing 
the  weight  of  the  body,  whilst  the  bandages,  etc.,  are  kept  from  being 
soiled.  If  a  long  splint  is  used  for  children,  a  double  one  {e.g., 
Hamilton's  splint)  with  a  crossbar  below  is  the  best. 

A  fractured  femur  usually  unites  well  in  from  six  to  eight  weeks, 
but  the  patient  must  not  bear  his  weight  on  it  for  another  month. 
The  limb  is  encased  in  plaster  of  Paris,  and  crutches  are  employed. 
There  is  certain  to  be  some  amount  of  stiffness  of  the  knee-joint, 
following  effusion,  after  all  fractures  of  the  femur ;  but  it  generally 
passes  away  in  time,  and  that  without  active  surgical  intervention. 

Fractures  of  the  Lower  End  of  the  Femur. 

1.  Transverse  Supracondyloid  Fracture  is  practically  identical  with 
that  involving  the  low^er  third  of  the  femur ;  the  lower  fragment  is 
rotated  backwards  by  the  action  of  the  gastrocnemii,  thus  endangering 
the  integrity  of  the  popliteal  vessels,  and  predisposing  to  non-union, 
if  the  deformity  is  overlookedc 

2.  T-  or  Y-shaped  Fracture  of  the  Condyles. — In  this  a  transverse 
fracture  is  complicated  by  a  fissure,  which  runs  into  the  joint, 
separating  the  two  condyles ;  or  a  Y-shaped  fissure  may  start  from 
the  intercondyloid  notch.  The  condition  is  A^ery  painful ;  the  joint 
is  distended  with  blood ;  the  bone  may  feel  broader  than  usual,  and 
crepitus  may  be  detected.  Treatment  is  best  effected  by  operation, 
in  order  to  empty  the  joint  of  blood,  bring  the  fragments  into  apposi- 
tion, and  fix  them  by  screws  or  pegs. 

3.  Separation  of  either  Condyle  usually  results  from  direct  violence, 
but  occasionally  has  followed  such  indirect  injury  as  catching  the  toe 
against  the  kerbstone.  There  is  no  shortening,  but  the  leg  may  be 
deflected  towards  the  side  injured,  and  the  joint  cavity  be  full  of  blood. 
The  fragment,  which  is  tilted  backwards  by  the  gastrocnemius,  may 
move  separately  from  the  shaft,  and  give  rise  to  crepitus.  Treatment. — - 
Reposition  is  effected  by  flexion  of  the  limb,  which  is  best  put  up  in 
this  position ;  but  in  healthy  adults  treatment  by  operation  is  desirable 
(Fig.  239). 

Occasionally  a  small  portion  of  the  condyle  may  be  detached  and 
lie  loose  in  the  knee-joint ;  when  the  immediate  symptoms  due  to  the 
injury  have  subsided,  the  signs  of  a  foreign  body  in  the  joint  may 
become  evident,  and  operation  will  be  required  for  its  removal. 

4.  Separation  of  the  Lower  Epiphysis  of  the  Femur  (Fig.  240)  is  not 
a  very  rare  accident,  and  is  not  unfrequently  due  to  children  sitting 


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INJURIES  OF  BGKIES— FRACTURES  547 

behind  a  cab  and  getting  their  leg  entangled  between  the  spokes  of 
the  revolving  wheel.  The  limb  is  thus  forcibly  hyper-extended  at 
the  knee,  and  the  epiphysis  yields,  and  is  carried  forwards.  The 
lower  end  of  the  diaphysis  projects  behind,  and  may  compress  the 
popliteal  vessels  ;  gangrene  has  been  known  to  result.  As  in  the 
humerus,  the  line  of  separation  does  not  always  correspond  tc 
the  epiphyseal  line,  but  sometimes  encroaches  on  the  shaft.  Sup- 
puration occurs  in  a  fair  proportion  of  the  cases.  Treatment. — 
Reduction  is  effected  by  an  assistant  making  traction  on  the  tibia  in 
the  line  of  the  limb  so  as  to  stretch  the  quadriceps ;  then  the  thigh 
is  gradually  flexed  by  the  surgeon,  standing  above  and  with  both 
hands  clasped  beneath  it  The  epiphysis  is  by  this  means  restored 
to  its  normal  position,  and  the  limb  is  kept  flexed  by  a  bandage  at 
about  an  angle  of  60°,  and  laid  on  its  outer  side  with  an  icebag 
applied.     Passive  movement  is  commenced  carefully  in  a  fortnight. 

Fractures  of  the  Patella. 

The  patella  is  broken  either  by  muscular  force  or  by  direct  violence, 
and.  the  conditions  produced  are  so  different  that  a  separate  descrip- 
tion is  necessary. 

I  Fractures  by  direct  violence  may  traverse  the  bone  in  any 
direction,  but  are  most  often  vertical  or  star-shaped,  and  frequently 
comminuted.  They  are  usually  mere  fissures  without  displacement, 
owing  to  the  aponeurosis  or  capsule  of  the  bone  remaining  intact. 
There  is  a  good  deal  of  subcutaneous  bruising,  and  perhaps  some 
effusion  into  the  joint,  whilst  on  careful  palpation  the  fissure  may 
be  felt,  and  crepitus  occasionally  detected.  Treatment  consists  in 
keeping  the  limb  at  rest  on  a  back-splint,  and  perhaps  applying 
evaporating  lotions.  Passive  movements  must  be  commenced  early 
where  there  has  been  much  haemorrhage  into  the  joint.  Operative 
measures  are  rarely  required, 

2.  Fractures  due  to  muscular  force  are  always  transverse,  usually 
complete,  and  since  they  involve  the  fibrous  aponeurosis,  considerable 
displacement  occurs. 

Mechanism. — When  the  knee  is  semi-flexed,  the  patella  is  poised 
upon  the  front  of  the  condyles  of  the  femur,  resting  upon  the  middle 
of  its  articular  surface  :  in  this  position  any  sudden  and  violent  con- 
traction of  the  quadriceps,  as  in  attempting  to  recover  one's  equili- 
brium after  having  slipped,  takes  the  bone  at  a  disadvantage,  and 
may  succeed  in  snapping  it.  Possibly  in  some  people  there  is  a 
predisposing  weakness,  as  cases  are  not  rare  in  which  the  other 
patella  is  broken  at  a  later  date.  The  fragments  may  be  almost 
equal  in  size  (Fig.  241),  but  the  lower  is  often  the  smaller  ;  either  of 
them  may  be  again  divided  vertically,  or  comminuted. 

The  Signs  of  this  fracture  consist  of  loss  of  power  in  the  limb,  pain, 
distension  of  the  joint  with  blood,  and  separation  of  the  fragments, 
which  can  be  readily  felt  and  sometimes  seen  (Fig.  242).  This 
displacement  is  due  to  unopposed  muscular  action,  and  is  always 


's4 


A  MANUAL  OF  SURGEIi'i' 


associated  with  rupture  of  the  lateral  expansions  of  the  vasti 
muscles.  Union  by  bone  is  rarely  obtained  apart  from  operation, 
owing  to  the  separation  of  the  fragments,  and  the  carrying  in  of  loose 
tags  of  the  fibrous  aponeurosis  or  capsule,  which  yields  at  a  different 
level  to  the  bone.  Fibrous  union  is  the  usual  result,  and  when  this 
is  short  and  strong,  it  is  quite  satisfactory ;  but  more  commonly  the 
bond  of  union  yields  when  the  limb  is  used,  so  that  the  two  fragments 
are  once  again  separated,  merely  a  bridge  of  fibrous  tissue  inter- 
vening, the  joint  being  left  in  a  weak  state,  and  the  power  of  active 
extension  of  the  leg  lost. 

The  Treatment  of  these  cases  may  be  grouped  under  three 
headings,  viz.,  by  retentive  apparatus,  by  subcutaneous  operation, 
or  by  the  open  method. 


Fig.    241.— Fracture   of   Patella,  Fjg_   242.  —  Appearance  of 

WITH  Separation  of  Fragments.  knee  after  Fracture  of 

(After  Gray's  'Anatomy.')  Patella. 

I,  Rectus;  2,  vastus externus;  3,  liga- 
mentum  patellae. 

I.  Simple  retentive  appavatiis  may  be  employed  in  cases  where  the 
fragments  are  not  widely  separated,  and  can  be  rea«iily  brought  into 
contact,  and  where  the  patient  is  not  a  good  subject  for  operation. 

Some  surgeons  depend  mainly  upon  plaster  of  Paris  to  maintain 
apposition  of  the  fragments.  If  there  is  but  little  effusion,  the  limb 
is  extended,  swathed  in  a  boracic  bandage,  and  over  this  a  plaster 
casing  of  the  Croft  type  is  applied.  The  apparatus  will  become 
loose  from  muscular  atrophy  in  a  week  or  ten  days,  and  will  then 
need  readjustment.  The  patient  is  kept  in  bed  for  three  or  four 
weeks,  but  the  plaster  is  removed  at  the  end  of  a  week,  and  regular 
massage  established  so  as  to  maintain  the  nutrition  of  the  muscles 
and  assist  in  the  repair  of  the  bone.  Flexion  of  the  limb  is  not 
permitted  until  a  suitable  knee  support  (Fig.  243)  which  limits  the 
degree  of  movement  has  been  obtamed.  This  may  commence  about 
four  weeks  from  the  injury,  and  the  appliance  must  be  worn  for 


INJURIES  OF  BONES—FRACTURES  549 

about  twelve  months.  Where  there  is  much  effusion  after  the 
accident,  the  hmb  is  placed  on  a  back-splint  and  kept  cool  by  ice  or 
evaporating  lotion,  until  the  fluid  has  been  absorbed  ;  or  the  joint 
may  be  aspirated  in  order  to  hasten  matters.  The  plaster  is  then 
applied,  and  the  same  routine 
followed. 

Another  method  consists  in 
applying  a  large  piece  of  mole- 
skin plaster  over  the  front  and 
sides  of  the  extensor  surface  of 
the  thigh,  reaching  half-way  up 
to  the  groin,  and  terminating 
below  in  two  lateral  elongated 
ends  or  tags,  to  which  elastic 
traction  is  applied.  The  limb 
is  placed  on  a  back-splint,  with 
a  foot-piece,  beneath  which  the 
elastic  accumulator  is  firmly 
tied.  Removal  of  the  effusion 
in  the  joint  may  be  hastened 
by  the  use  of  the  aspirator.  At 
the  end  of  about  six  weeks  the 
patient  is  allowed  to  get  about 
in  a  plaster  of  Paris  casing,  and 
then,  about  three  months  after 
the  accident,  a  special  knee- 
splint  is  substituted  (Fig.  243), 
which  allows  of  only  a  small 
amount  of  mobility  at  first  but, 
by  filing  away  a  stop,  this  can 
be  gradually  increased,  until  a 
full  range  of  movement  is  per- 
mitted. It  is  probable  that  only 
fibrous  union  is  obtained  by  this 
method  of  treatment,  but  this  is 
satisfactory  and  strong  enough 
if  the  patient  can  give  the  time 
to  insure  its  solidification.    The 


Fig.  243. — Splint  for  Fractured 
Patella.  * 
This  splint  is  intended  for  use  after  fibrous 
union  of  the  upper  and  lower  fragments. 
The  steel  joints  at  the  sides  are  so  made 
that  the  degree  of  flexion  can  be  gradu- 
ally increased.  In  case  of  a  slip  the  knee 
cannot  bend  more  than  is  allowed  by 
this  adjustable  stop,  and  thus  overstretch- 
ing or  rupture  of  the  newly-formed  bond 
of  union  is  prevented.  To  assist  exten- 
sion of  the  limb,  a  strong  elastic  band 
joins  the  upper  and  low^er  part  of  the 
splint  anteriorly  ;  this  also  is  adjustable, 
and  greatly  assists  the  weakened  quad- 
riceps in  walking, 
strength  of  this  fibrous  union  is 

best  illustrated  by  the  fact  that  if  the  bone  gives  way  a  second  time, 
the  lesion  takes  place  through  the  bony,  and  not  through  the  fibrous, 
tissue.  When,  however,  the  patient  has  to  work  for  his  living,  it  is 
essential  that  repair  should  be  established  at  as  early  a  date  as 
possible,  and  this  can  only  be  ensured  by  operative  treatment. 

2.  To  avoid  the  supposed  risks  of  laying  open  the  joint,  various 
subcutaneous  operations  have  been  adopted.  Of  these  the  least  objection- 
able is  that  recommended  by  Mr.  A.  E.  Barker,  who  ties  the  frag- 

*  For  the  loan  of  this  block  we  are  indebted  tc  the  late  Mr,  T.  Hawksley,  357, 
Oxford  Street,  W, 


550 


A  MANUAL  OF  SURGERY 


ments  together  by  silver  wire  (Fig.  244).  An  opening  is  made  with 
tenotomy  knife  into  the  joint  just  below  the  lower  segment,  through 
which  any  effused  blood  or  synovia  can  be  squeezed,  and  along  which 
a  curved  hernia  needle  is  passed,  traversing  the  articulation  from 
below  upwards,  and  emerging  through  the  skin  above  the  uppei 
fragment.  A  piece  of  sterilized  silver  wire  is  then  carried  back 
under  the  bone.  The  needle  is  again  inserted  at  the  same  spot 
below,  and  carried  in  front  of  the  bone  under  the  skin,  emerging  at 
the  same  point  above.  The  upper  end  of  the  wire  is  threaded 
through  it,  and  by  this  means  brought  out  at  the  lower  opening. 
The  bone  is  thus  encircled,  and  by  tightening  and  twisting  the  wire 
the  fragments  are  brought  into  apposition.  The  ends  are  cut  off  and 
pushed  back  under  the  skin.  The  limb  is  placed  on  a  back-splint  for  a 
week  or  so,  when  passive  movement  is  commenced,  the  patient  being 


Fig.  244.  —  Barker's  Fig.  245. — Lister's  Plan  Fig.  246. — G.  G.  Hamil- 
Method  of  Subcd-  of  Suturing  Patella  ton's  Method  of 
taneous    Suture    for        by  Open  Operation.  Introducing    Silver 

Fractured  Patella.  Wire  for   Fracture 

of  Patella. 

allowed  to  walk  about  at  the  end  of  the  second  week,  and  discarding 
all  apparatus  at  the  end  of  five  weeks. 

3.  The  open  plan  of  treatment,  advocated  and  perfected  by  Lord 
Lister,  is  undoubtedly  the  best,  in  that  it  permits  of  the  removal  of 
the  tags  of  fascia  and  aponeurosis,  which  always  intervene.  It  may 
be  wise  to  delay  operation  for  a  few  days  in  order  that  the  joint  may 
recover  from  the  immediate  effects  of  the  injury. 

A  horseshoe-shaped  flap  is  usually  dissected  up,  exposing  the 
fractured  ends  of  the  bone.  All  blood-clot  is  removed,  and  the  bony 
surfaces  cleared  of  all  clot  and  fibrous  shreds,  which  are  very  often 
adherent.  Tracks  for  the  wire  sutures  are  now  made  by  a  drill, 
extending  from  the  upper  or  lower  end  through  the  centre  of  the 
bone,  so  as  to  emerge  on  the  fractured  surface  just  in  front  of  the 
articular  cartilage  (Fig.  245)  ;    should  the  drill  emerge  at  different 


INJURIES  OF  BONES— FRACTURES  551 

levels  on  the  faces  of  the  fragments,  cartilage  or  bone  must  be 
chipped  away  to  make  a  channel  in  which  the  wire  may  lie,  so  that 
the  two  fragments  are  exactly  level,  with  no  inequality  of  the  articular 
cartilage.  A  sterilized  silver  wire  of  suitable  thickness  is  then  passed  ; 
the  bones  are  brought  into  apposition,  and  the  wire  twisted  into  a  knot 
or  loop,  which  is  hammered  or  pressed  down  into  the  tendinous  or 
periosteal  tissue  over  the  upper  fragment,  so  as  to  keep  it  from 
projecting  under  the  skin  and  causing  irritation.  A  second  wire  is 
sometimes  needed  in  order  to  prevent  rotation  of  the  fragments.  The 
wound  is  closed,  and  the  limb  kept  on  a  back-splint.  In  healthy 
adults  passive  movement  may  commence  in  ten  days,  and  by  the  end 
of  a  fortnight  the  patient  is  allowed  to  walk  in  the  simpler  cases  ;  but 
in  complicated  fractures  and  in  elderly  people  it  is  better  to  keep  the 
limb  immobihzed  for  a  longer  period. 

It  is  sometimes  wise  to  pass  the  wire  transversely  through  the 
fragments  (Fig.  246)  as  suggested  by  Mr.  G.  G.  Hamilton,  of  Liver- 
pool, a  firmer  and  more  secure  hold  being  obtained  in  that  way,  and 
the  wire  being  less  likely  to  cut  out. 

In  old  cases,  where  the  fibrous  union  has  stretched  and  the  utility  of 
the  limb  is  seriously  impaired,  operation  holds  out  the  only  hope  of 
helping  the  patient.  The  fibrous  tissue  must  be  dissected  away,  and 
the  surfaces  of  the  fragments  freshened,  if  need  be,  with  the  saw, 
and  drilled  for  the  passage  of  the  wire.  To  obtain  apposition,  the 
upper  fragment  must  be  detached  from  the  femur,  to  which  it  is  often 
adherent,  and  the  rectus  muscle,  which  is  secondarily  contracted,  may 
need  partial  division.  The  limb  should  be  well  raised  to  relax  the 
quadriceps  and  thus  diminish  tension  on  the  bond  of  union,  and 
lowered  inch  by  inch  on  succeeding  days.  The  muscle  is  thus 
stretched  to  accommodate  itself  to  the  altered  conditions. 

If  the  fragments  cannot  be  brought  absolutely  together,  the  same 
treatment  may  be  adopted,  and  the  patient  allowed  to  get  about  with 
a  loop  of  silver  wire  between  the  fragments ;  the  quadriceps  is 
stretched  by  this  means,  and  a  subsequent  operation  may  prove 
successful  in  gaining  bony  union. 

Fractures  of  the  Leg. 

Fractures  of  the  Tibia  alone. — Several  varieties  are  described. 
(a)  The  upper  end  is  usually  broken  as  a  result  of  direct  violence,  the 
fracture  being  often  comminuted.  The  characteristic  features  are 
not  always  very  evident  at  first,  since  considerable  swelling  and 
ecchymosis  are  produced.  Occasionally  as  a  result  of  falls  on  the  heel 
a  T-shaped  fracture  occurs,  the  tuberosities  being  broken  off  and  the 
upper  end  of  the  shaft  impacted  into  one  or  both  of  them.  A  few 
cases  of  vertical  separation  of  one  of  the  tuberosities  alone  are  also 
on  record.  Treatment  consists  in  placing  the  limb  upon  a  back-splint, 
e.g.,  Macintyre's,  with  the  knee  bent,  and,  as  a  rule,  satisfactory  union 
ensues,  though  possibly  with  some  distortion,  (b)  Fracture  of  the 
shaft  of  the  tibia,  apart  from  the  fibula,  is  usually  caused  by  direct 
violence.     It  is  transverse  in  the  upper  part  of  the  bone,  and  oblique 


552  A  MANUAL  OF  SURGERY 

below.  The  fracture  is  diagnosed  by  feeling  an  inequality  on 
running  the  fingers  along  the  shin,  together  with  pain  at  this  spot 
on  firmly  grasping  the  bones  above  and  below.  There  is  often 
but  little  displacement,  since  the  fibula  acts  as  a  splint,  but 
the  lower  end  of  the  upper  fragment,  which  is  usually  pointed,  is 
tilted  forwards  by  the  action  of  the  quadriceps  and  may  pierce  the 
skin.  The  Treatment  consists  in  the  application  of  back  or  side 
splints  (Cline's)  for  a  few  days  until  the  swelling  has  gone  down, 
and  then  the  limb  may  be  put  up  in  plaster.  If  the  bone  has  been 
comminuted,  treatment  will  be  more  protracted.  In  some  few  cases 
reposition  may  be  difficult  owing  to  the  character  of  the  lesion,  and 
operation  will  then  be  required.  Thus  in  the  patient  whose  fracture 
is  represented  in  Fig.  178,  although  the  limb  had  been  immo- 
bilized in  plaster  of  Paris,  the  fragments  were  not  in  apposition, 
and  operative  treatment  was  required,  {c)  The  internal  malleolus  is 
occasionally  separated  as  the  result  of  direct  injury,  apart  from 
any  other  osseous  lesions,  constituting  what  is  known  as  *  Wag- 
staffe's  fracture.'  There  is  comparatively  little  displacement,  but 
the  malleolus  is  loose,  and  crepitus  can  usually  be  obtained  on 
moving  it  backwards  and  forwards.  Union  by  fibrous  or  osseous 
tissue  ensues,  but  usually  in  a  more  or  less  abnormal  position,  in 
consequence  of  which  the  integrity  of  the  ankle-joint  is  disturbed, 
and  weakness  or  lameness  may  follow.  Treatment  consists  in 
securing  the  fragment  into  position  by  screw  or  nail ;  otherwise 
massage  and  the  application  of  lateral  splints  must  be  relied  on. 

Schlatter's  Disease. — This  term  is  applied  to  an  affection  of  the  upper  end  of 
the  tibia  in  young  people,  the  nature  of  which  is  a  little  doubtful.  Probably  it 
is  due  to  a  partial  separation  of  the  lower  tongue-shaped  prolongation  of  the 
upper  epiphysis,  which  forms  the  tubercle  of  the  tibia,  and  this  is  followed  by  a 
subacute  inflammation.  The  child  complains  of  a  tender  swelling  in  this  region 
without  any  affection  of  the  joint,  and  walks  with  a  limp.  The  part  requires  to 
be  kept  at  rest,  and  will  in  time  get  well.  Radiography  suggests  a  displacement 
forwards  of  the  epiphysis,  but  operative  treatment  is  not  desirable. 

Fractures  of  the  Fibula  alone  are  by  no  means  uncommon,  usually 
occurring  as  a  result  of  direct  violence.  There  is  no  displacement 
or  deformity,  but  the  patient  complains  of  pain  localized  to  some 
particular  spot,  and  this  can  usually  be  elicited  by  grasping  the  bones 
above  and  below,  and  compressing  them  laterally  ('springing'  the 
fibula).  Skiagraphy  will  make  the  diagnosis  clear.  Treatment 
consists  in  immobilizing  the  limb  in  a  plaster  case. 

Fracture  of  both  Tibia  and  Fibula  is  a  very  common  accident,  due 
to  both  direct  and  indirect  violence ;  if  to  direct  violence,  any  part 
may  be  injured,  both  bones  yielding  at  the  same  level ;  but  if  in 
consequence  of  an  indirect  injury,  the  tibia  usually  gives  way  at  its 
weakest  part,  viz.,  at  the  junction  of  its  middle  and  lower  thirds,  and 
the  fibula  at  a  slightly  higher  level.  The  fractures  are  often  oblique, 
running  in  any  direction  according  to  the  character  of  the  violence, 
although  the  obliquity  is  most  frequently  directed  downwards,  for- 
wards, and  inwards.    The  lower  fragment  is  generally  drawn  upwards 


INJURIES  OF  BONES— FRACTURES  555 

on  account  of  the  contraction  of  the  powerful  calf  muscles,  and  often 
rotated  outwards  from  the  weight  of  the  foot ;  hence  there  is  well- 
marked  shortening,  which  can  usually  be  overcome  by  traction. 
The  ordinary  characteristics  of  a  fracture  are  very  evident,  and  but 
little  difficulty  can  ever  be  experienced  in  making  a  diagnosis.  The 
fracture  is  likely  to  become  compound  when  due  to  indirect  violence, 
owing  to  the  sharp  end  of  the  upper  fragment  of  the  tibia  piercing 
the  skin. 

The  fracture  of  the  tibia  has  been  proved  by  skiagraphy  to  be 
frequently  of  a  spiral  character,  and  is  then  probably  always  due  as 
much  to  forcible  torsion  of  the  limb  as  to  vertical  strain.  The 
rotation  is  a  very  important  element  in  these  cases,  and  the  shorten- 
ing is  sometimes  less  marked  than  in  simple  oblique  fractures ;  there 
is  frequently  some  difficulty  in  getting  satisfactory  approximation  of 
the  fragments,  even  after  freeing  the  ends  of  the  tibia  by  operation, 
owing  to  the  broken  ends  becoming  engaged  in  the  fibro-muscular 
tissues  around. 

Treatment. — In  the  simpler  cases  reduction  is  accomplished  by 
flexing  and  fixing  the  knee,  so  as  to  relax  the  muscles  of  the  calf, 
and  then  making  traction  on  the  foot  and  manipulating  the  parts 
into  position.  The  tendo  Achillis  may,  if  necessary,  be  divided.  It 
will  usually  suffice  to  put  up  the  limb  in  a  pair  of  side-splints,  such 
as  Cline's,  the  longer  one  with  the  foot-piece  being  intended  for  the 
outer  side.  In  other  cases  it  may  be  better  to  apply  a  broad  posterior 
splint  with  a  rectangular  foot-piece,  e.g.,  Macintyre's,  and  two  lateral 
splints ;  or  the  old-fashioned  half-box  splint  may  be  employed. 
Some  surgeons  recommend  an  anterior  ware  splint,  extending  from 
above  the  knee  to  the  foot,  the  leg  being  subsequently  slung  in  the 
flexed  position.  This  may  be  advantageously  modified  by  combining 
it  with  an  additional  casing  of  plaster  of  Paris.  Whatever  treatment 
is  adopted,  it  is  necessary  to  see  that  the  length  of  the  limb  is  as  far 
as  possible  maintained,  and  that  no  rotation  of  the  lov/er  fragment  is 
present.  To  insure  absence  of  rotation,  all  that  is  needed  is  to  note 
that  the  inner  aspect  of  the  great  toe,  the  subcutaneous  surface  of 
the  internal  malleolus,  and  the  inner  border  of  the  patella,  are  in  the 
same  line,  and  correspond  with  the  opposite  limb.  Union  will  be 
sufficiently  advanced  in  two  or  three  weeks  at  the  latest  to  allow  of 
the  limb  being  put  up  in  a  removeable  plaster  casing,  which  must  be 
taken  off  daily  for  purposes  of  massage,  but  in  spite  of  this  much 
subsequent  lameness  is  the  usual  result.  In  oblique  and  spiral 
fractures  there  is  often  very  great  difficulty  in  getting  the  fragments 
together,  and  even  more  in  maintaining  them  in  good  position. 
Taking  into  consideration  the  degree  of  permanent  depreciation  that 
a  man  (especially  if  of  the  labouring  classes)  suffers  from  vicious 
union  of  these  bones,  surgeons  should  now  have  no  hesitation  in 
cutting  down  on  and  fixing  any  fracture  of  the  tibia  and  fibula  which 
is  determined  by  skiagraphy  to  be  oblique  or  spiral  in  nature  and 
with  well-marked  displacement. 

Fractures  in  the  neighlDourhood  of  the  Ankle-joint  are  usually  pro- 


5S6  A  MANUAL  OF  SURGERY 

duced  by  indirect  violence,  the  foot  slipping,  and  leading  primarily 
to  a  displacement  of  the  ankle,  the  fracture  being  a  secondary  result. 
They  would  therefore  be  better  described  as  Fracture- dislocations  at 
tlie  Ankle-joint. 

I.  Displacement  of  the  Foot  outwards  is  by  far  the  most  common 
variety,  resulting  usually  from  the  patient  slipping  on  the  inside  of 
the  foot,  as  from  off  a  kerbstone.  Several  distinct  varieties  of  lesion 
are  now  recognised. 

(a)  In  Pott's  Fracture  (Fig.  249)  sudden  abduction,  usually  com- 
bined with  eversion,  of  the  foot  results  in  severe  strain  upon  the 
internal  lateral  ligament,  which  gives  way,  or  the  base  of  the  internal 
malleolus  is  torn  off.  The  astragalus  is  at  the  same  time  driven 
outwards  against  the  external  malleolus,  and  the  force  is  thence 
transferred  up  the  fibula,  which  bends  and  breaks  at  some 
weak  spot.  Generally  the  line  of  fracture  runs  obliquely  from 
above  downwards  and  forwards  through  the  malleolus  ;  less 
frequently  it  is  situated  in  the  position  originally  described  by 
Pott,  viz.,  about  three  inches  above  the  tip  of  the  malleolus,  and  is 
transverse,  the  upper  end  of  the  lower  fragment  being  displaced 
inwards  towards  the  tibia.  The  inferior  interosseous  tibio-fibular 
ligament  remains  intact,  and  hence  the  foot  itself  is  merely  rotated 
outwards  and  abducted,  and  the  heel  is  drawn  upwards,  whilst  the 
toes  point  downwards.  If  the  internal  lateral  ligament  alone  is 
torn,  the  malleolus  projects  beneath  the  skin,  and  may,  indeed, 
protrude  through  it ;  there  is  always  much  bruising  and  ecchymosis 
on  the  inner  side  of  the  ankle.  If  the  malleolus  itself  is  broken  off,  a 
distinct  sulcus  can  usually  be  felt  between  it  and  the  lower  end  of 
the  tibial  shaft.  In  both  these  types  the  ankle-joint  is  necessarily 
laid  open,  and  there  is  probably  much  haemorrhage  into  neighbouring 
tendon  sheaths. 

{b)  In  Ditpuytren's  Fracture  (Fig,  250)  a  much  more  serious  lesion 
is  produced.  The  interosseous  tibio-fibular  ligament  yields  more 
or  less  completely,  or  the  flake  of  the  tibia  to  which  it  is  attached  is 
torn  off;  the  foot,  carrying  with  it  the  lower  portion  of  the  fibula 
and  the  superficial  flake  of  the  tibia,  which  has  been  detached,  is 
displaced  firstly  outwards,  and  so  long  as  the  upper  surface  of  the 
astragalus  does  not  clear  the  lower  articular  surface  of  the  tibia, 
there  is  merely  lateral  displacement  with  marked  abduction  of  the 
foot  and  increased  breadth  of  the  ankle.  Should  the  force  continue 
to  act,  the  astragalus  may  be  carried  sufficiently  outwards  to  clear 
the  lower  end  of  the  tibia,  and  then  an  upward  and  to  a  less  degree  a 
backward  displacement  is  added,  causing  great  eversion  of  the  foot 
and  deformity  of  the  ankle.  On  the  inner  side  either  the  ligament 
or  the  malleolus  may  yield. 

(c)  In  another  variety  the  injury  consists  in  the  usual  type  of 
fracture  of  the  fibula,  associated  with  an  almost  transverse  fracture 
of  the  tibia,  just  above  the  base  of  the  inner  malleolus.  In  this  form 
the  lower  end  of  the  shaft  of  the  tibia  projects  beneath  the  skin,  and 
is  likely  to  be  mistaken  for  the  tip  of  the  malleolus ;  if  this  error  is 


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INJURIES  OF  BONE'S— FRACTURES 


559 


committed,  and  the  fracture  allowed  to  unite  without  proper  rectifi- 
cation, considerable  deformity  results.  In  rare  instances,  the  lower 
end  of  the  tibia  may  project  through  the  skin,  thus  rendering  the 
fracture  compound. 

(d)  A  similar  injury  in  children  may  produce  a  separation  of  the 
lower  epiphysis  of  the  tibia,  whilst  the  fibula  yields  in  the  usual 
situation.  The  line  of  separation  in  the  tibia  is  more  or  less  trans- 
verse, but  may  extend  into  the  diaphysis  on  the  outer  side. 

In  almost  all  of  these  varieties  the  ankle-joint  itself  is  opened,  and 
this,  combined  with  the  amount  of  bleeding  that  occurs  into  tendon 
sheaths  and  muscles  around,  and  the  difficulties  often  associated  with 
fixation  of  the  fragments,  explains  why  the  results  of  these  cases  are 
frequently  so  unsatisfactory.  Should  union  occur  with  the  foot  in  a 
false  {i.e.,  everted)  position,  a  large  mass  of  callus  develops  between 
the  shaft  of  the  tibia  and  the  malleolus. 

2.  Displacement  of  the  Foot  inwards. — When  the  patient  slips  on  the 
outer  aspect  of  the  foot,  the  astragalus  is  forcibly  driven  against  the 
inner  malleolus,  which  may  be  broken  off"  or  impacted  into  it.  The 
outer  malleolus  is  dragged  inwards  with  the  foot,  and  owing  to  the 


Fig.  251. — Dupuytren's  Splint  applied  for  Pott's  Fracture.     (Tillmanns.) 

Integrity  of  the  inferior  tibio-fibular  ligament,  which  acts  as  a  fulcrum, 
the  fibula  yields  at  the  same  spot  as  in  Pott's  fracture.  The  foot  is 
displaced  inwards,  and  perhaps  slightly  backwards. 

3.  Displacement  of  the  Foot  backwards,  by  catching  the  heel  and 
tripping  forwards,  is  usually  associated  with  fractures  of  the  tibia 
and  fibula  in  the  same  position  as  in  Pott's  fracture,  but  eversion  of 
the  foot  is  absent  (see  dislocation  of  the  ankle  backwards,  p.  639). 

Treatment. —  In  reducing  these  fractures,  traction  should  be  made 
upon  the  foot  after  the  tension  of  the  calf  muscles  has  been  relieved 
by  flexing  the  knee  under  an  anaesthetic,  or  by  tenotomy  of  the  tendo 
Achillis  ;  the  position  of  the  internal  malleolus  must  be  accurately 
defined.  Before  applying  the  splints,  careful  attention  must  be  given 
to  the  following  points  :  {a)  The  foot  must  be  maintained  at  right 
angles  to  the  leg ;  {b)  the  heel  must  not  project  unduly  backwards ; 
and  (c)  the  foot  must  not  be  rotated  on  the  leg — i.e.,  the  inner 
surfaces  of  the  great  toe,  internal  malleolus,  and  patella  must  be  in 
the  same  line.  A  pair  of  Cline's  splints  is  often  sufficient  to  steady 
the  parts  in  simple  cases,  and  must  be  applied  with  sufficient  firm- 
ness to  keep  the  malleoli  together  and  prevent  subsequent  lateral 
play  in  the  ankle-joint.     Some  patients  are  better  treated,  however. 


S5o  A  MANUAL  OF  SVkGERV 

by  a  Dupuytren's  splint  (Fig.  251),  which  is  really  a  Listen's  splint 
on  a  small  scale.  It  reaches  from  the  knee  to  below  the  sole  of  the 
foot,  and  is  placed  on  the  inner  side  of  the  limb,  the  patient  lying  on 
the  sound  side  during  its  application.  A  firm  pad  extends  down  as 
far  as  the  base  of  the  internal  malleolus,  and  over  this  as  a  fulcrum 
the  foot  is  drawn  inwards  by  a  handkerchief  applied  around  the  ankle, 
and  tied  to  the  notches  at  the  end  of  the  splint.  The  foot  being  thus 
fixed,  the  upper  end  of  the  splint  is  bandaged  to  the  limb.  Marked 
tendency  to  backward  displacement  of  the  heel  may  be  counteracted 
by  the  application  of  a  Syme's  anterior  horseshoe  splint,  which  can 
be  used  in  combination  with  a  Dupuytren.  It  consists  of  a  flat  piece 
of  wood,  well  padded,  extending  from  the  knee  to  the  ankle  along  the 
crest  of  the  tibia ;  the  lower  end  is  shaped  like  a  horseshoe,  the  two 
hmbs  passing  one  on  either  side  of  the  foot.  A  handkerchief  or 
piece  of  bandage  is^ applied,  with  its  centre  over  the  point  of  the 
heel;  it  passes  up  on  either  side  between  the  splint  and  the  foot, 
winds  over  the  former  structure,  and  is  tied  behind  the  heel,  which 
is  thus  lifted  forwards.  A  similar  end  may  be  obtained  by  the  use 
of  a  Macintyre's  back  splint  combined  with  a  pair  of  Cline's  splints. 
As  soon  as  possible,  the  limb  should  be  put  up  in  water-glass  or 
plaster  of  Paris. 

In  the  simpler  forms,  early  massage  may  be  employed,  and  then 
all  the  retentive  apparatus  necessary  is  some  adhesive  plaster 
applied  so  as  to  cover  in  and  encase  the  foot  and  ankle.  In  the 
more  difficult  cases,  where  there  is  considerable  displacement  and 
much  difficulty  in  keeping  the  fragments  together,  operation  to  fix 
them  is  quite  justifiable. 

In  cases  of  vicious  union  after  Pott's  fracture,  it  is  usually 
necessary  to  re- divide  the  fibula,  and  to  excise  a  V-shaped  portion  of 
bone  from  the  tibia  extending  into  the  ankle-joint,  so  as  to  enable 
the  malleolus  to  be  brought  in  contact  with  the  shaft. 

Fracture  of  the  Os  Calcis  may  result  from  direct  violence,  such  as 
a  blow  or  fall  on  the  heel,  or  possibly  from  muscular  action,  the 
epiphysis  being  then  separated,  or  the  shell  of  bone  into  which  the 
tendo  Achillis  is  inserted  being  torn  off.  The  fragment  thus 
separated  is  displaced  upwards  by  the  contraction  of  the  calf 
muscles,  and  the  resulting  deformity  is  very  evident.  If  the  line  of 
fracture  passes  through  the  body  of  the  bone  there  may  be  no  dis- 
placement, owing  to  the  attachment  of  the  interosseous  and  lateral 
ligaments  ;  but  should  the  sustentaculum  tali  or  greater  process  be 
broken,  the  arch  of  the  foot  may  be  more  or  less  flattened.  When 
due  to  a  fall  from  a  height,  the  bone  is  often  comminuted  and  the  foot 
much  bruised  and  swollen  [compression  fraciure).  Treatment  consists 
in  immobilizing  the  foot  in  a  plaster  case  if  there  is  no  displacement ; 
but  where  the  posterior  part  of  the  bone  is  drawn  upwards,  it  must 
be  approximated  to  the  rest  of  the  bone  after  flexing  the  leg,  in  order 
to  relax  the  calf  muscles,  or  possibly  after  tenotomy.  A  more  satis- 
factory result  may,  however,  be  obtained  by  cutting  down,  and  wiring 
or  pegging.     In  fractures  which  are  likely  to  be  followed  by  traumatic 


INJURIES  OF  BONES—FRACTURES  561 

flatfoot,  the  patient  must  not  be  allowed  to  walk  without  an  effective 
metal  instep  support. 

Fracture  of  the  Astragalus  is  usually  due  to  falls  on  the  foot  from 
a  height,  or  from  direct  violence  applied  to  the  foot,  as  by  a  weight 
falling  upon  it.  The  lesion  is  often  a  severe  comminuted  one,  and 
portions  of  the  bone  may  be  displaced  forwards  or  backwards, 
making  a  marked  projection  beneath  the  skin.  Such  accidents  are 
often  associated  with  lesions  of  the  tibia  or  fibula,  and  possibly  even 
of  the  femur.  The  whole  region  of  the  ankle  becomes  infiltrated 
with  blood,  and  an  exact  diagnosis  is  sometimes  difficult.  Treatment 
consists  either  in  immobilization,  which  is  likely  to  be  followed  by 
stiffness  of  the  ankle,  or  in  bad  cases  by  excision  of  the  bone  or  of 
projecting  fragments. 

Occasionally  in  less  severe  accidents  the  bone  merely  splits  across, 
the  lesion  being  usually  situated  about  the  neck.  Such  is  due  either 
to  the  weight  of  the  body  flattening  out  the  arch  of  the  bone  beyond 
the  limits  of  elasticity,  or,  if  the  foot  is  dorsi-flexed,  to  penetration  of 
the  bone  by  the  anterior  edge  of  the  tibia,  impaction  being  sometimes 
produced  in  this  way.  Massage  and  early  mobilization  should  be 
employed  in  such  cases. 

Other  bones  of  the  foot  are  occasionally  fractured,  but  these 
lesions  require  no  detailed  description. 


36 


CHAPTER  XX. 
DISEASES    OF    BONE. 

Inflammation  of  Bone. 

General  Considerations. — Bones  are  divided  into  the  long,  the  short, 
and  the  flat,  each  of  these  consisting  of  compact  and  cancellous  tissue. 
In  the  short  bones  there  is  but  a  thin  layer  of  compact  tissue  sur- 
rounding a  cancellous  central  mass,  the  meshes  of  which  are  filled 
with  medullary  fat  and  connective  tissue.  In  the  flat  bones  the 
compact  tissue  forms  two  limiting  plates,  separated  by  a  layer  of 
cancellous  tissue  (known  in  the  skull  as  the  diploe).  In  long  bones 
the  shaft  consists  of  a  tube  of  compact  structure,  surrounding  a 
space  which  is  normally  filled  with  medulla,  and  known  as  the 
medullary  canal ;  at  each  end  it  gradually  merges  into  a  larger  mass 
of  loose  cancellous  tissue,  the  interstices  of  which  are  similarly  packed 
with  vascular  fatty  medulla,  which  apparently  performs  the  function 
not  only  of  maintaining  the  nutrition  of  the  bone,  but  also  of  elabo- 
rating the  blood.  Prolongations  from  the  medulla  extend  into  the 
Haversian  canals,  and  are  thence  continuous  with  the  periosteum,  so 
that  the  mineral  skeleton  has  incorporated  within  it  a  vascular  fibro- 
cellular  mass  which  permeates  its  whole  structure. 

The  vascular  supply  of  a  bone  is  derived  {a)  from  the  nutrient  artery 
which  passes  into  the  medullary  space,  and  there  breaks  up  into 
branches  which  ramify  through  the  whole  of  the  medullary  tissue, 
and  thence  extend  into  the  Haversian  canals ;  and  {h)  from  the  peri- 
osteum, an  exceedingly  vascular  ensheathing  membrane,  from  which 
small  vessels  pass  perpendicularly  into  the  Haversian  canals,  and 
establish  a  communication  between  the  two  systems.  These  latter 
vessels  are  especially  numerous  and  large  close  to  the  epiphyses. 
Large  veins  occur  in  the  medullary  and  cancellous  interior,  and  are 
frequently  thrombosed  in  inflammatory  mischief;  if  the  thrombus 
becomes  infected,  and  so  disintegrated,  pyaemia  is  very  likely  to  ensue. 

The  growth  of  bone  manifests  itself  in  three  different  directions: 
(i.)  It  increases  in  length  from  the  shaft  side  of  the  epiphyseal  cartil- 
age, the  epiphysis  itself  growing  but  little.  In  the  upper  limb  the 
chief  increase  in  length  occurs  at  the  shoulder  and  wrist,  whilst  in  the 
leg  it  is  mainly  evident  on  either  side  of  the  knee-joint,  and  this  in  spite 
of  the  fact  that  the  so-called  nutrient  arteries  are  directed  away  from 


DISEASES  OF  BONE  563 

these  points,  (ii.)  Increase  in  breadth  is  produced  by  new  formation 
under  the  periosteum.  There  is  some  difference  of  opinion  as  to 
whether  this  membrane  has  any  true  bone-forming  power.  That 
bone  is  formed  from  it  when  stripped  up  is  undoubted;  but  it  is 
possible  that  the  angular  nucleated  osteoblasts  found  on  its  under 
surface  have  been  derived  from  the  bone  itself  by  the  process  of 
detachment,  which  necessarily  tears  through  or  drags  out  the  vessels 
which  pass  from  the  periosteum  into  the  bone,  (iii.)  A  bone  increases 
in  density  by  a  new  deposit  of  osseous  tissue  around  the  Haversian 
canals  and  cancellous  spaces. 

In  considering  the  inflammatory  affections  of  bones,  it  must  always 
be  kept  in  mind  that  the  essential  pathological  phenomena  (viz., 
hyperaemia,  exudation,  and  tissue  changes,  active  or  passive)  are 
similar  to  those  manifested  in  any  other  vascular  structure,  but  that 
the  resulting  effects  are  modified  by  the  limited  space  in  which  the 
vessels  lie,  and  the  resisting  character  of  the  surrounding  osseous 
tissue.  Hence  any  acute  inflammation,  associated  with  rapid  vascular 
engorgement  and  considerable  exudation  quickly  poured  out,  leads  to 
necrosis  from  thrombosis,  due  to  increased  pressure  within  the  un- 
yielding bony  canals.  If,  however,  the  process  is  subacute,  so  that  the 
tissue-liquefying  properties  of  the  exudation  and  the  tissue-absorbing 
activity  of  the  leucocytes  can  come  into  play,  then  osteo-powsis  or  rare- 
faction of  the  bone  follows,  a  condition  sometimes  termed  caries.  On 
the  other  hand,  if  the  inflammation  is  chronic,  and  due  to  causes  other 
than  tubercle  or  the  pressure  of  tumours,  then  new  formation  occurs, 
and  osteosclerosis,  or  condensation,  is  most  likely  to  result.  Tubercle 
in  bones,  as  elsewhere,  causes  primary  rarefaction  of  the  tissue 
attacked,  though  sclerosis  may  be  associated  with  or  follow  it,  and 
the  chronic  pressure  of  tumours  or  aneurisms  leads  to  local  rare- 
faction and  atrophy,  although  a  certain  amount  of  sclerosis  may  be 
induced  around. 

Much  needless  confusion  has  arisen  in  connection  with  the  termi- 
nology of  inflammatory  affections  of  bone.  To  all  of  them,  whatever 
their  nature  or  position,  the  term  '  osteitis  '  might  rightly  be  applied  ; 
but  when  the  medullary  cavity  of  a  long  bone  is  particularly  affected, 
the  term  '  osteo-myelitis '  is  substituted,  as  also  sometimes  when 
masses  of  cancellous  tissue,  as  in  the  os  calcis,  or  sheets  of  it,  as  in 
the  diploe  of  the  cranial  bones,  become  the  seat  of  an  acute  inflamma- 
tion. The  vascular  continuity  between  the  periosteum  and  medulla 
through  the  Haversian  canals  will  explain  why  a  periostitis  is  always 
associated  with  osteitis  of  the  underlying  bone,  and  why  an  osteo- 
myelitis is  never  strictly  limited  to  the  medullary  cavity. 

It  is  also  important  to  realize  that  necrosis,  caries,  and  sclerosis 
are  results  of  inflammation,  and  must  neither  be  confounded  with 
the  pathological  processes  leading  to  them,  nor  described  as  distinct 
diseases. 

Necrosis,  or  death  of  bone,  may  occur  in  a  variety  of  forms,  and 
from  many  different  causes,  e.g. :  (a)  From  acute  localized  suppura- 
tive periostitis,  the  sequestrum  or  dead  mass  being  then  simply  a 


'5G4  A  MANUAL  OF  SURGERY 

superficial  plate  or  flake  of  the  compact  exterior  (Fig^.  252)  ;  (b)  from 
I  acute  infective  osteo-myelitis,  the  sequestrum  then  often  involving 
the  whole  thickness  of  the  bone,  and  invading  more  or  less  of  the 
length  of  the  diaphysis,  if  the  condition  is  not  early  and  efficiently 
treated  (Figs.  254  and  255) ;  (c)  from  acute  or  subacute  infective  osteitis 
of  cancellous  bone,  the  sequestra  being  small  spiculated  fragments  of 
the  bony  cancelli  which  have  escaped  al)sorption  by  the  granulation 
tissue  always  forming  in  such  a  process  ;  (d)  from  tuberculous  disease 
of  cancellous  tissue,  the  sequestrum  being  light  and  porous,  often 
infiltrated  with  curdy  material,  and  rarely  separated  completely  from 
surrounding  parts  (Fig.  262) ;  (e)  from  syphilitic  disease  of  cancellous 
>or  compact  tissue,  usually  resulting  from  excessive  sclerosis,  or  gum- 
matous disease  of  the  periosteum  which  has  become  septic  (Fig.  265); 
{/}  from  the  action  of  local  irritants,  e.g.,  mercury,  or  phosphorus 
fumes  gaining  access  to  the  interior  of  the  teeth  ;  (g)  occasionally  as 
a  simple  senile  loss  of  nutrition,  as  in  senile  gangrene ;  and  (h)  a 
variety,  described  by  Sir  James  Paget  under  the  name  of  '  quiet 
necrosis,'  occurs  as  a  result  of  direct  injury,  the  sequestrum  separat- 
ing without  suppuration  ;  it  is  one  &f  the  causes  of  loose  bodies  in 
joints,  and  especially  the  knee,  following  a  blow  on  one  of  the  condyles. 

The  presence  of  dead  bone  in  a  limb  may  be  suspected  when  one 
or  more  sinuses  are  present,  discharging  pus  or  serum  according  to 
circumstances,  with  puffy  granulations  pouting  round  the  opening, 
and  the  underlying  bone  thick  and  enlarged.  A  probe  passed  down 
the  sinus  can  usually  be  made  to  strike  against  the  sequestrum, 
perhaps  after  passing  through  a  casing  of  new  bone,  and  its  fixity  or 
freedom  may  be  demonstrated  in  this  manner. 

The  separation  of  sequestra  is  always  brought  about  by  a  process 
analogous  to  that  by  means  of  which  sloughs  and  gangrenous  materials 
are  cast  off  from  the  body,  viz.,  by  complete  absorption  if  small, 
aseptic,  and  surrounded  by  sufficiently  vascular  tissue  ;  by  absorption 
of  as  much  as  possible,  in  larger  aseptic  masses,  granulation  tissue 
invading  and  replacing  the  dead  mass,  and  a  line  of  separation  form- 
ing as  a  result  of  defective  nutrition  of  the  most  advanced  layer ;  or, 
if  septic,  an  active  rarefying  inflammation  occurs  in  the  neighbouring 
living  tissue,  which  in  time  breaks  down,  and  so  sets  free  the  dead 
mass.  (See  in  more  detail  at  p.  loi .)  From  the  eroding  action  of  the 
granulation  tissue,  the  detached  surface  of  the  sequestrum  is  always 
hollowed  out,  and,  as  it  were,  worm-eaten  in  appearance  (Fig.  256.) 
Where  sepsis  is  present,  the  process  is  more  active,  and  is  completed 
more  rapidly,  though  with  greater  risk  to  the  patient. 

Caries,  or,  as  it  is  sometimes  called,  osteo-porosis  or  rarefaction  of  bone, 
is  a  clinical  condition  resulting  from  inflammation,  and  consisting  in 
a  soft  and  spongy  state  of  the  bone,  which,  if  it  can  be  reached, 
readily  breaks  down  on  pressure  with  a  probe.  It  may  result  from 
the  following  conditions  :  {a)  A  simple  subacute  inflammatory  process, 
■e.g.,  during  the  early  stage  of  repair  in  a  fracture  ;  (b)  from  acute 
or  subacute  septic  or  infective  inflammation  of  cancellous  tissue ; 
(c)  from  tuberculous  affections  of  the  cancellous  tissue  or  periosteum  ; 


■~-    DISEASES  OF  BONE  565 

(d)  from  syphilitic  disease  of  the  medulla  or  of  the  under  surface  of 
the  periosteum. 

Pathologically,  it  is  characterized  by  the  replacement  of  the 
medulla  by  granulation  tissue,  which  usually  contains  some  large 
multi-nucleated  cells,  or  osteoclasts,  and  these  seem  to  be  closely  con- 
nected with  the  removal  of  the  bone.  The  cancellous  tissue  becomes 
hollowed  out  to  accommodate  these  granulations,  and  the  osteoclasts 
are  usually  found  occupying  shallow  depressions  known  as  '  How- 
ship's  lacunae.'  In  tuberculous  and  syphilitic  lesions  the  bone  cor- 
puscles often  undergo  fatty  degeneration. 

Caries  may  occur  with  or  without  suppuration  (C.  sicca  or  suppura- 
tiva) ;  sometimes  the  development  of  granulation  tissue  is  excessive, 
as  when  it  fungates  from  the  articular  end  of  a  bone  into  a  joint 
(C.  fungosa).  Not  unfrequently  it  is  associated  with  necrosis,  con- 
stituting a  condition  of  curio-necrosis  (or  C.  necrotica),  as  in  septic 
inflammation  of  cancellous  bone,  minute  spiculated  sequestra  being 
found  in  the  discharge,  whilst  in  tuberculous  osteitis  dead  portions  of 
larger  size  often  occur.  In  fact,  caries  and  necrosis  bear  much  the 
same  relation  to  one  another  as  ulceration  and  gangrene  of  the  soft 
tissues. 

If  caries  is  recovered  from,  a  subsequent  condition  of  sclerosis 
usually  follows,  with  loss  of  substance  and  often  deformity. 

Sclerosis  of  bone  (osteo- sclerosis)  is  invariably  the  result  of  some 
chronic  inflammatory  affection,  e.g.,  (a)  chronic  periostitis,  whether 
simple  or  syphilitic ;  (b)  chronic  osteo-myelitis,  simple,  tuberculous, 
or  syphilitic;  or  (c)  chronic  osteitis  of  the  compact  bone,  which  is 
always  secondary  to  one  of  the  former.  In  all  cases  the  condition  is 
due  to  a  slow  formation  of  new  bone  within  the  Haversian  canals  or 
cancellous  spaces,  thus  diminishing  their  lumen ;  in  syphilis  this 
may  progress  to  such  an  extent  as  to  lead  to  their  total  occlusion, 
and  even  to  localized  necrosis  from  lack  of  blood-supply,  especially 
when  sepsis  has  occurred.  In  tuberculous  bones  the  sclerosed  tissue 
is  always  at  some  distance  from  the  focus  of  mischief,  and  may  be 
looked  on  as  Nature's  attempt  to  limit  the  spread  of  the  disease ;  it 
forms  also  the  final  tissue  or  bone-scar  in  the  process  of  repair  in  those 
cases  where  a  cure  has  been  obtained  by  natural  or  surgical  means. 

Classification  of  InflLammatory  Affections  of  Bone. 

I.  Periostitis: 

(a)  Acute  localized,  with  or  without  suppuration. 

(b)  Acute  diffuse,  always  associated  with  or  secondary  to  acute 

mfective  osteo-myelitis. 

(c)  Chronic  simple,  or  hyperplastic. 

(d)  Chronic  tuberculous. 

(e)  Chronic  syphilitic. 

II.  Osteitis  of  compact  "bone,  which  is  always  associated  with  and 
secondary  to  either  periostitis  or  osteo-myelitis,  and  so 
need  not  be  described    separately.     The  acute  form 


566  A  MANUAL  OF  SURGERY 

results  in  necrosis,  the  subacute  in  osteo- porosis,  and 
the  chronic  in  sclerosis,  except  in  tuberculous  disease. 

III.  Osteo  myelitis,  or  inflammation  of  the  medulla  of  long  bones  : 

(a)  Acute  infective. 

(b)  Subacute  simple  or  infective,  e.g.,  during  the  separation 

of  sequestra,   resulting   primarily   in    rarefaction,  but 
finally  in  sclerosis. 

(c)  Chronic  simple,  tuberculous  or  syphilitic,  usually  causing 

general  enlargement  and  sclerosis  of  the  bone,  even  if 
locally  some  rarefaction  is  present. 

IV.  Osteitis  of  Cancellous  Tissue  may  similarly  be : 

(a)  Acute  infective. 

(b)  Subacute  simple  or  infective. 

(c)  Chronic  simple,  syphilitic,  or  tuberculous. 

When  limited  to  the  articular  end  of  a  bone  in  a  young  person, 
this  is  sometimes  termed  Epiphysitis. 

It  is  unnecessary  to  describe  in  detail  all  these  conditions,  since 
many  of  the  divisions  overlap,  and  hence  we  shall  group  together 
the  various  acute  and  chronic  affections. 

Acute  Inflammations  of  Bone. 

I.  Acute  Localized  Periostitis  usually  arises  as  a  result  of  trauma- 
tism applied  directly  to  the  bone,  with  or  without  an  open  wound ;  it 
may  also  be  determined  by  rheumatism,  or  by  an  extension  of  in- 
flammatory mischief,  as  in  an  alveolar  abscess. 

Pathologically,  the  process  consists  of  hyperaemia  of  and  exudation 
into  the  periosteum,  which  becomes  swollen,  turgid,  and  thickened. 
This  may  be  followed  in  due  course  by  resolution,  or  may  leave  the 
bone  thickened  and  in  a  condition  of  chronic  inflammation  ;  or  sup- 
puration may  ensue,  and  with  it  usually  a  limited  superficial  necrosis. 
In  the  last  event  pyogenic  organisms  of  no  great  virulence  find  an 
entrance  to  the  area  of  mischief,  and  probably  in  cases  due  to  trauma 
through  the  abraded  or  injured  skin  ;  in  other  instances  they  may 
come  from  neighbouring  foci  of  inflammation,  or  possibly  auto- 
infection  may  occur.  The  inflammatory  process  extends  to  the  small 
vessels  entering  the  bone  from  the  under  surface  of  the  periosteum  ; 
these  become  dilated,  next  thrombosed  and  strangled  by  the  pressure 
of  the  exudation  around  them,  and  finally  pulled  out  from  the  osseous 
canals  by  the  tension  of  the  subperiosteal  effusion.  Consequently, 
the  vitality  of  the  superficial  layer  of  bone  is  destroyed  for  an  area 
corresponding  almost  exactly  to  that  from  which  the  periosteum  has 
been  stripped  (Fig.  252,  A). 

As  soon  as  tension  has  been  relieved  by  the  escape  of  the  pus, 
repair  commences.  Where  the  mischief  is  slight  and  superficial, 
the  involved  bone  may  entirely  recover,  necrotic  portions  being 
absorbed,  if  the  surrounding  parts  are  sufficiently  vascular.  If  the 
dead  portion  of  bone  is  compact  and  more  extensive,  it  will  be 
separated  from  the  subjacent  living  tissues  by  one  of  the  processes 


DISEASES  OF  BONE 


567 


already  described  (p.  loi),  whilst  from  the  under  surface  of  the 
stripped-up  periosteum  a  casing  of  new  bone  is  developed,  constituting 
an  invohicnim  or  sheath,  at  first  spongy  and  cancellous  in  texture, 
but  finally  hard  and  sclerosed.  In  the  centre  of  this  new  formation 
are  found  one  or  more  openings  or  cloaca  through  which  the  dis- 
charge passes,  and  corresponding  in  position  to  the  apertures  in  the 
periosteum  and  skin  made  for  the  escape  of  the  pus  (Fig.  252,  B). 

Clinically,  the  symptoms  of  acute  localized  periostitis  consist  in  the 
ordinary  phenomena  of  acute  inflammation,  the  pain  being  of  an 
intense  aching  character,  worse  at  night,  and  increased  by  lowering 
the  limb  or  by  any  kind  of  pressure.     If  a  subcutaneous  portion  of 


Fig.  252. — Superficial  Necrosis  resulting   from  a  Localized  Periostitis 

(Diagrammatic). 

A  represents  the  necrosed  tissue  lying  in  continuity  with  the  surrounding  living 
bone  ;  the  periosteum  is  stripped  up  from  it,  and  has  an  opening  through 
which  the  pus  has  been  discharged.  B  shows  a  later  stage,  in  which  the 
sequestrum  is  being  separated  by  a  process  of  rarefying  osteitis  in  the 
immediately  contiguous  living  bone,  whilst  an  involucrum,  or  sheath  of 
new  bone,  is  formed  from  the  under  surface  of  the  periosteum  ;  a  cloacal 
aperture  remains  in  the  involucrum  for  the  escape  of  discharges.  C  shows 
the  condition  of  affairs  after  the  sequestrum  has  been  removed. 

bone  is  involved,  a  painful  swelling  develops,  at  first  brawny  in 
character,  but  when  suppuration  has  occurred  the  centre  softens, 
whilst  the  skin  over  it  becomes  red  and  oedematous.  When  an 
abscess  has  burst  or  been  opened,  bare  bone  is  felt  beneath  the 
periosteum,  and  the  greater  part  of  this  denuded  structure  usually 
dies,  and  must  then  be  either  absorbed  or  separated ;  in  either  case  a 
sinus  remains  for  a  time,  leading  down  through  a  cloaca  in  the  involu- 
crum to  the  sequestral  cavity.  From  this  either  pus  or  serum  will 
be  discharged,  according  to  whether  the  wound  has  become  septic  or 
not.  In  about  five  or  six  weeks'  time  the  sequestrum  is  loose,  and 
this  may  be  ascertained  by  moving  it  with  a  probe  within  the  osseous 
cavity,  which  is  now  lined  on  the  inner  aspect  with  granulation  tisstie. 
Treatment. — Rest,  elevation  of  the  limb,  and  fomentations  are 
usually  relied  on  locally  in  the  early  stages,  and  favourable  reports 
have  been  given  as  to  the  value  of  Bier's  induced  hyperaemia.     If, 


S6b  A  MANUAL  OP  SURGERY 

however,  the  affection  is  not  readily  checked,  and  suppuration 
threatens  or  develops,  a  free  aseptic  incision  down  to  the  bone  is  the 
best  means  of  preventing  or  limiting  necrosis.  When  necrosis  has 
occurred,  the  parts  must  be  carefully  dressed  and  kept  aseptic,  until 
the  sequestrum  is  absorbed  or  set  loose.  In  .  the  latter  case  an 
incision  is  made  over  the  involucrum,  the  periosteum  stripped  from 
it,  one  of  the  cloacae  enlarged,  and  the  dead  bone  removed.  The 
cavity  will  then  rapidly  fill  up  and  heal  by  granulation. 

2.  Acute  Infective  Osteo -myelitis  (Syw. ;  Acute  Necrosis,  Acute 
Diflfuse  or  Infective  Periostitis,  Acute  Diaphysitis,  Acute  Panostitis).— 
This  disease  usually  occurs  in  children,  often  of  a  tuberculous  inheri- 
tance, and  not  unfrequently  follows  one  of  the  exanthemata — e.g., 
measles  or  scarlet  fever.  It  generally  commences  before  the  age  of 
puberty,  and  is  an  affection  of  the  gravest  import ;  the  multiplicity 
of  names  attached  to  it  suggests  quite  accurately  that  its  manifesta- 
tions may  be  very  diverse  in  character. 

Pathology.— The  patients  are  always  in  a  state  of  depressed  general 
health,  so  that  their  germicidal  powers  are  considerably  diminished. 
Moreover,  spots  of  localized  ulceration  are  often  present  in  the  throat, 
mouth,  or  intestines,  which  give  a  ready  entrance  for  micro-organisms 
into  the  system.  Evidently  some  of  these  must  be  circulating  within 
the  blood,  ready  to  attack  any  area  of  diminished  tissue  resistance. 
A  slight  injury  in  the  shape  of  a  strain  or  a  wrench,  which  is  often 
entirely  overlooked  or  forgotten,  may  suffice  to  determine  the  com- 
mencement of  an  inflammatory  process  which  rapidly  spreads  by 
continuity  of  tissue,  until  perhaps  the  whole  structure  of  the  bone 
may  be  affected. 

The  majority  of  the  ligaments  and  not  a  few  tendons  are  inserted 
into  the  epiphysis,  and  hence  articular  strain  must  be  mainly  felt  in 
the  juxta-epiphyseal  region,  i.e.,  immediately  beyond  these  insertions. 
It  has  been  already  mentioned  that  the  traumatic  separation  of 
epiphyses  is  liable  to  be  followed  by  suppuration,  even  in  healthy 
children,  and  it  is  easy  to  understand  that  in  an  unhealthy  child  a 
very  slight  injury  in  the  epiphyseal  region  may  determine  a  similar 
process. 

The  disease  almost  always  starts  in  the  soft  vascular  tissue  on  the 
shaft  side  of  the  epiphyseal  cartilage,  but  occasionally  it  commences 
in  the  epiphysis  itself  at  the  margin  of  the  ossifying  centre,  and  in  a 
few  instances  (mainly  amongst  young  adults)  it  may  be  preceded  by 
a  patch  of  localized  periostitis,  suggesting  that  an  acute  infection 
has  supervened  upon  a  subacute  periosteal  focus.  The  bacteria, 
once  admitted,  multiply  rapidly,  and  give  rise  to  inflammatory 
phenomena,  the  nature  and  extent  of  which  depend  largely  on  the 
exact  situation  of  the  infective  focus,  the  amount  of  resistance  offered 
by  surrounding  tissues,  and  the  virulence  of  the  organisms.  As  in 
any  other  part  of  the  body,  the  trouble  is  most  likely  to  travel  along 
the  line  of  least  resistance. 

I.  If  the  process  commences  in  the  periphery  of  the  juxta-epiphy- 
seal region  close  to  the  periosteum,  the  line  of  least  resistance  will 


DISEASES  OF  BONE 


S6g 


be  towards  that  structure,  and  hence  a  subperiosteal  abscess  may  form, 
whilst  the  central  portions  of  the  bone  may  escape  almost  entirely. 
The  size  of  this  abscess  varies,  but  considerable  portions  of  the 
diaphysis  may  be  denuded,  resulting  in  extensive  necrosis.  It  rarely 
spreads  to  the  neighbouring  joint,  owing  to  the  close  bond  of 
union  which  exists  between  the  diaphyseal  periosteum  and  the 
epiphyseal  cartilage.  In  this  variety  an  early  incision  to  let  out 
the  pus  may  suffice  to  prevent  necrosis, 
or,  at  any  rate,  to  limit  it.  The  con- 
stitutional symptoms  will  be  less 
severe  than  in  other  varieties ;  there 
is  less  likelihood  of  the  development 
of  pyaemia,  and  the  toxic  fever  soon 
disappears  after  the  removal  of  the 
pus.  Subsequently  the  same  course 
of  events  occurs  as  in  the  localized 
variety  of  acute  periostitis  —  viz.,  an 
involucrum  forms,  perforated  by  one 
or  more  cloacae,  and  the  sequestrum 
in  time  separates. 

A  good  illustration  of  this  type  is 
to  be  found  in  the  acute  periostitis 
which  affects  the  lower  end  of  the  femur. 
It  almost  always  starts  posteriorly, 
stripping  the  thin  periosteum  off  the 
back  of  the  bone  as  far  as  the  bifurca- 
tion of  the  linea  aspera.  Its  prefer- 
ence for  this  situation  is  evidently  due 
to  the  fact  that  strains  upon  the  knee- 
joint  are  mainly  experienced  when  the 
limb  is  hyper-extended,  and  that  such 
strain  is  directed  to  the  posterior  liga- 
ments, and  hence  the  posterior  portion 
of  the  epiphyseal  line  is  likely  to  suffer. 
Suppuration  follows,  and  if  not  recog- 
nised and  treated  early,  may  burst 
through  the  thin  periosteum  and  be 
widely  diffused  under  the  quadriceps. 
The  involucrum  in  this  affection  is 
often   defective  behind.      Removal  of 

the  sequestrum  is  also  difficult  from  anatomical  reasons,  and  hence 
amputation  is  sometimes  required. 

2.  Should  the  process  start  in  the  centre  of  the  juxta-epiphyseal  region, 
it  may  spread  in  several  directions,  and  the  results  vary  considerably. 

(a)  The  process  may  reach  the  per-iosteum  first,  and  then  the 
phenomena  of  a  diffuse  subperiosteal  abscess,  as  indicated  above, 
with  the  addition  of  the  symptoms  due  to  its  deeper  origin,  will 
manifest  themselves.  This  is,  perhaps,  the  most  usual  course  for 
the  disease  to  take. 


• \ 

Fig.  253.  —  Acute  Osteo- 
myelitis OF  THE  Lower  End 
OF  THE  Femur  in  a  Child 
OF  Nine  Weeks.  (After 
Lexer.) 

IC,  Internal  condyle  ;  K,  centre 
of  ossification  in  epiphysis; 
A,  abscess  cavity  in  epiphyseal 
line;  S,  sequestrum;  I,  in- 
volucrum. 


S7o  A  MANVALOF  SURGERY 

(b)  If  the  infection  extends  along  the  medullary  cavity,  the  most 
typical  form  of  osteo-myelitis  ensues  (Fig.  253).  The  medulla 
becomes  intensely  hyperaemic ;  the  veins  are  thrombosed  ;  localized 
foci  of  suppuration  and  gangrene  appear  ;  and  in  consequence  of  the 
increased  pressure  infective  emboli  are  likely  to  be  detached  and 
pyaemia  to  follow.  Even  if  the  latter  does  not  supervene,  the  general 
condition  is  profoundly  affected  by  the  absorption  of  toxins.  Sup- 
puration also  occurs  beneath  the  periosteum,  although  the  amount 
of  pus  may  not  be  great  at  first ;  but  the  membrane  is  stripped  up 
from  the  diaphysis,  perhaps  to  such  an  extent  as  to  involve  the 
whole  length  and  circumference  of  the  shaft.  Unless  prompt 
measures  are  taken  to  limit  the  progress  of  the  disease,  necrosis  is 
certain  to  follow,  usually  implicating  the  whole  thickness  of  the 
diaphysis,  and  sometimes  its  whole  length.  In  fact,  the  diaphysis 
is  occasionally  found  lying  loose  in  an  abscess  cavity,  the  two 
epiphyses  having  been  detached. 

(c)  It  has  been  already  mentioned  that,  owing  to  the  intimate 
connection  between  the  periosteum  of  the  diaphysis  and  the 
epiphyseal  cartilage,  the  neighbouring  joint  usually  escapes  infection. 
Should,  however,  the  epiphyseal  line  be  within  the  joint,  as  in  the 
hip,  it  must  perforce  become  the  seat  of  an  acute  infective  arthritis 
as  soon  as  the  bacteria  reach  its  periphery.  The  elbow-joint  is 
similarly  liable  to  suffer  when  bacteria  attack  the  upper  end  of  the 
ulna,  since  the  epiphysis  is  a  mere  flake  of  bone,  and  the  greater 
part  of  the  olecranon  is  derived  from  the  shaft.  Sometimes  the 
junction  cartilage  is  softened  and  destroyed  by  the  organisms,  so  that 
the  inflammation  spreads  through  the  epiphysis  to  the  articular 
cartilage,  which  is  eroded,  and  the  joint  opened.  Occasionally  the 
pus  burrows  along  the  soft  tissues  outside  the  bone,  as  along  the 
biceps  groove  into  the  shoulder-joint. 

In  infants,  where  there  is  little  or  no  bone,  the  cartilage  may  be 
rapidly  destroyed,  and  an  opening  made  through  it  into  the  joint, 
giving  rise  to  what  was  described  by  Sir  Thomas  Smith  as  the  acute 
arthritis  of  infants. 

(d)  When  the  organisms  are  of  a  less  virulent  type,  the  process 
may  be  much  more  localized  and  subacute  in  nature,  resulting  in  a 
limited  central  necrosis,  or  in  a  chronic  abscess  inside  the  bone  if  the 
part  involved  consists  01  a  mass  of  cancellous  tissue,  as  in  the  head 
of  the  tibia.  A  similar  condition  may  affect  certain  epiphyses  which 
occur  away  from  joints,  and  some  chronic  abscesses  in  such  situa- 
tions as  the  great  trochanter  may  be  explained  on  these  grounds. 
An  occasional  result  of  a  subacute  non-suppurative  osteo-myelitis  is 
bending  of  the  affected  bone,  especially  if  the  patient  is  able  to  put 
any  pressure  or  weight  on  it. 

The  organism  generally  found  in  this  disease  is  the  Staphylococcus 
pyogenes  aureus,  but  occasionally  others  are  responsible  for  it,  and  the 
symptoms  vary  somewhat  with  the  causative  microbe.  Thus,  if  due 
to  the  Staph,  pyog.  alhus,  the  process  is  less  acute ;  a  good  deal  of 
brawny  infiltration  of  the  periosteum  ensues,  and  necrosis  is  more 


DISEASES  OF  BONE 


s:i 


easily  prevented  by  early  treatment;  tt.is  variety  is  sometimes 
termed  '  periostitis  albuminosa.'  The  Streptococcus  pyogenes,  if  present 
at  all,  is  only  found  in  young  children,  and  the  resulting  necrosis  is 
often  less  extensive.  The  Pneumococcus  has  also  been  frequently 
discovered  in  this  disease  in  children,  as  well  as  the  B.  colt,  which 
latter  only  occurs  in  association  with  other  organisms ;  the  resulting 
pus  is  very  foul. 


B 


Fig. 


254- 


-Diagram  of  Massive  Necrosis  after  Acute  Osteo-myelitis. 
(Billroth.) 

In  A  (early)  the  necrosed  tissue,  though  continuous  above  and  below  with  the 
healthy  bone,  is  surrounded  by  a  cavity  formed  by  the  stripping  up  of  the 
periosteum,  and  from  it  two  sinuses  pass  to  the  exterior  ;  in  B  (late)  the 
sequestrum  is  supposed  to  have  been  loosened  and  removed,  and  the  cavity 
remaining  is  lined  by  granulation  tissue,  and  surrounded  by  a  thick  in- 
volucrum  of  new  bone,  in  which  the  two  cloacae  still  persist. 


Clinical  History. — The  disease  usually  commences  abruptly  with  a 
rigor,  followed  by  high  fever  and  severe  pain  in  the  limb,  which  soon 
becomes  swollen,  brawny,  and  congested.  It  may  at  first  be  mis- 
taken for  an  acute  attack  of  rheumatism,  although  the  fact  that  the 
interarticular  portion  is  affected,  and  not  the  articulation,  should 
readily  prevent  this  error.  The  pain  is  of  an  extremely  severe 
nature,  so  that  the  child  screams  whenever  the  limb  or  even  the  bed 
is  touched. 

Should  the  trouble  be  mainly  limited  to  the  periosteum,  evidences 


57^ 


A  MANUAL  OF  SURG^R^ 


of  its  being  stripped  off  the  bone,  and  of  the  accumulation  of 
pus  beneath  it,  soon  show  themselves.  An  abscess  forms  which 
may  quickly  transgress  its  periosteal  boundary  and  burrow  under 
fascial  or  muscular  planes ;  its  limitation  to  the  diaphysis  has  been 

_. ,— -*.  already  explained  ;   but,  although  the  neigh- 

'a  bouring   joints    may   escape    infection,   they 

W  are  very  likely  to  suffer  from  a  serous  exuda- 

^  tion,    and    subsequently   some   restriction    of 

\  movement    may    be    observed.      Sooner    or 

later  the  abscess  bursts  or  is  opened,  giving 
exit  to  a  larger  or  smaller  quantity  of  pus, 
and  the  subjacent  bone  is  found  bare  and 
apparently  dead.  Possibly  the  relief  of  tension 
may  suffice  in  such  cases  to  limit  the  mischief, 
the  periosteum  again  becoming  adherent  to 
the  bone,  and  a  cure  being  estabUshed  without 
extensive  necrosis.  More  frequently  a  con- 
siderable portion  of  the  shaft  loses  its  vitality, 
and  has  to  be  separated  in  the  manner  already 
described,  whilst  an  involucrum  forms  around 
it  from  the  periosteum  (Figs.  254  and  255). 
If  a  mixed  infection  has  not  occurred,  no 
fever  or  bad  constitutional  symptoms  need  be 
expected  during  this  later  stage.  Sometimes 
the  process  is  so  acute  as  to  cause  actual 
sloughing  or  disintegration  of  the  periosteum, 
so  that  the  involucrum  does  not  develop,  and 
subsequent  repair  becomes  difficult  or  impos- 
sible. 

When  the  medulla  itself  is  more  especially 
involved,  the  symptoms  of  pyaemia  or  of 
severe  toxaemia  become  very  prominent,  and 
the  child  may  die  from  this  cause  before  the 
local  mischief  has  been  able  to  advance  very 
considerably.  The  pain  will  continue  to  be 
of  a  severe  character,  although  the  patient's 
perceptions  may  be  so  blunted  by  the  toxic 
condition  that  he  becomes  more  or  less  un- 
conscious. The  swelling  of  the  limb  is  not 
so  great  as  in  the  former  type,  but  the  mis- 
chief may  be  very  extensive,  and  although 
there  is  no  great  collection  of  pus  beneath  the 
periosteum,  yet  it  may  be  stripped  up  along 
the  whole  length  of  the  shaft,  and  even  de- 
tached from  the  epiphysis  at  each  end.  Should  the  child  not  die  of 
toxaemia,  extensive  destruction  of  bone  is  certain  to  result. 

In  infants  and  very  young  children,  especially  if  the  subjects  of 
inherited  syphilis,  the  disease  early  spreads  through  the  epiphysis  to 
the   neighbouring  joint,  and   the   symptoms  of   acute    suppurative 


Fig.  255. — Necrosis  fol- 
lowing Acute  Osteo- 
myelitis. (From  Speci- 
men IN  College  of 
Surgeons'  Museum.) 

The  irregular  new  bone 
of  the  involucrum  is 
well  seen,  and  within 
it  portions  of  the 
questrum. 


se- 


DISEASES  OF  BONE  573 

arthritis  supervene.  The  head  of  the  humerus  and  the  upper  and 
lower  ends  of  the  femur  are  the  parts  most  commonly  involved  in 
this  way.  In  some  of  these  cases  the  ligaments  are  so  seriously 
weakened  and  relaxed  that  a  loose  flail-joint  results. 

In  the  milder  types  of  osteo-myelitis,  the  patients  complain  of  severe 
pain  in  one  of  the  bones  (one  type  of  'growing  pain  '),  and  this  may 
be  attended  by  some  degree  of  fever  and  of  local  disability.  The 
symptoms  may  quiet  down  after  a  time  and  no  harm  result,  but 
in  some  cases  the  growth  of  the  bone  will  be  checked  or  entirely 
stopped.  In  other  patients  a  subacute  or  chronic  abscess  may  form 
and  perhaps  come  to  the  surface  at  a  later  date,  and  on  opening  it  a 
sinus  is  found  leading  to  the  interior  of  the  bone,  in  which  a  seques- 
trum of  cancellous  tissue  is  found.  In  such  a  case  the  surrounding 
bone  may  at  first  be  rarefied  to  such  an  extent  as  to  bend  under  the 
weight  of  the  body,  but  in  the  later  stages  is  certain  to  be  much 
thickened  and  very  sclerosed. 

The  Prognosis  of  the  acute  form  is  always  grave.  Life  may  be 
threatened  by  pyaemia  or  toxaemia  in  the  early  stages,  whilst  later  on 
hectic  fever,  amyloid  disease,  and  exhaustion,  may  terminate  the  case 
if  a  mixed  infection  has  occurred. 

The  utility  of  the  limb  may  be  unimpaired  if  the  disease  has  not 
been  too  extensive,  and  if  prompt  treatment  has  been  adopted ;  but 
if  life  is  threatened  by  toxaemia,  or  if  neighbouring  joints  suppurate, 
or  if  the  osteogenetic  powers  of  the  periosteum  have  been  destroyed 
by  the  acuteness  of  the  process,  amputation  may  be  required.  In 
cases  which  have  recovered,  excessive  growth  of  the  bones  sometimes 
follows,  owing  to  the  long-standing  hyperaemia  of  the  part ;  but  if  the 
epiphyseal  cartilage  has  been  much  affected  the  limb  may  be  stunted 
in  its  subsequent  development. 

Treatment.— Prompt  surgical  interference  must  be  adopted  in  order, 
if  possible,  to  cut  short  the  malady.  As  soon  as  the  local  pain  and 
high  fever  give  evii^.ence  that  this  affection  is  present,  a  free  incision 
should  be  made  in  the  long  axis  of  the  Hmb  through  the  periosteum, 
whether  pus  can  be  detected  or  not.  The  surgeon  will  then  proceed 
to  investigate  carefully  the  condition  of  the  bones  by  inspection  and 
the  use  of  the  finger  and  probe.  As  a  rule,  he  will  find  himself  in 
the  neighbourhood  of  the  epiphyseal  cartilage,  and  if  the  case  has 
been  taken  in  hand  early,  it  is  possible  that  the  mischief  will  be  quite 
limited  ;  all  that  is  then  required  is  to  scrape  or  gouge  away  the 
softened  and  hyperasmic  bone  at  the  end  of  the  diaphysis,  together 
with  any  necrotic  tissue  which  may  be  present,  taking  the  greatest 
care  not  to  perforate  the  epiphyseal  cartilage.  The  cavity  thus 
formed  is  douched  with  an  antiseptic ;  a  drainage-tube  or  gauze 
packing  is  inserted,  and  in  all  probability  recovery  will  rapidly  ensue. 

If  the  case  has  gone  further,  the  periosteum  will  be  found  stripped 
from  the  bone  for  a  varying  distance,  although  but  little  pus  may  be 
present  beneath  it.  Under  these  circumstances  it  is  always  necessary 
to  open  up  by  gouge,  drill,  or  cutting-pliers  the  medullary  canal,  so 
as  to  allow  pus  to  escape  and  the  hyperaemic  and  gangrenous  fatty 


574  A  MANUAL  OF  SURGERY 

tissue  contained  therein  to  be  scraped  out.  If  this  proceeding  involves 
a  considerable  portion  of  the  shaft,  it  may  be  possible  to  leave  bridges 
of  compact  tissue  here  and  there,  scraping  out  the  medullary  cavity 
beneath  them.  When  grave  constitutional  phenomena  are  present, 
associated  with  loosening  of  the  epiphysis,  it  will  often  be  found 
expedient  to  amputate  in  order  to  prevent  death  from  toxaemia. 

If  the  periosteum  has  been  more  extensively  involved,  a  large 
amount  of  bone,  possibly  the  whole  diaphysis,  is  denuded,  and 
perhaps  both  epiphyses  are  loosened.  The  dead  diaphysis  should  be 
removed  at  once  if  the  leg  or  fore-arm  is  involved,  as  there  is  always 
a  second  bone  to  maintain  the  length  of  the  limb  ;  but  for  the  femur 
and  humerus  sequestrotomy  should  be  delayed — immediate  removal 
would  lead  to  hopeless  shortening  and  crippling  of  the  limb. 

When  it  is  probable  that  the  medulla  is  not  much  involved,  the 
pus  is  given  a  free  exit  through  an  incision,  the  cavity  is  irrigated, 
and  the  stripped -up  periosteum  allowed  to  fall  back  upon  the  bone, 
■and  regain  adhesions  to  it,  if  possible.  Drainage  is  provided  for,  strict 
asepsis  maintained,  and  the  discharge  soon  becomes  merely  serous. 
A  portion  of  the  bone  dies,  and  during  its  separation  from  neighbour- 
ing parts  becomes  encased  in  a  newly-formed  involucrum.  When  the 
sequestrum  is  free — that  is,  in  about  five  or  six  weeks — sequestrotomy 
will  be  required  ;  it  consists  in  reflecting  the  periosteum  from  the 
new  casing,  and  in  enlarging  or  uniting  one  or  more  of  the  cloacae, 
so  as  to  allow  the  sequestrum  to  be  withdrawn.  The  cavity  thus 
left  is  drained  or  packed  with  gauze,  so  as  to  allow  it  to  heal  from 
the  bottom  by  granulation.  Occasionally  the  operation  for  removal 
of  the  sequestrum  is  difficult  and  dangerous,  owing  to  the  situation 
of  the  sinuses,  and  in  some  places — e.g.,  the  posterior  aspect  of  the 
lower  end  of  the  femur— it  is  almost  impracticable  to  reach  it ;  under 
such  circumstances  amputation  may  be  preferable.  This  summary 
proceeding  may  also  be  needed  in  the  course  of  this  disease  on 
account  of  pyaemia,  defective  repair,  exhaustion  from  chronic  sepsis, 
or  suppuration  in  a  neighbouring  joint. 

3.  The  Acute  Traumatic  Osteo- myelitis  which  arises  as  a  result  of 
infection  from  without,  e.g.,  in  cases  of  compound  fractures,  and  after 
amputation,  excision,  or  even  osteotomy,  requires  a  separate  de- 
scription. The  clinical  history  of  a  case  involving  the  shaft  of  a 
long  bone  is  as  follows  :  The  patient  during  an  attack  of  septic 
traumatic  fever  due  to  an  injury  or  operation  has  one  or  more 
rigors,  which  suggest  the  existence  of  pyaemia,  and  is  suddenly 
seized  with  severe  pain  in  the  limb,  which  becomes  intensely 
sensitive.  On  examining  the  wound,  the  soft  parts  are  found  to  be 
unhealthy  and  infiltrated,  the  lower  end  of  the  bone  is  bare  and 
yellow,  and  from  the  interior  a  stinking  mass  of  gangrenous 
medullary  tissue  sometimes  protrudes.  Should  early  and  efficient 
treatment  not  be  undertaken,  the  patient  runs  a  considerable  risk  of 
succumbing  to  acute  pyaemia  or  toxaemia,  whilst  a  varying 
amount  of  the  interior  of  the  bone  dies  {central  or  tubular  necrosis), 
and  a  small  segment  of  its   whole   thickness   below,    so    that    the 


DISEASES  OF  BONE 


575 


sequestrum  which  ultimately  separates  is  annular  and  conical 
(Fig.  256).  Should  the  patient  survive,  the  necrotic  tissue  gradually 
separates,  and  during  this  process  a  mass  of  new  bone  is  formed 
from  the  under  surface  of  the  periosteum,  so  that  the  shaft  becomes 
much  thickened  externally.  In  the  slighter  cases  a  mass  of  granula- 
tions projects  from  the  medullary  cavity  of  the  divided  end  of  the 
bone,  and  in  this  there  may  be  a  newly-formed  bony  substratum, 

Treatmeut. — The  wound  is  thoroughly  opened  up  as  early  as  pos- 
sible, flushed  out,  and  the  sloughing  medullary  tissue  scraped  from 
the  interior  of  the  bone,  which  is  subsequently 
disinfected  with  pure  carbolic  acid,  a  drainage-  \ 

tube  or  gauze  wick  being  placed  in  it  for  a  |\ 

few    days.      A    certain    amount    of    necrosis  ti  > 

follows,  but  without  high  fever  or  toxaemia. 
Should  this  treatment  fail,  amputation  will  be 
required. 

A  similar  process  may  also  invade  the  short 
bones,  and  the  cancellous  extremities  of  long 
bones,  being  often  secondary  to  acute  infective 
arthritis,  or  to  a  compound  fracture  involving 
such  parts.  The  local  and  general  phenomena 
are  very  similar  to  those  detailed  above,  except  j^j  1^/ 

that  no  large  sequestra  are  formed,  the  dead 
bone  coming  away  in  small  spicules  (one  form 
of  caries  necrotica),  whilst  the  pain  and  fever  are 
less  severe,  and  there  is  less  likelihood  of  the 
development  of  pyaemia.  Treatment  consists 
in  free  drainage,  removal  of  the  infected  tissue, 
and  efficient  purification  of  the  wound. 


Fig.  256. ^Tubular  oe 
Conical  Sequestrum 
FROM  Acute  Osteo- 
myelitis    OF    Femur 

AFTER    AMPUTA.TION. 


Typhoid  Osteitis. 

Affections  of  the  osseous  system  are  not  uncommon 
in  typhoid  fever,  and  usually  come  on  about  the  third 
week  or  during  the  early  stages  of  convalescence.  The 
tibia  and  ribs  are  most  often  affected,  and  in  a  large 
percentage  of  cases  typhoid  bacilli,  with  or  without 
pyogenic  cocci,  will  be  found.  It  is  curious  to  note 
how  long  the  organisms  may  lie  latent  in  the  tissues 
before  causing  an  abscess — in  one  case  (Sultan's)  for 
six  years.  The  trouble  commences  either  as  a  periostitis  or  osteo-myelitis,  sub- 
acute in  character,  often  improving  for  a  time,  and  then  relapsing.  It  often 
develops  an  abscess,  and  then  some  amount  of  necrosis  or  caries  may  follow ; 
thus  in  a  case  operated  on  by  one  of  us  a  considerable  sequestrum  was  re- 
moved from  the  upper  third  of  the  femur,  whilst  in  the  opposite  leg  there 
had  been  an  abscess  in  a  similar  position,  but  without  death  of  bone.  The 
abscess  is  generally  subacute  or  chronic,  and  the  affected  bone  may  be  carious 
rather  than  necrotic.  On  its  first  appearance  the  affected  limb  should  be 
elevated  and  fomented,  and  frequently  the  more  acute  symptoms  will  yield  ; 
but  the  part  often  remains  enlarged,  swollen,  and  tender,  a-nd  exacerbations 
of  pain  are  not  unlikely  to  develop  from  time  to  time,  sooner  or  later  leading 
up  to  the  formation  of  an  abscess.  When  suppuration  has  occurred,  the 
parts  must  be  freely  incised,  diseased  bone  removed,  granulation  tissue  scraped 


576 


A  MANUAL  OF  SURGERY 


away,  and  the  parts  disinfected  with  liquefied  carbolic  acid.  The  wounds  are 
usually  found  to  be  extremely  chronic  and  indolent,  and  may  require  scraping 
several  times. 

Chronic  Inflammation  of  Bone. 

Cliroiiic  Osteo-periostitis. — -By  this  disease  is  meant  a  chronic 
inflammatory  condition  of  the  bone,  which 
results  in  overgrowth,  thickening,  and  con- 
densation. 

Varieties. — [a)  It  may  arise  as  a  localized 
chronic  periostitis,  traumatic,  toxic,  rheumatic, 
or  syphiUtic  in  origin,  or  due  to  the  close 
proximity  of  a  chronic  ulcer ;  it  is  characterized 
by  a  formation  of  new  bone  beneath  the  peri- 
osteum, the  so-called  node  (Fig.  257).  The 
cancelli  are  arranged  at  right  angles  to  the 
surface,  in  consequence  of  the  new  tissue 
forming  around  the  small  vessels,  which  enter 
the  bone  from  the  under  surface  of  the  peri- 
osteum. At  first  this  new  material  is  soft 
and  spongy,  but  it  rapidly  becomes  hard  and 
sclerosed,  and  a  similar  condition  affects  the 
subjacent  compact  structure,  which  is  thickened 
and  indurated  by  a  new  formation  around  the 
Haversian  canals.  If  the  irritation  persists, 
as  in  the  case  of  a  chronic  ulcer,  this  condition 
may  run  on  into  the  following  variety. 

(b)  The  diffuse  form  of  chronic  osteo-peri- 
ostitis usually  originates  in  some  deep-seated 
or  central  affection,  tuberculous  or  syphilitic 
in  nature,  and  tends  to  involve  the  whole 
bone,  although  it  is  sometimes  limited  to  one 
or  other  end.  If  tuberculous,  there  may  be  a 
small  abscess  or  some  central  necrosis,  and 
around  this  focus  of  prolonged  irritation  the 
bone  becomes  thick  and  indurated.  In  the 
later  stages  a  considerable  new  formation 
may  occur  beneath  the  periosteum,  and  the 
medullary  canal  become  entirely  obliterated 
(Fig.  261).  If  syphilitic  in  origin,  it  may  be 
due  to  a  central  gumma,  or  to  a  general  condi- 
tion of  sclerosis,  developing  without  any 
localized  focus. 

The  Symptoms  consist  of  deep  aching  pain  in 
the  limb,  worse  in  bed,  with  perhaps  tender- 
ness over  some  particular  spot.  This  latter 
condition  is  especially  evident  in  cases  where 
an  encysted  abscess  exists  in  the  head  of  a 
bone,  such  as  the  tibia.     On  examination  the 


Fig.  257. — Chkonic 
osteo  -  periostitis 
^  OF  Tibia,  showing 
Fusiform  Swell- 
ing ON  THE  Front 
OF  THE   Bone,  con- 

-  sisting  of  Dense 
Osseous  Tissue, 
AND  THE  Medul- 
lary Cavity  en- 
croached upon. 
(Museum  of  Royal 
College  of  Sur- 
geons.) 


DISEASES  OF  BONE  577 

bone  is  felt  to  be  thickened,  and  its  surface  more  or  less  nodulated. 
If  the  disease  is  limited  and  superficial,  a  distinct  node  may  be  felt, 
consisting  of  a  hard,  fusiform,  and  tender  swelling.  Where  the  en- 
largement is  more  general,  there  is  less  tenderness,  though  the  pain 
is  constant. 

The  Diagnosis  of  such  cases  is  not  always  easy,  the  enlargement 
of  the  bone  being  sometimes  mistaken  for  the  early  stage  of  a  malignant 
tumour.  The  rate  of  growth  will  be  of  little  assistance,  since  it  is 
very  variable ;  but  a  tumour  may  have  more  defined  limits,  and  its 
tension  is  often  not  the  same  throughout.  Skiagraphy  is  valuable  in 
this  direction,  since  in  simple  chronic  periostitis  the  bone  is  solid  and 
throws  a  continuous  and  well-defined  shadow,  while  in  malignant 
disease  a  certain  amount  of  soft  tissue  is  always  present,  either 
centrally  or  peripherally,  easily  penetrated  by  the  rays,  and  hence 
leaving  gaps  in  the  shadow.  If,  in  spite  of  such  assistance,  the  case 
is  still  doubtful,  an  exploratory  incision  will  be  required. 

The  Treatment  at  first  consists  in  resting  the  limb,  applying  counter- 
irritation  {e.g.,  iodine  paint  or  the  actual  cautery),  and  giving  iodide  of 
potassium  internally.  If  relief  is  not  thereby  obtained,  an  operation 
will  be  necessary.  An  incision  is  made  over  the  whole  length  of  the 
thickened  bone  through  the  periosteum,  which  is  stripped  aside,  and 
if  merely  a  nodular  enlargement  is  present,  the  new  formation  is 
chiselled  away.  When  the  whole  thickness  of  the  bone  is  involved, 
a  gutter  or  trench  must  be  made  by  gouge  and  mallet,  extending  into 
the  medullary  cavity,  and  its  length  corresponding  to  the  enlarge- 
ment. The  soft  parts  are  then  loosely  drawn  together  and  the  wound 
dressed  ;  the  hollow  will  fill  with  blood-clot,  and  this  is  allowed  to 
organize  (p.  256).  If  enough  bone  has  been  removed,  most  satis- 
factory results  follow ;  but  in  some  aggravated  conditions  which  have 
lasted  for  many  years  amputation  is  required. 

Tuberculous  Diseases  of  Bone. 

Bone  may  be  affected  in  two  ways  by  tubercle,  either  the  periosteum 
or  the  cancellous  tissue  being  primarily  involved. 

I.  In  Tuberculous  Periostitis  a  specific  infiltration  of  the  perios- 
teum is  met  with,  consisting  of  a  deposit,  partly  in  that  membrane 
and  partly  under  it,  of  pulpy  granulation  tissue  containing  the 
characteristic  miliary  tubercles,  which  are  chiefly  developed  around 
the  vessels  passing  from  the  periosteum  into  the  bone.  As  in  tuber- 
culous disease  elsewhere,  caseation  and  suppuration  are  likely  to 
follow,  leading  to  the  formation  of  abscesses,  which  are  primarily 
subperiosteal  and  filled  with  curdy  pus  ;  these  in  time  find  their  way 
to  the  surface,  either  directly  or  by  more  or  less  tortuous  channels, 
and  leave  sinuses,  extending  down  to  the  bone.  The  final  effect  of 
such  a  condition  depends  largely  on  whether  the  subjacent  bone 
consists  of  thick  or  thin  compact  tissue.  If  the  compact  bone  is 
thick,  the  disease  is  usually  limited  to  the  part  first  affected,  the 
surface  of  the  bone  escaping  entirely,  except  some  slight  superficial 

37 


^7^  A  MANUAL  OF  SURGEkY 

erosion.  Occasionally,  however,  the  disease  may  spread  along  the 
periosteum,  and  involve  a  neighbouring  epiphysis  or  joint.  If  the 
compact  bone  is  thin,  as  in  the  ribs  or  bodies  of  the  vertebrae,  the 
underlying  cancellous  tissue  is  almost  certain  to  be  secondarily 
affected. 

Clinical  History. — In  the  early  stages  a  diffuse  elastic  or  pulpy 
swelling  forms  over  the  bone,  which  is  slightly  tender  on  pressure. 
It  takes  some  weeks  or  months  to  develop,  and  on  skiagraphy  the 
underlying  osseous  tissue  may  appear  quite  normal  in  texture.  In 
the  later  stages,  when  caseation  or  suppuration  is  present,  the 
swelling  often  becomes  more  defined  and  somewhat  resembles  an 
ordinary  node,  but  is  usually  more  irregular  in  shape,  of  somewhat 
unequal  consistency,  and  on  firm  pressure  small  portions  may  be 
felt  to  give  way.  If  an  abscess  forms,  the  skin  becomes  reddened, 
the  swelling  is  elastic  \.o  the  touch,  and  the  pain  greater,  but  it 
diminishes  as  soon  as  tension  is  relieved  by  discharge  of  the  pus. 
The  admission  of  pyogenic  infection,  however,  increases  the  trouble. 

Treatment. — In  the  early  stages,  constitutional  treatment  may 
suffice,  together  with  rest  and  carefully-adjusted  pressure,  as  by 
strapping  with  Scott's  dressing,  or  Bier's  induced  hyperasmia.  The 
condition,  however,  demands  incision  if  a  neighbouring  joint  is 
threatened,  or  when  suppuration  has  occurred.  Free  removal  of  all 
the  granulation  tissue  and  softened  bone  with  a  Volkmann's  spoon  is 
required,  disinfection  of  the  cavity  with  undiluted  carbolic  acid,  and 
packing  it  with  gauze  soaked  in  a  sterilized  emulsion  of  glycerine 
and  iodoform  (lo  per  cent.),  the  wound  being  allowed  to  granulate 
from  the  bottom. 

2.  Tuberculous  Osteitis  arises  m  cancellous  tissue,  and  usually  in 
the  epiphyses,  or  under  the  articular  cartilage ,  occasionally  it 
develops  in  the  medullary  cavity  as  a  chronic  osteo-myelitis. 

Pathology.— The  tubercle  bacilli  are  deposited  in  the  interior  of 
the  bone,  which  may  have  been  previously  rendered  hyperaemic 
as  the  result  of  an  injury.  The  outcome  of  this  is  the  transformation 
of  the  normal  medulla  into  pulpy  granulation  tissue  containing 
tubercles,  the  bony  cancelli  becoming  meanwhile  eroded  and  rarefied, 
and  the  bone  corpuscles  undergoing  fatty  degeneration  {vide  Caries, 
p.  564).  Sequestra  occasionally  form,  but  more  often  in  adults  than 
in  children,  owing  to  the  greater  density  of  the  bone  in  the  former. 
They  are  due  to  a  cutting-off  of  the  blood-supply  of  a  definite 
portion  of  the  bony  tissue,  either  as  a  result  of  tuberculous 
endarteritis,  or  from  earlv  caseation  within  the  cancelli  of  the  whole 
of  the  granulation  tissue.  The  sequestra  are  soft  and  friable,  usually 
yellowish-white  in  colour  from  the  presence  of  the  caseating  tissue 
in  their  substance,  and  are  seldom  completely  separated  from  the 
surrounding  bone.  When  the  tuberculous  disease  does  not  involve 
the  whole  bone,  the  nearest  healthy  tissue  may  become  sclerosed, 
and  thus  one  not  unfrequently  finds  a  central  sequestrum  surrounded 
by  rarefied  bone,  which  in  turn  is  enclosed  by  a  zone  of  sclerosed 
tissue.     Very  frequently  the  disease  extends  from  the  interior  of  the 


DISEASES  OF  BONE 


579 


bone  either  to  a  neighbouring  joint  or  to  the  periosteum,  or  possibly 

to  adjacent  tendon  sheaths,  and  external  abscesses  are  then  likely  to 

develop.     The  admission  of  pyococci   leads   to  increasing  rapidity 

of  the  destructive  process,  and  minute  spiculated   sequestra  often 

come    away   in    the    discharge. 

Skiagraphy  is  a  useful  adjunct 

in    estimating    the    amount    of 

disease   present,   since  the 

affected  bone  offers  little  or  no 

resistance    to    the    passage    of 

X  rays  (Fig.  258). 

(a)  The  short  bones  of  the  hands 
and  feet  are  very  liable  to  this 
condition  in  weakly  children 
whose  general  health  has  been 
depressed  by  one  of  the  exan- 
themata. Some  slight  injury 
may  determine  the  onset  of  the 
attack,  which  frequently  in- 
volves several  bones  simulta- 
neously. When  the  phalanges 
are  involved,  the  disease  is 
known  as  Tuberculous  Dac- 
tylitis. 

Clinical  History.  —  The  af- 
fected segment  of  the  finger 
becomes  slowly  enlarged,  bul- 
bous, and  painful,  the  pain  being, 
however,  slight  in  amount, 
though  sometimes  worse  at 
night.  At  first  the  finger  looks 
white,  and  the  skin  is  smooth 
and  shiny  ;  but  after  a  time  one 
spot  rapidly  increases  in  size, 
becoming  red  and  tender,  and 
finally  an  abscess  forms,  which 
bursts  or  is  opened,  leaving  a 
sinus,  down  which  a  probe  can 
be  passed  into  the  carious 
interior  of  the  bone.  Occa- 
sionally contiguous  joints  are 
involved  in  this  process,  whilst 
the  tendon  sheaths  are  also  liable 
to  be  affected ;  a  large  portion  of 
the  swelling  is  often  due  to  periosteal  infiltration  (Fig.  259).  In 
some  cases  the  bone  appears  to  be  expanded,  but  the  term  expansion 
is  scarcely  correct,  inasmuch  as  the  enlargement  is  due  to  absorption 
on  the  inner  aspect,  whilst  there  is  a  new  formation  of  bone  under 
the  periosteum. 


Fig. 


258. — TaBERCOLOus  Disease 
OF  Radius. 


The  patient  was  a  lady  over  fifty  years  of 
age,  who  had  suffered  for  some  months 
from  pain  and  swelling  of  this  bone. 
The  site  and  extent  of  the  disease  is 
indicated  by  the  light  area  in  the 
shadow  of  the  bone.  Eventually  am- 
putation was  required. 


580 


A  MANUAL  OP  SURGERY 


The  Treatment  of  tuberculous  dactylitis  in  the  early  stages  con- 
sists in  attention  to  the  general  health,  together  Avith  local  rest, 
venous  engorgement  by  Bier's  method,  and  perhaps  strapping  the 
parts  with  Scott's  dressing.  Should  the  disease  progress  or  suppura- 
tion occur,  operation  must  not  be  unduly  delayed,  since  neighbouring 
joints  and  tendon  sheaths  are  likely  to  be  attacked.  An  incision  is 
made  down  to  the  bone  at  some  suitable  spot  where  tendons  or 
other  important  structures  will   not  be  injured ;  the  periosteum  is 

divided,  and  the  outer  layer  of  com- 
pact bone  removed  by  gouge,  so  as  to 
allow  the  diseased  medulla  to  be 
scraped  away  withaVolkmann's  spoon. 
The  cavity  is  swabbed  out  with  liquefied 
carbolic  acid,  any  excess  being  washed 
away  with  absolute  alcohol,  and  the 
wound  packed  with  gauze  soaked  in 
iodoform  emulsion,  in  order  to  ensure 
healing  by  granulation.  In  this  opera- 
tion the  integrity  of  epiphyses  and 
of  articular  cartilages  must  be  ca.re- 
fully  respected.  Not  unfrequently  the 
growth  of  the  bone  is  considerably 
hindered,  either  by  the  disease  or  by 
the  treatment  requisite  in  order  to 
eradicate  it ;  the  part  becomes  stunted 
or  deformed  in  consequence,  but  a 
useful  hand  is  often  left.  In  the 
worst  cases,  however,  amputation  is 
required. 

(b)  Any  of  the  bones  of  the  tarsus  may 
be  involved  in  exactly  the  same 
manner,  the  clinical  history  and  treat- 
ment being  identical,  although  pos- 
sibly articular  lesions  are  somewhat 
more  common  than  when  the  disease 
is  limited  to  the  phalanges.  The 
affected  portion  of  the  foot  becomes 
swollen,  shiny,  and  pulpy,  since  the 
overlying  periosteum  is  often  involved 
in  the  process  ;  and  it  is  sometimes 
difficult  to  determine  whether  the  lesion  is  limited  to  the  bones  or 
also  involves  the  joints.  In  the  early  stages  one  part  of  the  foot 
may  be  more  swollen  than  another,  according  to  the  location  of  the 
trouble.  The  os  calcis  is  most  often  affected,  and  afterwards,  in 
order  of  frequency,  come  the  first  metatarsal,  astragalus  (the  head), 
and  scaphoid.  When  it  starts  in  the  astragalus,  the  swelling  occurs 
below  the  level  of  the  ankle-joint  in  front  of  or  behind  the  malleoli, 
whilst  pressure  over  the  head  of  the  bone  gives  rise  to  pain.  The 
foot  is  usually  in  a  position  of  equinus,  but  not  to  such  a  marked 


Fig.  259.  —  Tuberculous  Dac- 
tylitis. (Royal  College  of 
Surgeons'  Museum.) 

The  disease  started  in  the  proxi- 
mal phalanx,  and  has  spread 
to  the  periosteum  and  flexor 
tendon  sheath,  whilst  the  first 
interphalangeal  joint  is  becom- 
ing invaded. 


DISEASES  OF  BONE 


581 


degree  as  when  the  ankle-joint  itself  is  affected ;  the  subastragaloid 
movements  (inversion  and  eversion,  abduction  and  adduction)  are 
also  considerably  limited,  or  may  be  absent.  An  examination  of  the 
accompanying  illustration  (Fig.  260)  will  explain  the  fact  that  tuber- 
culous disease  starting  in  the  astragalus  is  very  likely  to  involve  the 
ankle-joint,  or  to  spread  to  the  os  calcis  or  scaphoid.  Disease  of  the 
OS  calcis  leads  to  more  limited  swelling  of  the  back  of  the  foot  on  one 
or  both  sides  of  the  heel ;  the  movements  of  the  ankle  will  not  be 
impaired,  although  walking  is  painful,  and  hence  the  patient  limps, 
treading  only  on  the  toes.     Further  forwards,  tuberculous  disease  is 


Fig.  260. — Arrangement  of  Synovial  Membranes  of  Foot. 

I,  Posterior  calcaneo-astragaloid,  behind  the  interosseous  ligament;  2,  anterior 
calcaneo-astragaloid  and  astragalo-scaphoid  ;  3,  calcaneo-cuboid ;  4,  cubo- 
metatarsal  ;  5,  the  large  common  sac  between  scaphoid  and  cuneiform, 
between  the  three  cuneiform  bones,  and  between  the  cuneiform  and  second 
and  third  metatarsals  ;  6,  between  the  internal  cuneiform  and  first  metatarsal. 

most  likely  to  start  in  or  around  the  scaphoid,  the  bulbous  swelling 
of  the  foot  being  then  shifted  anteriorly,  and  the  movements  of  the 
ankle  remaining  unimpaired.  Owing  to  the  arrangement  of  the 
synovial  membranes,  the  prognosis  is  much  worse  when  the  disease 
attacks  the  inner  half  of  the  foot,  comprising  the  astragalus,  scaphoid, 
cuneiform,  and  three  inner  metatarsal  bones,  than  when  it  affects 
the  outer  segment,  consisting  of  the  cuboid  and  two  outer  metatarsals, 
which  are  excluded  from  the  general  synovial  membrane,  and  are 
thus  more  amenable  to  treatment. 

Sooner  or  later  suppuration  occurs,  with  increased  pain,  and, 
should  the  sinus  which  results  from  opening  the  abscess  become 
septic,  the  trouble  is  sure  to  spread  much  more  rapidly,  and  the 
prognosis  becomes  increasingly  grave. 

The  Treatment  consists  in  the  usual  local  and  constitutional 
measures  adopted  in  tuberculous  disease  (p.  174).  In  the  early 
stages  the  foot  and  ankle  are  immobilized,  and  preferable  in  plaster 
of  Paris  or  water-glass,  and  the  child  is  not  allowed  to  use  the  foot 
for  walking  until  all  pain  has  ceased.     Older  patients  are  fitted  with 


582  A  MANUAL  OF  SURGERY 

a  Thomas's  knee-splint  and  a  patten,  and  allowed  to  get  about  on 
crutches. 

Should  the  disease  persist  in  spite  of  such  treatment,  or  should 
suppuration  occur,  removal  of  the  tuberculous  tissue  by  operation 
may  be  required.  If  the  os  calcis  alone  is  involved,  it  will  usually 
suffice  to  open  it  from  one  or  both  sides,  to  scrape  out  its  interior, 
and  then  pack  it  with  iodoform  and  gauze  after  disinfecting  it  with 
liquefied  carbolic  acid.  The  cavity  fills  up  with  granulation  tissue, 
and  subsequently  with  fibrous  tissue,  with  perhaps  a  few  bony 
spicules,  and  a  marked  permanent  depression  always  remains  at  the 
site  of  operation.  If  the  disease  mainly  affects  the  astragalus,  it  may 
suffice  to  remove  it  entirely,  neighbouring  articulations  being 
curetted,  if  need  be ;  but  probably  the  disease  will  have  spread  so 
far  that  amputation  will  be  required,  and  then  Syme's  operation  is 
better  than  methods,  such  as  Pirogoff's,  which  retain  any  portion  of 
the  tarsus.  Disease  of  the  cuboid  and  outer  half  of  the  foot  in  front 
of  the  OS  calcis  can  often  be  dealt  with  efficiently  by  scraping,  but 
when  the  common  synovial  membrane  on  the  inner  side  is  involved, 
amputation  will  probably  be  required,  failing  success  by  conservative 
measures. 

(c)  If  the  tuberculous  disease  affects  the  ends  of  long  hones,  it  most 
commonly  starts  in  the  epiphysis,  or  under  the  articular  cartilage, 
though  sometimes  on  the  shaft  side  of  the  epiphyseal  cartilage. 
The  changes  already  described  take  place,  and  lead  to  early  destruc- 
tion of  the  latter  cartilage,  so  that  the  adjacent  parts  of  both  epiphysis 
and  diaphysis  become  involved  (tuberculous  epiphysitis).  The  general 
signs  are  similar  to  those  present  when  the  smaller  bones  are  affected, 
but  the  results  produced  may  vary  considerably,  (i.)  In  the  earlier 
cases  where  efficient  treatment  is  adopted,  the  tuberculous  tissue 
may  be  totally  absorbed,  and  the  process  thus  comes  to  an  end, 
though  the  affection  of  the  epiphyseal  cartilage  may  lead  to  subse- 
quent impairment  of  growth,  (ii.)  In  others  it  may  be  circumscribed 
by  the  bone  becoming  sclerosed  around  a  caseating  focus,  and  then, 
if  suppuration  ensues,  a  deep  abscess  in  the  end  of  the  bone  may  be  pro- 
duced (Fig.  261).  Such  is  rarely  of  large  size,  containing  at  most 
I  or  2  drachms  of  curdy  pus,  and  is  lined  by  a  definite  pyogenic 
membrane  of  the  usual  tuberculous  type.  The  effects  produced  by 
this  condition  are  similar  to  those  of  any  chronic  inflammation  of 
bone,  viz.,  a  deep  aching  or  boring  pain,  worse  at  night,  together  with 
enlargement  of  the  affected  bone,  whilst  one  spot  is  often  very  tender 
on  palpation.  If  it  has  existed  for  any  length  of  time,  the  whole 
shaft  may  become  enlarged  as  a  result  of  chronic  osteo-periostitis. 
(iii.)  The  disease  may  burrow  along  the  epiphyseal  line,  and  find 
its  way  into  the  neighbouring  joint,  if  the  epiphysis  is  intra-articular, 
as  in  the  hip ;  but  if  the  epiphyseal  cartilage  is  placed  beyond 
the  limits  of  the  capsule,  a  subperiosteal  extra-articular  abscess  will 
develop  (Fig.  262).  Should  the  disease  spread  equally  in  all  direc- 
tions, the  epiphysis  may  actually  be  separated,  (iv.)  A  more  common 
result  is  for  the  whole  or  part  of  the  cancellous  tissue  of  the  epiphysis 


Fig.  261. — Chronic  Abscess  in  the  Lower  End  of  the  Tibia.     (King's 
College  Hospital  Museum.) 


B 


'•^*  .t. 


Fig.  262. — Lower  End  of  Tibia  affected  with  Tuberculous  Disease. 
(King's  College  Hospital  Museum.) 

In  A,  a  subperiosteal  deposit  of  new  bone  is  seen  surrounding  an  opening  (cl), 
which  leads  into  the  interior  of  the  bone  ;  in  B,  the  interior  of  the  same  bone 
is  seen,  and  shows  a  sequestrum  (S)  just  abqve  the  epiphyseal  line-  The 
ankle-joint  is  healthy. 


DISEASES  OF  BONE 


S8S 


to  become  involved,  and  the  joint  to  be  secondarily  affected  with 
tuberculous  arthritis,  either  by  perforation,  erosion,  or  necrosis  of 
the  articular  cartilage,  or  by  extension  to  the  synovial  membrane 
around  its  margins,  (v.)  The  process  may  sometimes  extend  upwards 
along  the  medulla  into  the  shaft,  causing  a  diffuse  osteo-periostitis, 
with  or  without  a  medullary  abscess  (Fig.  263). 

The  Treatment  of  tuberculous  epiphysitis  is  conducted  in  the  first 
place  by  absolute  immobilization  and  hygienic  measures  ",  but  the 


Fig.  263. — Localized  Abscess  in  the  Lower  End  of  the  Femur,  extending 
FROM  THE  Epiphyseal  Line  Upwards  into  the  Medulla.  (From  Specimen 
IN  the  College  of  Surgeons'  Museum.) 


surgeon  must  not  be  tempted  to  trust  too  long  to  such  a  regime,  for 
fear  of  the  joint  becoming  also  affected.  If  considered  necessary, 
an  opening  is  made  into  the  interior  of  the  epiphysis,  and  all  the 
pulpy  granulation  tissue,  caseous  debris,  or  diseased  bone  removed 
with  a  sharp  spoon,  the  cavity  being  subsequently  disinfected,  and 
packed  with  gauze  infiltrated  with  iodoform.  Of  course,  the  utmost 
care  must  be  taken  not  to  open  the  joint  by  scraping  through  the 
articular  cartilage.  Where  a  chronic  abscess  exists  in  the  end  of  a 
bone,  a  trephine  should  be  applied  over  the  tender  spot,  and,  if  the 


586  A  MANUAL  OF  SURGERY 

cavity  is  not  at  first  opened,  the  bone  may  be  drilled  in   different 
directions  to  ascertain  whether  or  not  pus  exists. 

(d)  The  medullary  canal  of  the  shaft  of  a  long  bone  sometimes 
becomes  the  seat  of  tuberculous  disease  ;  this,  as  also  the  abscess  of 
bone  described  above,  is  more  common  in  adults  than  in  children. 
The  part  thus  affected  becomes  carious,  with  or  without  the  forma- 
tion of  sequestra  or  pus ;  but  the  most  marked  feature  of  this  deep- 
seated  central  trouble  is  that  the  whole  bone  passes  into  a  state  of 
chronic  inflammation,  which  we  have  described,  as  well  as  the  treat- 
ment necessary  for  it,  under  the  title  of  chronic  diffuse  osteo-peri- 
ostitis  (p.  576). 

Syphilitic  Diseases  of  Bone. 

In  the  Secondary  Stage  flying  pains  about  the  bones  (sometimes 
termed  osteocopic)  are  often  complained  of ;  they  are,  however,  of  but 
little  importance,  and  disappear  rapidly  as  the  patient  gets  under 
the  influence  of  mercury.  In  the  late  secondary  or  early  tertiary 
periods,  a  t>enosteal  node  is  often  met  with,  as  a  result  of  chronic 
periostitis.  It  usually  affects  only  one  bone,  and  most  commonly 
the  tibia,  and  consists  of  an  infiltration  and  thickening  of  the  peri- 
osteum, which  may  entirely  disappear,  but  later  on  is  accompanied 
by  a  formation  of  new  bone.  This  is  at  first  spongy  and  soft  in 
character,  but  after  a  while  becomes  hard  and  sclerosed.  When 
such  has  once  occurred,  absorption  of  the  newly-formed  bone  does 
not  readily  follow,  even  under  treatment,  the  part  perhaps  remaining 
permanently  thickened.  It  is  recognised  clinically  as  a  fusiform 
swelling,  a  Httle  tender  on  pressure,  and  the  seat  of  deep  achirig 
pain,  usually  worse  at  night.  It  must  be  understood  that  the  pain 
is  not  so  much  associated  with  the  onset  of  night  as  with  the 
increased  warmth  of  the  Hmbs  when  in  bed  ;  indeed,  patients  with 
syphihtic  tibiae  frequently  sleep  with  their  legs  exposed.  Night- 
watchmen  and  others,  on  the  contrary,  complain  of  pain  during  the 
day,  when  they  take  their  rest.  Suppuration  does  not  often  occur, 
and  constitutional  rather  than  local  treatment  is  required. 

In  the  Tertiary  Period  the  bones  may  participate  in  the  changes 
which  involve  any  and  every  tissue  of  the  body.  The  following 
lesions  are  described : 

(a)  The  formation  of  subperiosteal  gummata,  either  localized  or  diffuse, 
probably  resulting  in  caries  of  the  subjacent  bone  ;  if  the  affection  is 
limited,  only  a  small  portion  may  be  thus  involved  ;  but  where  it  is 
widely  diffused,  an  extensive  surface  of  the  bone  may  become  eroded 
and  irregular.  This  process  is  sometimes  accompanied  by  a  develop- 
ment of  new  bone  under  the  adjacent  periosteum,  and  is  very  often 
compHcated  by  sclerosis  and  necrosis.  The  calvarium  is  the  part 
most  frequently  involved,  and  as  but  little  new  bone  forms  in  this 
situation  the  skull  often  presents  a  curiously  pitted  or  worm-eaten 
appearance  (Fig.  264).  Frequently  the  overlying  scalp  is  invaded 
and  destroyed  by  the  gummatous  process,  permitting  the  entrance  of 
pyogenic  organisms,  and  giving  rise  to  deep  and  sometimes  extensive 


DISEASES  OF  BONE  587 

wounds,  discharging  an  abundance  of  foul  pus,  at  the  bottom  of 
which  bare  and  even  dead  bone  may  be  felt. 

{b)  At  the  same  time  a  condition  of  sclerosis  may  be  produced  in  the 
underlying  or  surrounding  parts,  and  this  may  progress  to  such  a 
degree  as  seriously  to  compress  and  constrict  the  vessels  in  the 
Haversian  canals.  Moreover,  an  obliterative  endarteritis  is  almost 
always  present,  and  these  factors,  combined  with  the  separation  of 
the  periosteum  by  the  above-mentioned  gummatous  changes,  so 
interfere  with  the  vitality  of  the  bone  that,  should  sepsis  be  admitted, 
necrosis  is  almost  certain  to  ensue. 

The  effects  produced  vary  considerably  in  different  cases,  and 
especially  with  the  situation.  When  the  calvarium  is  attacked,  septic 
phenomena  often  supervene,  owing  to  the  thinness  of  the  scalp  and 
the  depth  to  which  the  hair  follicles  penetrate,  and  consequently 
necrosis  is  common.  The  process  in  such  a  case,  as  is  represented 
in  Fig.  265,  is  probably  as  follows :  The  pericranium  corresponding 
to  the  necrotic  area  becomes  gummatous,  and  at  the  same  time  the 


J       '  ''t 


Fig.  264. — Syphilitic  Cariks  of  Skull  from  Diffuse  Gummatous  Disease 
(From  King's  Collegj!:  Hospital  Museum.) 

subjacent  bone  undergoes  sclerosis.  Sooner  or  later  the  gummata 
burst  or  are  opened ;  pyogenic  infection  occurs,  and  the  scalp  tissues 
are  stripped  off  the  calvarium  to  the  limits  of  the  disease,  necrosis 
resulting  in  the  sclerosed  area  of  bone.  A  line  of  rarefaction  sub- 
sequently forms  around  the  sequestrum  in  consequence  of  Nature's 
attempts  to  separate  it.  The  later  stages  of  the  disease  are  marked 
by  extreme  chronicity,  the  sequestrum  lying  bare  in  the  wound 
perhaps  for  years  without  being  separated,  owing  to  the  slight  degree 
of  vascularity  and  the  extreme  condensation  of  the  surrounding 
parts.  Moreover,  as  explained  above,  there  is  an  entire  absence  of 
an  involucrum.  In  the  shafts  of  long  bones,  where  the  compact  tissue 
is  thick  and  resistant,  there  may  be  extensive  periosteal  disease, 
with  but  little  affection  of  the  underlying  parts  ;  but  if  this  compact 
layer  is  thin,  and  especially  when  the  cancellous  ends  are  involved, 
a  considerable  amount  of  destruction  from  caries  may  result,  though  if 
pyococci  are  not  admitted  there  will  be  an  entire  absence  of  necrosis. 


588 


A  MANUAL  OF  SURGERY 


In  the  Treatment  constitutional  remedies,  in  the  form  of  iodide  of 
potassium  and  mercury,  should,  if  possible,  be  depended  on.  Gum- 
mata  should  never  be  opened  without  the  strictest  attention  to 
asepsis.  If  suppuration  is  present,  the  wounds  may  be  treated  by 
applying,  iodoform  and  dressing  with  sterilized  gauze  steeped  in  lotio 
nigra,  or  covered  with  mercurial  ointment.  Counter-openings  are 
often  required  for  purposes  of  drainage,  especially  in  the  scalp. 
Necrosed  portions,  when  separated,  are  to  be  removed,  carious 
tissue  may  be  scraped  away  with  a  sharp  spoon,  and  the  surface 
powdered  with  iodoform  and  dressed  antiseptically.     In  the  calvarium 

no  attempt  should  be  made 
to  chisel  away  the  dead  bone. 
{c)  Occasionally  a  guni- 
matous  osteo -myelitis  is  met 
with,  in  which  a  gumma 
forms  in  the  interior  of  a 
bone.  It  results  in  the  so- 
called  expansion  of  bone  and 
secondary  thickening  and 
enlargement  of  its  whole 
structure  —  i.e.,  a  diffuse 
chronic  osteo-periostitis.  The 
symptoms  are  the  same  as 
those  described  for  the  latter 
affection,  and  if  it  resists  the 
administration  of  anti-syphi- 
litic remedies,  it  must  be 
treated  in  the  same  way, 
viz.,  by  separation  of  the 
periosteum,  freely  opening 
the  medullary  cavity,  and 
removing  all  diseased  tissue. 
These  cases  when  affecting 
the  long  bones  have  often 
been  mistaken  for  malignant 
growths ;  necessarily,  it  is  a  matter  of  the  greatest  importance  to 
come  to  a  right  conclusion  as  to  their  nature.  The  greater  rapidity 
of  growth  in  the  syphilitic  cases,  and  the  evidences  of  tertiary  lesions 
elsewhere,  or  of  a  syphihtic  history,  will  often  guide  the  surgeon 
to  a  right  conclusion,  whilst  radiography  is  also  helpful ;  but  if 
there  is  any  doubt  an  exploratory  incision  and  a  microscopic 
examination  of  the  diseased  tissues  should  always  be  made  before 
amputation  is  undertaken. 

In  Inherited  Syphilis  any  of  the  above  manifestations  may  be  seen, 
but  with  more  or  less  special  features  added,  and,  in  addition  to  these, 
certain  forms  which  do  not  occur  in  the  acquired  type  of  the  disease 
have  been  described. 

I.  A  new  formation  of  bone  beneath  the  periosteum  is  perhaps  the 
most  frequent  result,  and  this  occurs  with  but  little  pain.     Perhaps 


Fig.  265.— S\  philitic  Necrosis  of  the 
Skull.  (King's  College  Hospital 
Museum.) 

The  sequestrum  is  becoming  separated,  and 
a  ring  of  caries  is  forming  around  it. 


DISEASES  OP  BONE  589 

the  most  common  situation  of  this  lesion  in  infants  is  the  calvariura, 
where  bony  masses  known  as  Parrofs  nodes  form  around  the  anterior 
fontanelle,  causing  the  top  of  the  skull  to  resemble  a  '  hot  cross  bun  ' 
in  shape.  In  the  early  stages  the  bone  is  soft  and  spongy,  and  on 
post-mortem  examination  is  dark  red  or  maroon  in  colour.  If  the 
process  is  not  checked  by  suitable  antisyphilitic  treatment,  the  newly- 
formed  osseous  tissue  becomes  dense  and  sclerosed,  and  the  deformity 
may  then  persist  through  life  (Fig.  35,  p.  163).  Any  part  of  the 
calvarium  may,  however,  be  affected,  and  the  change  is  not  neces- 
sarily limited  to  the  first  years  of  life. 

2.  A  somewhat  similar  condition  is  met  with  in  the  shafts  of  long 
bones,  due  to  the  deposition  of  alternating  lamellae  of  soft  and  hard 
bone  outside  the  ordinary  compact  tissue  and  beneath  the  periosteum. 

3.  Syphilitic  epiphysitis  (or,  as  it  is  termed,  syphilitic  osteo-chondritis) 
is  a  lesion  characterized  by  enlargement  of  the  ends  of  the  bones, 
as  in  rickets,  but  coming  on  within  the  first  year,  or  sometimes  soon 
after  birth.  The  enlargement  is  mainly  situated  in  the  epiphysis, 
but  not  uncommonly  extends  some  way  along  the  shaft,  thus  con- 
trasting forcibly  with  rickets.  Occasionally  only  one  side  of  the 
epiphysis  is  affected.  The  change  commences  in  the  zone  of  calci- 
fied cartilage  nearest  the  diaphysis,  which  becomes  friable,  opaque, 
and  irregular,  and  as  the  condition  progresses  it  may  be  transformed 
into  granulation  tissue,  so  that  separation  of  the  epiphysis  follows. 
This  in  turn  sometimes  results  in  suppuration  and  acute  arthritis,  or 
the  limb  hangs  powerless  in  a  condition  known  as  syphilitic  pseudo- 
paralysis. The  disease  is  usually  symmetrical,  and  often  multiple, 
and  situated  in  much  the  same  positions  as  rachitic  affections,  the 
knees,  elbows,  and  wrists  being  perhaps  most  often  affected. 

4.  A  symmetrical  overgrowth  of  the  tibiae,  perhaps  combined  with 
an  anterior  curvature,  also  occurs  in  syphilitic  children,  resulting  in 
permanent  elongation  of  the  legs  (p.  450). 

5.  Craniotabes  consists  of  a  localized  absorption  of  the  osseous  tissue 
of  the  cranium,  leaving  small  areas  where  the  bone  is  thinned  or 
absent,  so  that  on  pressure  a  sensation  of  crackling,  like  that  of 
parchment,  is  imparted  to  the  finger.  It  occurs  most  frequently  in 
the  parietal  bone  (in  60  per  cent,  alone  ;  in  95  per  cent,  with  other 
bones — Carpenter*),  and  in  the  majority  of  cases  within  the  first  six 
months  of  life,  a  fact  that  throws  considerable  doubt  on  the  idea  that 
it  is  due  to  rickets. 

The  Treatment  of  syphilitic  lesions  in  children  must  be  carried  out 
in  accordance  with  general  principles,  and  mainly  by  the  administra- 
tion of  suitable  drugs. 

Rickets. 

Rickets  is  a  general  disease  of  malnutrition,  occurrmg  in  children, 
and  manifesting  itself  mainly  in  lesions  connected  with  the  bones. 
It  usually  commences  within  the  first  three  years  of  life,  but  some- 
times appears  later. 

•  Carpenter,  '  Syphilis  of  Children  in  Every-day  Practice.'  Bailliere,  Tindall 
and  Cox.     1901. 


596  A  MANUAL  OF  SURGERV 

Causes. — Rickets  is  induced  chiefly  by  giving  to  the  child  in- 
sufficient or  improper  food,  especially  by  the  too  early  administration 
of  starchy  materials  and  the  want  of  suitable  fats,  whilst  uncleanli- 
ness  and  want  of  air  and  light  also  predispose  to  it.  Prolonged 
lactation  is  not  necessarily  a  cause,  if  the  mother  is  healthy  and 
capable  of  feeding  the  child  ;  but  amongst  poor  patients  this  habit 
is  frequently  responsible  for  its  appearance,  although  in  Japan, 
where  the  children  are  suckled  for  two  or  three  years,  the  disease  is 
unknown.  Syphilis  has  no  causative  connection  with  rickets,  except 
by  inducing  marasmus  and  digestive  and  assimilative  disorders. 


Fig.  266. — Section  of  Costal  Cartilage  and  of  End  of  Rib  in  Rickets, 
SHOWING  Depression  at  the  Junction  on  Anterior  Surface  and  Pro- 
jection on  Inner  Surface. 

The  Symptoms  may  be  divided  into  the  early  or  general,  and  the 
later  or  osseous.  The  general  symptoms  are  mainly  referable  to  a 
state  of  irritability  of  the  gastro-intestinal  mucous  membrane.  The 
child  may  be  fat  and  flabby,  or  thin  and  emaciated  ;  the  mucous 
membranes  are  pale,  and  vomiting  and  diarrhoea  are  constantly 
present,  the  motions  being  often  green,  slimy,  and  very  offensive. 
The  spleen  is  enlarged,  the  abdomen  tumid,  and  profuse  sweating 
of  the  head  is  very  characteristic. 

The  commencement  of  the  osseous  changes  is  usually  indicated  by 
increasing  irritability  and  restlessness,  the  child  tossing  off  his  bed- 
clothes at  night,  and  crying  out  when  handled  or  touched.  The 
articular  ends  of  the  long  bones  becc^ne  enlarged,  as  also  the  junction 
of  the  costal  cartilages  with  the  ribs.  Sooner  or  later  the  shafts  of 
the  long  bones  soften,  and  may  bend  in  various  directions,  and  thus 
many  deformities  may  be  produced. 

The  head  usually  becomes  flattened  antero-posteriorly,  so  that 
the  forehead  appears  square  in  shape  and  enlarged,  whilst  frontal 
bosses  may  develop  on  either  side,  due  to  new  formation  of  bone 
under  the  periosteum ;  it  is  a  question,  however,  whether  these  are 
not  syphilitic  rather  than  rachitic  in  origin.  The  fontanelles  remain 
open  much  longer  than  usual,  and  craniotabes  is  said  to  occur.  The 
teeth  do  not  erupt  till  late,  and  are  stunted,  defective  in  enamel,  and 
easily  eroded,  so  that  the  ends  of  the  incisors  are  often  concave ;  they 
must  not  be  mistaken  for  syphilitic  teeth,  since  the  concavity  is  a 
small  arc  of  a  large  circle,  whilst  the  typical  notch  of  syphilis  is 
a  large  segment  of  a  small  circle. 

The  spine  may  be  affected  by  kyphosis  (p.  434),  or  less  frequently 
by  scoliosis  (p.  429) ;  the  kyphotic  curve  results  when  the  patient 
is  allowed  to  lie  too  much  in  bed  with  the  head  on  a  high  pillow, 


DISEASES  OF  SONB  S9» 

ftir  if  the  child  is  carried  about  with  a  curved  back ;  scoliosis  more 
often  occurs  when  the  patient  is  able  to  walk.  Occasionally  a 
kypho-scoliosis  is  produced  as  a  result  of  the  child  being  carried 
about  sitting  on  a  nurse's  arm  with  the  pelvis  tilted. 

Changes  in  the  thorax  are  produced  by  enlargement  of  the  costo- 
chondral  junctions  {beaded  ribs),  which,  when  present  on  either  side  of 


Fig.  267. —Pelvis  and  Leg-bones  in  Rickets.      (From  College  of  Surgeons' 

Museum.) 

The  photograph  on  the  left  is  taken  from  the  side,  in  order  to  show  the  extent 
of  the  antero-posterior  curvature  of  the  bones. 

the  sternum,  produce  what  is  known  as  the  rickety  rosary.  The  swell- 
ing is  more  marked  on  the  pleural  aspect  than  on  the  outer  side  of  the 
bone  (Fig.  266).  If  there  is  any  obstruction  to  the  entrance  of  air  into 
the  lungs,  as  from  tracheitis  or  bronchitis,  the  atmospheric  pressure 
may  cause  the  softened  bone  and  cartilage  to  sink  inwards,  and  as  a 
result  of  this  the  sternum  may  be  pushed  forwards  (pigeon  breast), 
.whilst  the  curvature  of  the  ribs  at  the  angle  is  increased.     A  very 


592 


A  MANUAL  OF  SURGERY 


characteristic  feature  of  the  rickety  change  consists  in  the  lateral 
groove  thus  produced  on  each  side  of  the  sternum,  which  may  meet 
with  a  transverse  depression  below,  caused  by  the  projection  of  the 
lower  floating  ribs  by  the  tumid  abdomen. 

The  pelvis  is  flattened  antero-posteriorly,  or  more  rarely  triradiaie, 
the  former  condition  being  produced  when  the  patient  lies  habitually 
on  his  back,  the  latter  only  occurring  when  walking  is  permitted, 
the  acetabula  being  then  pressed  inwards  and  backwards  by  the 
heads  of  the  femora. 

The  deformity  of  the  loitg  bones  (Fig.  267)  usually  consists  in  an 
increase  in  their  natural  curves,  especially  at  points  where  powerful 

muscles  are  attached.  The  femora 
are  curved  antero-posteriorly,  and  the 
tibiae  in  a  similar  direction,  although 
there  is  often  some  lateral  displace- 
ment superadded.  Most  commonly 
the  lower  end  of  the  tibia  is  bent 
inwards  —  i.e.,  in  a  direction  oppo- 
site to  that  represented  in  Fig.  267. 
Genu  valgum  or  varum  may  also 
result  from  these  changes  (Figs.  158 
and  159). 

When  the  acute  stage  of  rickets  has 
passed  away,  any  deformities  present 
become  fixed  by  the  complete  ossifi- 
cation of  the  softened  bony  tissues. 
As  a  rule,  the  density  of  such  de- 
formed bones  is  increased,  whilst 
their  natural  shape  is  altered  by  de- 
posits of  new  subperiosteal  bone  or 
struts  in  the  concavities,  so  that  on 
section  they  are  usually  more  or  less 
flattened  from  side  to  side.  Growth 
is  often  checked  by  this  disease,  and 
thus  the  individual  becomes  stunted 
and  dwarf-like. 

Pathologically,  the  chief  changes  in 
rickets  are  found  in  the  neighbour- 
hood of  the  epiphyses.  Ordinarily, 
the  epiphyseal  cartilage  is  a  lamella 
about  a  line  in  thickness,  bounded  on  either  side  by  a  zone  of 
calcified  tissue,  containing  regular  alveolar  spaces  filled  with  vascular 
medulla,  and  lined  by  osteoblasts,  passing  gradually  into  normal 
cancellous  bone.  In  rickets  the  epiphyseal  cartilage  is  not  only 
circumferentially  enlarged,  but  also  thickened  and  irregular  (Fig.  268), 
outgrowths  of  cartilage  projecting  on  either  side  into  the  calcified 
tissue,  which  is  more  abundant  and  more  open  in  texture  than 
usual,  whilst  it  passes  irregularly  into  the  cancellous  bone.  Thus, 
there  is  an  increased  preparation  for  the  formation  of  bone,  but  the 


Fig.  268.  —  Section  through 
Lower  End  of  Rickety 
Radius,  showing  Exagger- 
ated Depth  and  Irregular 
Borders  of  the  Prolifer- 
ating Epiphyseal  Cartilage. 

(From  Ashby  and  Wright's 
'  Diseases  of  Ctiildren.') 


DISEASES  OF  BONE  593 

ossifying  process  is  inefficiently  carried  out.  In  addition  to  this, 
the  Haversian  canal  systems  and  the  medullary  spaces  in  the 
diaphyses  are  enlarged,  so  that  the  bones  become  weaker  and  less 
rigid  from  the  insufficient  amount  of  lime  salts  present,  and  thus 
readily  bend  under  the  weight  of  the  body  or  from  muscular  action. 
Less  frequently  the  subperiosteal  compact  bone  becomes  similarly 
rarefied.  When  the  disease  comes  to  an  end,  the  deformities  may 
persist,  and  the  bone  becomes  harder  and  stronger  than  usual,  the 
medullary  canal  being  often  narrowed  in  the  long  bones,  and 
displaced  towards  the  convex  side  of  the  curve. 

In  the  Treatment  of  rickets  the  most  essential  feature  in  the  early 
stages  is  the  correction  of  all  errors  in  the  personal  hygiene.  The 
diet  should  consist  of  good  cow's  milk,  diluted  if  need  be,  and  with 
lime-water  added  ;  whilst  the  juice  expressed  from  raw  beef,  or  one 
of  the  many  meat  juices  now  sold,  may  also  be  administered.  The 
condition  of  the  bowels  must  be  attended  to,  and  the  child  placed 
in  as  good  surroundings  as  possible.  Cod-liver  oil  must  be  adminis- 
tered, together  with  Parrish's  food  (syr.  ferri  phos.  co.).  Deformities 
must,  if  possible,  be  prevented  by  keeping  the  child  in  the  recumbent 
posture,  and  not  allowing  it  to  crawl  or  run  about.  The  early  stages 
of  deformity  in  young  children  can  often  be  corrected  by  daily 
manipulation  of  the  affected  bones;  for  the  legs,  it  may  suffice  to 
keep  them  off  their  feet,  as  by  a  splint  which  extends  from  the 
thighs  6  inches  below  the  soles  ;  a  certain  amount  of  pressure  can 
also  be  exercised  by  this  appliance.  Osteotomy,  or  even  resection 
of  portions  of  bone,  is  required  in  the  severer  cases  where  the 
deformity  persists,  and  the  bony  changes  have  become  consolidated 
(see  p.  450). 

Adolescent  Rickets  comes  on  about  puberty,  and  is  usually  independent  of 
an  early  rachitic  history,  although  in  a  few  cases  it  may  be  looked  on  as  a  re- 
crudescence of  the  infantile  ailment.  Imperfect  nutrition  is  probably  a  less 
important  etiological  factor  than  in  infancy  ;  but  strain,  mental  or  physical,  com- 
bined with  defective  hygiene,  has  been  present  in  most  instances.  The  chief 
changes  are  to  be  found  in  the  juxta-epiphyseal  regions  of  the  shafts  of  the  long 
bones,  which  become  bent,  especially  in  the  legs,  from  the  superjacent  weight 
of  the  body.  Deformities  in  the  upper  extremities  are  less  frequent.  Enlarge- 
ment of  the  epiphyses  of  a  characteristic  type  is  sometimes  observed.  There  is 
usually  no  sweating  of  the  head,  but  the  patient  is  pale,  and  complains  of  fatigue 
and  languor,  but  not  of  pain.  The  softened  bones  bend,  and  no  buttresses  or 
struts  are  formed  in  the  concavities ;  hence  the  deformities  produced  are  often 
serious,  and  the  course  of  the  case  is  slow.  (See  Fig.  159,  which  occurred  in  a 
girl  of  thirteen  years,  the  subject  of  this  affection.)  Treatment  must  be  directed 
towards  an  improvement  of  the  general  health  and  of  the  conditions  of  life ; 
undue  mechanical  strain  must  be  avoided,  and,  if  need  be,  the  patient  kept  at 
rest.  Deformities  are  dealt  with  by  the  use  of  orthopaedic  appliances  or  by 
osteotomy. 

Infantile  Scurvy  {Syn. :  Barlow's  Disease,  Scurvy  Rickets,  Haemorrhagic  Rickets). 
— This  condition,  first  accurately  described  by  Sir  Thomas  Barlow,  presents  the 
symptoms  of  scurvy  in  a  rachitic  child,  and  in  its  manifestations  either  one. 
or  the  other  set  of  phenomena  may  predominate.  It  is  usually  seen  in  the 
children  of  well-to-do  people  from  four  to  eighteen  months  old,  and  apparently 
arises  from  defective  nutrition,  especially  from  the  prolonged  administration  of 
peptonized  or  prepared  foods,  or  even  possibly  of  sterilized  milk.     In  the  slighter 

3^ 


594  ^   MANUAL  OF  SURGERY 

cases  there  may  be  but  little  evidence  of  the  scorbutic  condition,  beyond  the  fact 
that  in  a  rickety  child  there  is  some  tendency  for  the  gums  to  bleed,  or  a  little 
hsematuria ;  but  in  those  that  are  more  marked  the  rickety  signs  are  of  little 
importance  compared  with  those  due  to  haemorrhagic  extravasations.  The 
disease  otten  comes  on  suddenly  with  some  amount  of  pyrexia,  rarely  exceeding 
102°  F.,  but  the  child  is  evidently  ill,  and  perhaps  complains  of  tenderness  of 
the  limbs,  which  may  be  kept  so  quiet  as  to  suggest  that  they  are  paralyzed. 
This  is  followed  by  the  appearance  of  swellings  of  some  size,  due  to  sub-periosteal 
extravasations,  the  skin  over  the  affected  parts  being  at  first  shiny  and  oedema- 
tous,  but  subsequently  becoming  stained  by  the  blood-pigment.  The  femur  and 
tibia  are  most  often  affected  in  this  way,  and  the  epiphyses  may  occasionally 
become  detached,  or  even  spontaneous  fractures  occur.  Bleeding  may  also 
take  place  beneath  the  conjunctiva  or  in  the  orbit,  leading  to  protrusion  of  the 
eyeball,  whilst  there  may  be  blood-stained  diarrhcEa,  hsematuria,  or  epistaxis. 

The  disease,  when  recognised,  is  readily  amenable  to  treatment,  but  should  its 
nature  be  overlooked,  the  child  is  likely  to  become  emaciated  and  die.  Attention 
to  the  diet  is  the  main  point  to  be  attended  to,  for  when  fresh  milk,  lime-juice, 
or  vegetables  are  given,  the  symptoms  soon  disappear.  The  affected  limbs  must 
be  kept  at  rest,  and  cooling  lotions  applied,  whilst  splints  are-  required  when 
epiphyses  are  separated  or  fractures  have  occurred. 

Achondroplasia  (Chondrodystropliia  fcetalis)  is  a  curious  congenital  condition, 
somewhat  resembling  rickets,  in  which  the  growth  of  osseous  tissue  on  the  shaft, 
side  of  the  epiphyses  of  the  long  bones  of  both  arms  and  legs  is  defective,  so 
that  the  limbs  are  short  and  stunted,  and  the  stature  correspondingly  diminished 
although  the  epiphyses  are  normal.  The  bones  generally  are  not  bent  or  curved 
abnormally,  though  there  is  probably  some  change  of  the  neck  or  shaft  of  the 
femur,  resulting  in  lordosis,  which  is  very  marked  when  the  patient  stands.  The 
fingers  taper  to  their  tips,  and  are  separated  one  from  another  in  '  spoke-like ' 
fashion.  The  bones  at  the  base  of  the  skull,  being  of  cartilaginous  origin,  undergo 
premature  sjmostosis,  whilst  the  upper  half  of  the  skull,  being  derived  from 
membrane,  and  therefore  developing  naturally,  looks  unusually  large  ;  the  face 
is  small,  and  the  bridge  of  the  nose  depressed  as  in  congenital  syphilis.  The 
children,  if  they  live,  are  usually  efficient  in  their  mental  development,  and  the 
thyroid  body  normal.     No  known  treatment  is  of  any  value. 

Osteo -genesis  imperfecta  (or  idiopathic  psathyrosis)  is  a  rare  congenital  con- 
dition, characterized  by  a  defective  development  of  osseous  tissue  from  cartilage, 
so  that  the  bones  are  brittle  or  soft,  and  thus  are  easily  bent  or  broken,  con- 
stituting a  condition  of  fragilitas  ossium.  Nothing  is  known  as  to  astiology, 
except  that  there  is  a  strong  hereditary  tendency.  Not  a  few  of  the  subjects  are 
stillborn,  with  broken  or  deformed  limbs,  whilst  many  die  within  the  first  year  of 
life.  Cases  in  which  fractures  occur  more  or  less  spontaneously  and  frequently 
in  older  life  are  probably  due  to  some  other  condition,  such  as  osteo-malacia.  If 
the  child  lives,  one  fracture  occurs  after  another,  and  the  limbs  may  become 
terribly  deformed,  although  with  care  they  sometimes  unite  very  well.  In 
addition  to  the  deformities  due  to  the  malunion  of  fractures,  the  bones  are 
usually  bent  and  distorted,  and  thus  the  case  may  be  confused  with  rickets  or 
osteo-malacia.  The  cranial  bones  sometimes  participate  in  the  process,  and  the 
basi-occiput  may  be  driven  upwards  into  the  cranial  cavity  by  the  thrust  of 
the  spine  ;  this  condition  is  demonstrable  by  radiography.  The  actual  anatomical 
changes  in  the  bones  consist  in  a  persistence  of  the  cartilage  cells  in  their 
capsules  and  a  calcification  of  the  trabeculas  between,  very  little  bone  being 
formed  and  that  of  a  defective  type.  No  known  remedies  are  of  any  avail,  and 
all  that  can  be  done  is  to  protect  the  patient  from  mechanical  injuries  and 
treat  the  fractures  as  they  occur. 

Mollities  Ossium  {Syn.  :  Osteo  malacia)  is  an  acquired  disease  of  somewhat 
unusual  occurrence,  characterized  by  the  absorption  of  the  osseous  substance  of 
the  bones,  as  a  result  of  which  softening  and  rarefaction  are  produced,  followed 
by  bending  or  spontaneous  fracture. 

The  complaint  is  almost  limited  to  the  female  sex  (only  8  per  cent,  of  the  cases 
reported  are  in  males),  and  often  commences  during  pregnancy  ;  it  is  said  to  be 
sometimes  connected  with  a  rheumatic  tendency.     Any  part  of  the  skeleton  may 


DISEASES  OF  BONE  595 

be  affected ;  in  females  the  change  usually  attacks  the  pelvis,  spinal  column,  and 
ribs  first,  and  the  limbs  later;  in  men  the  process  starts  in  the  long  bones. 

Pathologically,  the  change  consists  in  a  replacement  of  the  medullary  sub- 
stance by  a  soft  fibro-cellular  tissue,  which  is  exceedingly  vascular,  and  into 
which  haemorrhage  often  occurs ;  the  resulting  material  looks  in  the  fresh  state 
somewhat  like  splenic  pulp.  The  bony  cancelli  are  absorbed,  as  also  the  greater 
part  of  the  compact  tissue,  with  the  exception  of  a  thin  layer  situated  beneath  the 
periosteum ;  in  a  well-marked  case  the  mineral  salts  may  be  diminished  to  about 
one-sixth  of  their  normal  amount,  but  the  relative  proportion  of  phosphate  of  lime 
to  the  carbonate  is  not  changed.  Part  of  the  bone  substance  remains  for  a  time 
in  a  decalcified  state,  with  the  corpuscles  evident,  but  in  a  condition  of  fatty 
degeneration.  Probably  some  acid — e.g.,  lactic  acid— is  the  active  agent  in  dis- 
solving the  earthy  salts,  which  escape  partly  in  the  urine,  partly  in  the  faeces.  It 
is  possible  that  the  process  is  connected  with  the  absorption  of  some  internal 
secretion,  normal  or  vitiated,  particularly  that  from  the  ovary,  an  idea  suggested 
by  the  fact  that  the  removal  of  the  uterine  appendages  has  in  a  few  cases  stayed 
the  disease. 

Clinically,  the  onset  is  usually  somewhat  indefinite,  the  only  complaint  being 
of  pain  in  various  parts  of  the  body,  whilst  the  patient  becomes  emaciated  and 
exhausted.  Sooner  or  later  skeletal  changes  ensue  and  demonstrate  the  character 
of  the  disease.  In  women  the  mischief  usually  commences  in  the  pelvis,  which 
becomes  flattened  at  first,  and  subsequently  triradiate,  owing  to  the  acetabula 
being  pressed  inwards  and  backwards  by  the  weight  of  the  body,  and  in  pregnant 
women  this  may  cause  so  much  deformity  as  to  necessitate  C^sarian  section  or 
Porro'3  operation.  The  spine  is  also  affected,  and  various  curves  develop,  whilst 
the  limbs  bend  and  break ;  in  the  latter  case  sometimes  no  attempt  at  repair 
is  made,  or  healing  may  occur  with  deformity.  Death  may  result  from 
exhaustion,  or  from  obstruction  to  parturition,  or  the  patient  may  live  more 
or  less  bedridden  for  years,  the  limbs  becoming  useless,  shortened,  and  perhaps 
contorted  in  a  strange  and  abnormal  fashion.  In  women  the  disease  may  cease 
to  progress,  or  even  recovery  may  occur  at  the  menopause. 

Treatment  is  unsatisfactory.  Opiates  may  be  administered  to  relieve  pain, 
which  is  often  very  severe,  and  various  drugs,  such  as  alum,  and  phosphate  or 
hypophosphite  of  lime,  have  been  recommended.  In  cases  not  associated  with 
parturition  or  pregnancy,  oophorectomy  is  said  to  have  been  employed  with 
benefit.  The  induction  of  premature  labour  is  considered  by  some  to  be  bene- 
ficial, not  only  for  the  sake  of  obviating  the  necessity  for  such  operations  as 
Caesarian  section,  but  also  on  the  chance  of  checking  the  disease. 

Osteitis  Deformans. 

Osteitis  deformans  is  an  inflammatory  disease  of  the  osseous  skeleton,  first 
described  by  Sir  James  Paget  in  1876.  The  onset  is  insidious,  and  the  progress 
very  slow.  It  is  characterized  by  a  painful  overgrowth  of  the  long  bones,  spine, 
cranium,  and  pelvis,  which  are  also  softened,  so  that  those  which  bear  the  weight 
of  the  body  become  curved.  It  may  commence  in  one  bone  alone,  and  then 
usually  the  tibia  or  femur,  but  more  often  many  bones  are  affected  at  the  same 
time.  Attention  may  be  drawn  to  the  condition,  either  by  the  pain,  which  the 
patient  at  first  considers  to  be  rheumatic,  or  by  the  general  enlargement  and 
bending  of  the  bones,  or  by  the  increased  size  of  the  head,  necessitating  the  use 
of  larger  hats.  The  cranial  overgrowth  is  eccentric  in  character,  and  the  cal 
varium  may  become  very  thick  ;  the  facial  skeleton,  however,  is  not  much 
affected.  The  spine  becomes  markedly  kyphotic  (Fig.  269),  the  dorsal  curve 
being  increased,  and  the  lumbar  concavity  obliterated ;  it  is  nearly  rigid  from 
ankylosis  of  the  vertebrae,  and  may  be  very  painful.  The  head  is  carried  forwards 
by  the  bend  of  the  spine,  the  height  is  diminished,  the  shoulders  are  round, 
and  the  chest  sunken  towards  the  pelvis ;  the  gait  is  slow  and  awkward.  The 
disease  usually  attacks  middle-aged  men  ;  its  progress  is  exceedingly  slow,  the 
patient  often  living  to  an  advanced  age,  or  dying  from  some  intercurrent  malady. 
Some  cases  have  terminated  in  multiple  sarcomata  of  the  bones.  The  structure 
of  the  osseous  tissue  is  suggestive  of  inflammatory  rather  than   degenerative 


596 


A  MANUAL  OF  SURGERY 


changes.  It  is  softer  and  more  uniform  in  structure  than  usual,  the  difference 
between  the  cancellous  and  compact  tissue  being  less  defined  ;  the  Haversian 
canals  are  large,  and  arranged  irregularly,  whilst  the  bony  substance  is  chalky- 
looking. 

Differential  Diagnosis. — From  arthritis  deformans,  which  it  resembles  by  the 
attitude  and  gait  of  the  patient,  it  is  known  by  the  absence  of  articular  lesions, 
especially  in  the  fingers,  and  the  enlargement  of  the  bones,  notably  of  the 
cranium.  From  acromegaly  it  is  distinguished  by  the  absence  of  enlargement 
of  the  hands,  feet,  and  lower  jaw. 

Treatment  is  most  unsatisfactory,  no  remedy  at  present  known  having  any 
control  over  the  disease. 

Acromegaly. 

Acromegaly  is  a  rare  condition  the  characteristics  of  which  were  first  described 
by  Dr.  Pierre  Marie  in  1885.  It  is  a  general  affection  involving  mainly  the 
osseous  system,  commencing  usually  in  young  adults,  and,  after  lasting  for  a 
long  time,  killing  the  patient  by  syncope  or  cerebral  compression,  if  some  inter- 
current malady  does  not  destroy  him. 


Fig.  269. — Early  Stage  of  Osteitis  Deformans.     (From  Photographs.) 

It  is  characterized  by  a  very  definite  enlargement  of  the  hands  and  feet,  which 
are,  however,  not  lengthened,  so  that  the  hands  have  been  compared  to  battle- 
dores, and  the  fingers  to  sausages.  The  bones  themselves  are  enlarged,  and  the 
soft  structures  on  the  palmar  aspects  project  as  pads.  The  nails  and  skin  are 
unchanged,  whilst  the  other  segments,  both  of  the  upper  and  lower  limbs,  are 
usually  unaffected,  though  sometimes  considerable  overgrowth  in  length  occurs  ; 
in  fact,  many  of  the  so-called  giants  who  have  been  exhibited  are  typical  illustra- 
-tions  of  acromegaly.     Both  the  upper  and  lower  jaws  are  thickened  and  promi- 


DISEASES  OF  BONE 


597 


nent,  whilst  the  lower  lip  is  enlarged  and  overhanging.  The  orbital  ridges 
project,  and  the  forehead  is  usually  low  ;  the  nose  and  tip  of  the  tongue  are  also 
more  or  less  enlarged.  The  spine  is  kyphotic  in  the  dorsal  region,  with  a  slight 
lumbar  lordosis.     The  ribs  and  sternum  project  anteriorly. 

The  patient  usually  suffers  from  headache,  lassitude,  and  great  fatigue,  wander- 
ing pains  about  the  body,  and  excessive  appetite  and  thirst ;  amenorrhoea  is  a 
marked  symptom  in  women,  whilst  men  suffer  from  a  loss  of  virile  power.  The 
urine  is  abundant,  but  of  a  low  specific  gravity.  Vision  is  usually  diminished, 
and  optic  neuritis  has  been  observed  in  some  cases. 

Morbid  Anatomy. — But  little  is  known  as  to  the  cause  or  pathological  changes 
occurring  in  this  disease,  beyond  the  fact  that  the  anterior  glandular  half  of  the 
pituitary  body  is  hypertrophied,  and  the  sella  turcica  expanded.  The  changes 
in  the  bones  are  merely  those  of  overgrowth. 

Diagnosis. — The  disease  has  been  mistaken  for  myxcedema,  but  there  is  not 
much  difficulty  in  distinguishing  the  two  if  it  be  remembered  that,  in  the  latter 
condition,  the  skin  is  not  mobile  over  the  thickened  subcutaneous  tissue,  that  the 
face  is  broad,  pasty,  and  puffy,  and  that  masses  of  gelatinous  tissue  are  found 
above  the  clavicle,  whilst  in  acromegaly  the  face  is  elongated  and  the  skin  and 
subcutaneous  tissues  normal.  The  mental  condition  and  speech  of  a  patient 
suffering  from  myxcedema  are  widely  different  from  those  in  acromegaly  ;  whilst 
in  the  former  the  thyroid  body  is  either  absent  or  diseased,  and  in  the  latter 


Fig.  270.- 


-Head  of  WoxMan  with  Acromegaly. 

AND    FROM    THE    SiDE.  * 


Seen  from   the  Front 


skeletal  changes  are  present.  From  chronic  osteo-arthritis  affecting  the  hands,  the 
diagnosis  is  easy,  in  that  there  are  usually  no  signs  of  articular  disease,  and 
much  less  pain.  From  osteitis  defoymans,  the  distinguishing  features  have 
already  been  indicated. 

Treatment  is  merely  symptomatic,  antipyrine  being  useful  in  relieving  the 
headache,  as  also  valerianate  of  caffeine.  Possibly  thyroid  extract  may  be  of 
some  use  in  combating  the  functional  phenomena,  though  it  will  not  influence 
the  skeletal  changes. 


*  Reproduced   from    the  Edinburgh   Medical  Journal,    by   kind   permission   of 
Dr.  G.  A.  Gibson. 


598  A  MANUAL  OF  SURGERY 

Hypertrophic  Osteo-arthropatliy.* 

It  has  long  been  known  that  clubbing  of  the  terminal  phalanges  is  associated 
with  chronic  pulmonary  and  cardiac  disease ;  and  it  is  probable  that  such  is  the 
■earliest  stage  of  this  more  generalized  affection,  first  described  by  Pierre  Marie. 
In  it  the  ends  of  the  fingers  and  toes  are  enlarged  and  bulbous,  with  the  nails 
curved  over  towards  the  palm  or  sole  ;  in  the  early  stages  the  change  may 
be  limited  to  the  soft  tissues,  but  radiography  has  demonstrated  that  in  the  later 
there  is  a  well-marked  new  formation  of  bone  along  the  shafts  of  the  phalanges 
and  also  of  the  metatarsal  and  metacarpal  bones.  There  is  a  considerable 
swelling  of  the  bones  just  above  the  wrists  and  ankles,  extending  some  way  along 
the  shafts,  and  similar  bony  enlargements  sometimes  occur  elsewhere  ;  the}'  are 
due  to  a  diffuse  osteoperiostitis.  The  spine  is  kyphotic  in  the  upper  dorsal 
region,  but  with  well-marked  lordosis  below.  It  is  thus  seen  that  the  changes 
are  somewhat  like  those  of  acromegaly,  from  which  they  are  distinguished  by 
{a)  the  implication  chiefly  of  the  fingers  and  toes,  and  particularly  of  the  terminal 
phalanges,  whilst  in  acromegaly  the  enlargement  of  the  different  portions  of  the 
hands  and  feet  is  general  ;  \h)  the  nails  are  not  affected  in  acromegaly  ;  (c)  the 
joints  are  but  little  involved  in  acromegaly  ;  and  {d)  the  enlargements  of  face, 
tongue,  jaw,  etc.,  so  marked  in  acromegaly,  are  absent  in  osteo-arthropathy. 
These  phenomena  probably  result  from  chronic  toxic  absorption,  since  the  con- 
dition arises  in  such  diseases  as  chronic  bronchitis,  bronchiectasis,  and  chronic 
empyema,  where  suppuration  has  existed  for  some  time.  It  is,  however,  some- 
times associated  with  lesions  other  than  pulmonary — e.g.,  chronic  jaundice, 
syphilis,  and  even  influenza,  and  has  even  been  found  in  otherwise  apparently 
healthy  individuals.  Little  can  be  done  in  the  way  of  treatment,  except  to  deal 
with  the  cause,  if  obvious. 

Tumours  of  Bone. 

The  characters  of  the  osteomata,  chondromata,  and  fibromata  of 
bone  have  been  described  in  Chapter  VIII.,  and  various  solid  and 
cystic  tumours  connected  with  the  teeth  are  dealt  with  elsewhere. 

Sarcoma  is  the  most  important  primary  tumour  of  bones,  and 
almost  any  variety  may  occur.  The  microscopical  characters  have 
been  detailed  in  the  chapter  on  tumours,  and  we  shall  here  chiefly 
refer  to  their  clinical  characteristics.  They  may  be  divided  into  two 
main  groups— the  endosteal  or  central,  and  the  periosteal ;  and  the 
endosteal  again  into  two  varieties,  the  myeloid,  which  has  little 
malignancy,  and  the  true  central  malignant  sarcoma,  usually  of  the 
round-celled  type. 

Myeloid  Sarcoma  (Fig.  271)  is  practically  a  benign  tumour,  never 
giving  rise  to  secondary  deposits  either  in  lymphatic  glands  or  viscera, 
and  its  growth  within  the  bone  is  strictly  limited,  with  no  tendency 
to  diffusion  along  the  medulla;  occasionally  a  layer  of  condensed 
bone  demonstrable  by  radiography  forms  an  effective  barrier  in 
this  direction.  The  sites  of  election  for  myeloid  tumours  are  the 
growing  ends  of  the  long  bones,  especially  the  lower  ends  of  the 
femur  and  radius,  and  the  upper  ends  of  the  humerus,  tibia  and 
fibula,  whilst  they  also  occur  in  the  diploe  and  lower  jav/,  and 
constitute  the  sarcomatous  epulis.  The  development  of  the' 
tumour  leads  to  the  so-called  expansion  of  the  bone,  in  which  the 
osseous  tissue  is  absorbed  from  the  inner  aspect,  and  new  bone  is 

*  See  Janeway,  Amer.  Jour,  of  Med.  Sci.,  October,  1903. 


Fig.  271. — MvELOiD  Sarcoma  of  Head  of  Tibia. 
(King's  College  Hospital  Museum.) 


Fig.  272. — Round-celled  Endosteal 
Sarcoma,  disseminating  Itself  in 
THE  Medullary  Cavity.  (King's 
College  Hospital  Museum.) 


Fig.  273. — Soft  Periosteal  Sarcoma 

of  Lower  End  of  Femur,  eroding 

'Bone  and  leading  to  Spontaneous 

Fracture.     (King's    College 

Hospital  Museum.) 


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SARcOiMA  of  Fibula,  (King's 
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DISEASES  OF  BONE  605 

laid  down  externally  ;  the  outer  layers,  however,  gradually  become 
thinned,  so  that  after  a  time  the  osseous  lamina  can  be  pressed 
inwards,  giving  rise  to  a  feeling  known  as  '  eggshell  crackling ';  and 
finally  the  tumour  projects  through  the  bony  wall.  This  expansion 
may  be  central,  and  the  bone  end  thus  becomes  more  or  less  globular, 
or  it  may  be  eccentric,  and  then  the  growth  projects  merely  on  one 
side.  Sooner  or  later  spontaneous  fracture  is  likely  to  occur. 
Neighbouring  joints  usually  escape,  but  in  old-standing  cases  the 
growth  may  project  around  the  articular  cartilage  and  somewhat 
impair  the  movements  ;  there  may,  however,  be  some  serous  effusion 
in  the  cavity.  The  Symptoms  may  be  so  slight  at  the  commence- 
ment that  nothing  is  noted  until  fracture  has  taken  place  ;  but  some- 
times pain  similar  to  that  of  a  chronic  osteo-periostitis  draws 
attention  to  the  enlargement  of  the  bone.  Radiographic  examination 
reveals  a  well-defined  area  of  bone  which  is  unduly  translucent,  but 
with  a  characteristic  "  stippling,"  due  to  the  presence  of  calcareous 
foci  scattered  through  the  growth  (Fig.  275). 

Central  Round-  or  Spindle-celled  Sarcoma  is  of  a  very  different  type, 
being  extremely  malignant.  There  is  usually  more  pain  in  its 
development,  which  is  much  more  rapid  than  with  a  myeloid  growth, 
but  the  bone  may  be  but  little  expanded  (Fig.  272),  since  the 
growth  tends  rather  to  diffuse  itself  along  the  medullary  cavity,  and 
encroaches  more  closely  upon  the  neighbouring  joint.  The  outer 
wall  is  likely  to  be  absorbed  earlier  than  in  a  myeloid,  and  invasion 
of  the  surrounding  tissues  results.  Lymphatic  glands  and  viscera 
are  soon  involved  by  dissemination  of  the  disease.  The  tumour 
substance  itself  is  usually  of  a  soft  nature,  not  containing  much 
newly-formed  bone  ;  cartilaginous  and  myxomatous  foci  are  often 
associated  with  it.  The  growth  is  highly  vascular,  and  cysts  may 
form  therein,  but  not  so  frequently  as  in  the  myeloid  tumours. 
Radiography  shows  an  irregular  removal  of  bony  tissue,  and  there  is 
no  sharply  defined  limiting  zone  of  thickened  bone  (Fig.  276).  The 
rapidity  of  growth  and  the  radiographic  characters  are  the  features  on 
which  a  diagnosis  of  a  malignant  endosteal  sarcoma  must  be  based. 

Periosteal  Sarcomata  are  round-  or  spindle-celled  in  nature,  and 
occur  less  frequently  than  the  endosteal  variety.  They  often 
develop  rapidly  without  giving  rise  to  much  pain,  unless  causing 
erosion  of  the  bone.  They  usually  start  on  one  side,  but  may 
surround  the  whole  circumference  later  on,  and  spread  for  some 
distance  along  the  shaft.  A  high  degree  of  malignancy  is  attained 
by  them,  secondary  growths  occurring  in  lymphatic  glands  or  the 
viscera.  Ossification  often  occurs  in  their  substance  with  or  without 
the  previous  development  of  cartilage,  and  in  such  .cases  the  subjacent 
bone  may  become  sclerosed  and  thickened,  so  that  spontaneous 
fracture  is  not  common  in  this  variety.  The  bony  skeleton  of  such  a 
growth  is  very  characteristic,  consisting  of  fine  spiculated  trabeculse, 
radiating  more  or  less  regularly  from  the  surface,  and  looking  in  the 
dried  state  somewhat  like  asbestos  (Fig.  274).  These  ossifying  sarco- 
mata have  a  very  characteristic  appearance  on  skiagraphy  (Fig.  277). 


6o6  A  MANUAL  OF  SURGERY 

WTien  a  periosteal  sarcoma  does  not  become  ossified,  the  growth 
often  erodes  the  underlying  bone  (Fig.  273),  and  may  lead  to 
spontaneous  fracture  ;  the  tumour  in  such  cases  is  softer  and  more 
elastic  than  in  the  former  variety,  and  usually  attacks  the  bone  from 
one  side  and  not  equally  all  round-  Osseous  sarcomata  are  always 
exceedingly  vascular,  and  may  even  pulsate,  whilst  the  superficial 
veins  are  obviously  dilated  beneath  the  stretched  integument,  giving 
rise  to  a  blue  network. 

The  Diagnosis  of  osteo-sarcoma  in  the  early  stages  is  often  a  matter 
of  the  greatest  difficulty.  The  endosteal  form  may  easily  be  mis- 
taken for  chronic  osteo-periostitis,  medullary  gumma,  or  a  deep 
abscess  of  the  bone,  and  can  sometimes  only  be  distinguished  from 
them  by  an  exploratory  incision  and  microscopic  examination  of  a 
portion  of  the  growth  ;  this  should  always  be  undertaken  in  doubtful 
cases  prior  to  radical  operations,  such  as  amputation.  In  the  later 
stages,  the  presence  of  '  eggshell  crackling '  or  cystic  changes  will 
help  to  maike  evident  the  nature  of  the  disease.  The  periosteal  form 
may  at  first  be  looked  upon  as  a  periosteal  node,  or  a  deeply-placed 
abscess.  The  rounded  and  definite  edge  of  the  growth,  its  irregular 
consistency,  and  the  history  of  the  case,  will  assist  in  the  determina- 
tion of  its  nature ;  but  in  the  early  stages  an  exploratory  operation 
is  not  unfrequently  necessary.  For  the  diagnosis  of  a  pulsating 
sarcoma  from  an  aneurism,  see  p.  312.  When  either  form  involves 
the  articular  end  of  a  bone,  especially  the  lower  end  of  the  femur,  it 
may  simulate  tuberculous  disease  of  the  adjacent  bone.  It  will, 
however,  be  noted  that  the  centre  of  the  swelling  corresponds  to  a 
point  well  above  or  below  the  joint,  that  a  certain  amount  of  move- 
ment is  possible  and  even  painl^,  whilst  the  starting  pains  at  night 
characteristic  of  joint  mischief  are  absent.  The  age  of  the  patient, 
and  the  presence  or  not  of  cachexia,  are  also  important  features 
which  have  to  be  taken  into  consideration-  Skiagraphy  serves  in 
most  cases  as  an  important  diagnostic  adjuvant  (see  Figs.  275-278). 

It  is  of  the  great^t  importance  that  a  cl^  opinion  as  to  the 
diagnosis  be  made  at  the  earliest  possible  moment,  as  thereby  both 
prognosis  and  treatment  are  immensely  iuSuenced.  We  have 
already  stated  that  the  prognosis  of  a  myeloid  tumour  is  good,  its 
malignancy  being  merely  local ;  involvement  of  glands  and  viscera 
is  rare.  Periosteal  sarcomata  have  a  bad  prt^^osis,  as  general 
dissemination  occurs  early ;  the  small  spindle-ceUed  are  the  worst. 
Secondary  deposits  often  contain  ossific  material — e^.,  in  the  lungs. 
Central  sarcovaata.  axe  not  quite  so  malignant,  although  the  round- 
celled  variety  is  decidedly  un&vourable. 

The  Treatment  of  osteo-sarcoma  must  always  be  of  a  radical  nature, 
and,  remembering  the  highly  malignant  characters  of  many  of  these 
growths,  the  importance  of  an  early  exploratory  operation  in  doubt- 
ful cases  cannot  be  over-estimated.  If  the  case  is  left  until  increased 
growth  reveak  the  true  state  of  affairs,  it  is  more  than  likely  that, 
except  in  the  myeloid  variety,  it  will  be  too  late  for  successful 
operative   interference.     In   every  form  of  the   disease  except  the 


DISEASES  OF  BONE  607 

myeloid,  the  affected  limb  should  be  removed  if  possible  through  the 
joint  above  the  tumour  ;  if  the  amputation  takes  place  through  the 
bone,  a  microscopic  examination  of  the  medulla  at  the  point  of  section 
should  be  made  at  once  to  ascertain  that  it  is  not  atlected.  Thus,  if 
the  tumour  is  growing  from  the  lower  end  of  the  tibia,  disarticulation 
at  the  knee-joint  should  be  performed  ;  if  at  the  upper  end  of  the  tibia, 
amputation  through  the  middle  or  lower  third  of  the  thigh ;  if  from 
the  lower  end  of  the  femur,  amputation  through  the  upper  third  of 
the  bone,  if  not  at  the  hip-joint.  For  sarcoma  of  the  head  of  the 
humerus,  disarticulation  through  the  shoulder-joint  r>!ay  suffice,  but 
it  is  usually  wiser  to  remove  the  scapula  and  greater  part  of  the 
clavicle  as  well  (interscapulo-thoracic  amputation).  The  results 
of  the  latter  proceeding,  as  regards  final  cure,  have  been  much 
more  satisfactory  than  those  of  the  former.  When  muscular  bellies 
have  been  invaded,  it  is  desirable,  though  not  always  practicable,  to 
include  the  whole  extent  of  them  in  the  scope  of  the  operation. 

Myeloid  sarcomata  being  practically  non-malignant,  except  locally, 
are  dealt  with  in  a  conservative  manner  by  excision  of  the  growth, 
amputation  being  reserved  for  the  more  advanced  cases  and  for  those 
where  excision  would  leave  a  more  or  less  useless  limb.  Thus  a 
myeloid  tumour  of  the  upper  end  of  the  tibula  can  be  treated  by 
excision,  care  being  taken  of  the  external  popliteal  nerve  and  its 
branches  ;  but  if  the  upper  end  of  the  tibia  or  lower  end  of  the  femur 
is  involved,  amputation  will  usually  be  required.  When  aflectiug  the 
lower  end  of  the  radius  or  upper  end  of  the  humerus,  and  not  in  too 
advanced  a  stage,  an  attempt  may  be  made  to  save  the  limb  by 
excising  the  diseased  portion  of  bone.  In  the  wrist  the  lower  part  of 
the  ulna  is  taken  away,  as  well  as  the  growth  in  the  radius ;  by  this 
plan  there  is  less  chance  of  the  hand  being  drawn  up  and  abducted, 
and  hence  it  is  more  likely  to  become  useful,  A  leather  gauntlet  to 
steady  the  part  subsequently  will  almost  certainly  be  required. 
Central  sarcoma  of  the  lower  jaw,  if  myeloid  in  nature,  may  be  treated 
by  i:iaking  a  free  opening  in  the  bone  from  the  mouth,  scraping  the 
diseased  tissue  away,  and  swabbing  out  the  cavity  with  pure  carbolic 
acid.  The  continuity  of  the  jaw  may  thus  be  maintained,  even  if  the 
•teeth  are  lost. 

Secondary  Sarcoma  of  bone  is  by  no  means  unconuuon.  It  is 
usually  endosteal  in  character,  and.  except  in  the  most  unusual 
circumstances,  will  not  demand  treatment,  owing  to  the  general 
infection  of  the  system.  Possibly  where  it  has  led  to  spontaneous 
fractiu"e,  and  there  is  much  pain  owing  to  the  difficulty  of  hxation, 
it  would  be  justitiable  to  remove  the  limb. 

Carcinoma  of  bone  is  always  secondary  in  nature,  although 
it  may  be  involved  by  direct  extension  in  a  primary  growth. 
Secondary  growths  are  endosteal  in  character,  and  often  extremely 
painful  ;  they  may  occasionally  lead  to  spontaneous  fracture 
(Fig.  278),  but  the  bone  may  consolidate  again  satisfactorily. 
After  scirrhus  mamnue,  the  upper  end  of  the  femur  and  vertebra^  are 
the  bones  most  often  aifected,  apart  from  those  of  the  chest  wall. 

For  the  so-called  Thyroid  Cancer  of  bone,  see  Chapter  XXXI. 


6o8  A  MANUAL  OF  SURGEr^Y 

Pulsating  Tumours  of  Bone,  or  Osteo-aneurism.  — Apart  from  pulsat- 
ing sarcoma,  two  other  conditions  are  met  with,  the  nature  of  which 
cannot  be  considered  as  yet  settled,  in  which  distinct  pulsation  is  also 
noticeable. 

In  the  first  of  these  the  medullary  cavity  is  occupied  by  a  non- 
malignant  vascular  tissue,  practically  identical  with  what  we  have 
already  described  as  an  aneurism  by  anastomosis.  A  large  number  of 
small  arterioles  open  into  spaces  without  the  intervention  of  capil- 
laries, and  thus  an  erectile  tissue  similar  in  nature  to  the  corpus  caver- 
nosum  penis  results.  Such  tumours  are  situated  most  frequently  in 
the  cranial  bones,  and  may  be  multiple,  the  medullary  tissue  being 
in  consequence  atrophied,  and  the  compact  tissue  thinned,  so  that 
'  eggshell  crackling  '  may  be  obtained. 

The  second  form  is  found  most  commonly  in  the  upper  end  of  the 
tibia,  or  some  such  cancellous  mass.  It  consists  of  a  hollow  cavity, 
filled  with  blood.  Several  distinct  arterial  twigs  may  open  into  it, 
and  the  overlying  bone  is  thinned  and  absorbed.  It  is  probable  that 
the  majority  of  such  cases  are  in  reality  due  to  the  breaking  down  of 
a  sarcoma  of  extreme  tenuity,  possibly  a  myeloid. 

The  Treatment  of  these  cases  necessarily  varies  with  the  condition 
found  after  a  preliminary  incision  into  its  substance,  which  should 
always  be  made  after  rendering  the  limb  bloodless.  Where  it  seems 
probable  that  the  condition  is  not  associated  with  malignant  disease, 
or  is  merely  due  to  a  myeloid  tumour,  the  cavity  should  be  well 
scraped,  swabbed  out  with  pure  carbolic  acid,  and  then  firmly  packed 
with  gauze,  so  as  to  obtain  healing  by  granulation  from  the  bottom. 
In  other  cases  amputation  is  the  only  treatment,  especially  in  the 
former  variety,  where  it  is  almost  impossible  to  stop  the  haemor- 
rhage. 

Hydatid  Disease  of  Bone.- — -The  cancellous  tissue  of  bones  occa- 
sionally becomes  the  site  of  hydatid  development,  any  part  either  of 
the  medullary  cavity  or  of  the  ends  being  involved.  The  bone 
becomes  expanded,  with  all  the  symptoms  of  an  endosteal  growth. 
Considerable  deformity  may  occur,  and  when  the  compact  layer  has 
been  sufficiently  absorbed,  spontaneous  fracture  may  follow.  In 
this  affection  there  is  no  limiting  wall,  the  small  daughter  cysts  being 
diffused  through  the  affected  area.  A  diagnosis  is  little  likely  to  be 
made  (at  any  rate  in  countries  where  hydatid  disease  is  rare) 
prior  to  an  exploratory  incision.  Treatment. — If  all  the  cysts  can  be 
removed  without  interfering  with  the  integrity  of  the  shaft,  a  recovery, 
with  good  subsequent  utility  of  the  limb,  should  follov/.  Where,  how- 
ever, the  disease  has  enroached  widely  on  the  bony  tissue,  whether 
spontaneous  fracture  has  occurred  or  not,  amputation  holds  out  the 
only  prospect  of  cure. 

Simple  Cysts  of  Bone  are  observed  most  frequently  in  the  tibia  or 
upper  end  of  the  humerus.  The  condition  develops  insidiously, 
probably  without  pain,  and  may  be  mistaken  for  a  sarcoma,  the  true 
state  of  affairs  not  being  recognised  until  after  amputation  of  the 
limb  ;  or  attention  may  be  drawn  to  the  part  by  the  occurrence  of  a 


DISEASES  OF  BONE 


609 


spontaneous  fracture.     The  cyst  is  found  to  be  lined  with  a  thin 
layer   of  fibrous  tissue,  with  no  endothelial  covering.     The  actual 
pathology  is  not  clear,  but  it  is  thought  possible  that  it  is  akin  to 
osteitis  deformans  or  osteo-malacia,  since  in  all  three  conditions  the 
true  bony  tissue  disappears  and  the  medullary  tissue  increases     In 
osteo-malacia  it  remains  fatty  ;  •  in  osteitis  deformans  new  irregular 
bone  IS  deposited  in  its  place ;  and  in  this  condition  there  is  a  new 
tormation  of  fibrous  tissue,  which,  however,  subsequently  becomes 
cystic.     This  osteitis  fibrosa,  as  it  has  been  termed,  may  be  more  or 
less  generalized  through  a  bone,  or  may  be  localized,  and  then  a 
simple  cyst  may  develop.     The  only  available  means  of  diagnosis 
apart  from  incision,  is  radiography.    The  thinning  of  the  bone  is  more 
regular  than  in  any  sarcomatous  condition,  and  there  is  a  complete 
absence  of  mottling  or  detail  such   as  is  usually  seen  in  cases   of 
myeloid   disease.     Treatment  consists   in   laying   open  the   cavity 
scraping  it  out,  and  packing,  so  as  to  determine  healing  by  granula- 
tion ;  or  by  excising  the  affected  portion  of  bone,  and  replacing  it 
by  a  bone  graft.  ^ 


39 


CHAPTER  XXI. 

INJURIES  OF  JOINTS— DISLOCATIONS. 

Sprains  and  Strains  result  from  sudden  violence  applied  to  a  joint 
either  directly  or  indirectly,  as  in  the  football  field  or  in  many 
laborious  occupations.  They  consist  in  a  tearing  or  stretching  of 
the  synovial  membrane,  partially  detached  portions  of  which  may  be 
tucked  inwards,  or  of  ligaments,  which  in  bad  cases  may  be  torn 
from  their  attachments  to  the  bones.  The  accident  itself  isf- 
associated  with  severe  pain,  and  is  immediately  followed  by  more  or 
less  haemorrhage  into  the  surrounding  tissues,  or  into  the  articular 
cavity.  Inflammatory  effusion  follows,  and  unless  wisely  treated, 
persistent  weakness  and  pain  in  the  joint,  either  from  the  formation 
of  adhesions,  or  from  imperfect  repair  of  the  ligaments,  may  result. 
A  neglected  sprain  may  originate  tuberculous  disease  in  those  who 
are  so  predisposed,  whilst  osteo-arthritis  is  by  no  means  an  un- 
common sequela.  If  the  patient  is  in  a  bad  state  of  health  at  the 
time  of  the  injury,  an  attack  of  acute  infective  arthritis  may  be 
determined.  Treatment. — The  joint  should  be  firmly  supported  by 
a  wet  bandage  as  soon  after  the  accident  as  possible,  in  order  to 
limit  the  amount  of  effusion.  The  part  is  raised  and  kept  quiet,  and 
the  bandage  dabbed  over  with  evaporating  lotion  from  time  to  time. 
In  the  slighter  cases  the  patient  may  be  allowed  to  use  the  limb  in  a 
few  days,  the  part  being  supported  by  strapping  or  an  elastic 
bandage  ;  but  in  severe  sprains  it  may  be  necessary  to  keep  the  part 
absolutely  at  rest  for  a  much  longer  period,  before  the  pain  and 
tenderness  disappear.  Friction  with  stimulating  liniments,  douching 
the  joint  alternately  with  hot  and  cold  water,  massage,  passive  and 
active  movements,  and  finally  exercises  against  resistance,  are  useful 
in  restoring  the  limb  to  full  functional  activity.  Splints  are  only 
required  when  the  ligaments  are  badly  torn. 

Penetrating  Wounds  of  Joints  are  often  accompanied  by  an  escape 
of  synovia,  which  is  recognised  as  a  glairy,  oily  fluid,  floating 
perhaps  on  the  surface  of  the  blood;  if,  however,  the  aperture  is 
small,  this  may  not  occur.  It  is  always  followed  by  a  certain 
amount  of  reaction,  the  character  of  which  depends  on  whether  or 
not  the  joint  is  infected.  If  no  infection  has  taken  place,  and  the 
joint  is  kept  quiet,  a  simple  synovitis  ensues,  and  soon  passes  off;  if, 

6io 


INJURIES  OF  JOINTS— DISLOCATIONS  bii 

however,  micro-organisms  have  entered,  acute  arthritis  probably 
supervenes,  leading  to  destruction  and  disintegration  of  the  joint. 
(For  symptoms  and  treatment,  see  p.  647.)  A  penetrating  wound, 
even  if  untreated,  does  not  necessarily  become  septic ;  thus,  if 
the  lesion  is  produced  by  a  small,  clean  instrument,  and  especially 
if  this  is  inserted  in  a  slanting  direction,  so  that  the  wound  is 
valvular,  or  if  the  incision  is  a  large  one,  allowing  free  vent  to  all 
discharges,  recovery  without  septic  inflammation  is  possible. 
•  Treatment. — If  the  wound  is  small,  and  there  is  reason  to  believe 
that  the  instrument  inflicting  it  was  aseptic,  the  external  skin  should 
be  thoroughly  purified,  and  an  antiseptic  dressing  applied.  A  careful 
watch  must  be  kept  upon  the  condition  of  the  joint  and  upon  the 
temperature  of  the  patient ;  as  soon  as  any  signs  of  acute  arthritis 
manifest  themselves,  free  incisions  are  made  into  the  joint,  so  as  to 
relieve  tension  and  allow  the  cavity  to  be  irrigated.  If,  however,  the 
wound  was  inflicted  by  a  dirty  instrument,  and  there  is  but  little 
doubt  that  the  joint  has  been  penetrated,  it  is  most  important  to 
make  certain  of  this  fact.  For  this  purpose  the  wound  should  be 
enlarged  so  that  its  depths  may  be  purified,  and  then  carefully 
examined.  If  it  is  found  that  the  cavity  has  been  opened,  the 
aperture  should  be  increased  in  size  so  as  to  allow  it  to  be  washed 
out  and  a  drainage-tube  inserted ;  if  acute  arthritis  supervenes,  it 
must  be  treated  in  the  usual  way. 

Dislocations. 

Although  the  term  '  dislocation '  is  most  commonly  applied  to  a 
forcible  displacement  of  one  of  the  bones  entering  into  an  articula- 
tion, as  the  result  of  an  injury,  it  must  not  be  forgotten  that  con- 
genital and  pathological  displacements  also  exist. 

Congenital  Dislocation. — This  term  is  applied  generally  to  any 
defect  of  a  joint  present  at  birth,  but  is  really  a  misnomer,  since  the 
condition  is  almost  always  due  to  an  error  of  development,  as  a  result 
of  which  a  normal  location  of  the  bony  constituents  has  never  been 
present,  and  hence  a  (^wlocation  cannot  have  taken  place.  The  hip- 
joint  is  most  frequently  affected  ;  but  similar  malformations  have 
occurred  in  the  shoulder,  wrist,  and  jaw,  whilst  the  patella  may  be 
congenitally  absent  or  displaced.  For  congenital  dislocation  of  the  hip, 
see  p.  440. 

Pathological  Dislocations  are  produced  as  the  result  of  some  intra- 
articular affection,  e.g.,  tuberculous  disease,  osteo-arthritis,  Charcot's 
disease,  etc.     It  is  unnecessary  to  describe  them  here. 

Traumatic  Dislocations. — The  Causes  are  divided  into  predisposing 
and  exciting.  Under  the  former  head  may  be  included  anatomical 
peculiarities,  such  as  the  shallow  socket  of  the  glenoid  cavity,  or  some 
rnuscular  or  ligamentous  weakness.  Dislocations  are  rare  in  children, 
since  any  violence  directed  to  a  joint  or  its  neighbourhood  is  more 
likely  to  lead  to  an  epiphyseal  separation.  Moreover,  in  old  people 
the  bones  become  brittle,  and  thus  fractures,  rather  than  dislocations 


6i2  A  MANUAL  OF  SURGERY 

are  produced ;  hence  the  latter  lesions  are  almost  limited  to  adults, 
and,  owing  to  their  greater  exposure  to  injury,  occur  in  men  rather 
than  in  women. 

The  Exciting  Causes  are  the  application  of  external  violence  and 
muscular  force,  acting  alone  or  in  combination.  The  former  may 
be  direct,  but  is  more  commonly  indirect,  the  force  being  applied  at 
a  distance  from  the  joint.  Muscular  action  by  itself  can  only  pro- 
duce dislocation  in  certain  joints ;  the  head  of  the  humerus,  the 
patella  and  condyle  of  the  jaw,  are  the  bones  most  often  affected  in 
this  way.  If,  however,  the  ligaments  of  a  joint  have  been  stretched 
by  previous  disease  or  displacement,  recurrent  dislocations  from 
muscular  action  are  not  unusual. 

The  term  complete  dislocation,  or  hixation,  is  applied  to  that  condition 
,  in  which  the  articular  surfaces  of  the  bones  are  completely  separated 
from  one  another.  An  incomplete  dislocation,  or  subluxation,  is  one  in 
which  the  surfaces  are  only  partially  separated. 

1A  componnd  dislocation  is  one  in  which  the  skin  has  been  ruptured 
and  a  communication  established  with  the  external  air.  A  complicated 
dislocation  is  one  in  which  there  has  been  some  associated  injury  ot 
vessels,  nerves,  or  viscera.  The  term  fracture  -  dislocation  is  one 
applied  to  a  condition  in  which  a  dislocation  is  complicated  by 
fracture  of  one  or  both  bones  involved. 

The  Signs  of  a  dislocation  are  as  follows  :  (i)  The  evidences  of 
a  local  trauma,  e.g.,  pain,  bruising,  and  swelling  of  the  soft  tissues, 
due  to  their  laceration  and  the  effusion  of  blood  into  them :  the 
amount  of  this  varies  in  different  cases  ;  (2)  deformity  of  the  limb, 
due  to  the  articular  end  of  the  displaced  bone  being  in  some  abnormal 
position,  where  it  can  often  be  felt  and  sometimes  seen ;  and  (3)  re- 
stricted mobility  of  the  affected  joint,  and  hence  impairment  of 
function  of  the  limb.  The  degree  to  which  this  latter  phenomenon 
obtains  is  necessarily  variable,  but,  as  a  rule,  it  is  very  marked ;  if, 
however,  fracture  is  also  present,  passive  movements  may  be  possible, 
though  associated  with  pain  and  crepitus. 

The  Effects  produced  by  a  dislocation  extend  to  all  the  structures 
entering  into  and  surrounding  the  site  of  injury.  The  ligaments  are 
partially  or  completely  torn  ;  the  bony  surfaces  are  not  unfrequently 
fractured,  especially  in  closely-fitting  hinge  joints,  such  as  the  elbow 
and  ankle ;  the  cartilages  may  be  bruised,  or  portions  of  them 
detached,  and  neighbouring  muscles  and  tendons  lacerated  and 
displaced  ;  adjacent  vessels  and  nerves  are  often  contused  or  com- 
pressed. Considerable  effusion  of  blood  is  always  present,  infiltrating 
the  whole  area  involved. 

The  character  of  the  injury  explains  the  difficulties  that  are  met 
with  in  its  reduction.  These  arise  from  two  main  causes :  (a)  The 
anatomical  arrangement  of  the  joint  and  its  hgaments,  resulting  in  the 
hitching  of  bony  prominences  against  one  another,  whilst  the  head  of 
the  bone  does  not  always  lie  opposite  the  hole  in  the  capsule  through 
which  it  originally  passed.  In  a  few  cases  the  end  of  the  bone  may 
be  grasped  by  neighbouring  ligaments  and  tendons  in  such  a  way 


INJURIES  OF  JOINTS— DISLOCATIONS 


613 


as  to  render  its  replacement  a  matter  of  the  greatest  difficulty, 
(b)  Muscular  contraction  also  constitutes  an  obstacle,  which,  though  it 
can  be  counteracted  by  suitable  traction,  is  more  effectively  overcome 
by  the  use  of  an  anaesthetic.     Not  only  does  the  patient  maintain  the 


A  B 

Fig.  279. — Old-standing  Subcoracoid  Dislocation  of  the  Shoulder,  show- 
ing Atrophy  of  True  Glenoid  Cavity,  together  with  Formation  of 
New  Joint  and  Alteration  in  Shape  of  Head  of  Bone.  A,  View 
from  the  Front;  B,  from  the  Outer  Side.  .(From  College  of 
Surgeons'  Museum.) 

limb  in  a  condition  of  rest  by  a  voluntary  tonic  contraction,  but  it  be- 
comes fixed  by  the  involuntary  passive  tension  of  the  displaced  muscles. 

When  once  reduced,  there  is  usually  but  little  tendency  for  a  disloca- 
tion to  recur.  Reparative  changes  quickly  manifest  themselves ;  blood- 
clot  is  absorbed,  the  rent  in  the  capsule  closes  by  cicatrization,  and 
in  many  cases  no  permanent  lesion  remains ;  in  some,  however,  the 
joint  is  left  in  a  weak  and  relaxed  state,  and  liable  to  a  recurrence  of 
the  displacement, "while  intra-articular  adhesions,  or  the  cicatricial 
contraction  of  the  injured  ligaments  and  muscles,  may  cause  some 
loss  of  mobility. 

If  a  dislocation  is  allowed  to  remain  unreduced,  the  true  articular  cavity 
becomes  shallow  and  partly  filled  up  by  a  transformation  of  its  cartilage 
into  fibrous  tissue,  whilst  the  displaced  head  of  the  bone  becomes 
adherent  to  the  structures  amongst  which  it  lies ;  as  the  result  of  a 
plastic  inflammation,  either  dense  fibrous  adhesions  are  formed,  or  a 
new  false  joint  (pseudarthrosis).  The  articular  cartilage  is  eroded,  and 
the  exposed  bone  eburnated  and  sclerosed,  whilst,  owing  to  chronic 
periostitis,  the  end  of  the  shaft  may  be  considerably  deformed.     The 


6i4  A  MANUAL  OF  SURGERY 

portion  of  bone  upon  which' the  displaced  head  rests  undergoes  changes, 
partly  atrophic  (from  pressure),  partly  hypertrophic  (as  a  result  of 
chronic  periostitis),  whereby  a  new  socket  is  produced  (Fig.  279). 
Neighbouring  muscles  are  secondarily  shortened,  and  accommodate 
themselves  to  the  abnormal  position  of  the  limb,  and  tendons  which 
have  been  torn  gain  fresh  attachments.  These  changes  necessarily 
interfere  more  or  less  seriously  with  the  power  of  the  limb  and  the 
movements  of  the  joint.  Serious  pain  is  not  unfrequently  caused  by 
pressure  on  neighbouring  nerves. 

Treatment. — The  treatment  of  dislocations  consists  in  the  reduction 
of  the  displaced  bone  with  as  little  delay  as  possible.  There  are  two 
chief  methods  of  gaining  this  end,  viz.,  manipulation  and  extension. 

Manipulation  is  always  the  best  means  to  employ  where  practicable, 
less  injury  being  sustained  by  the  surrounding  tissues.  It  consists 
in  moving  the  limb  in  such  directions  as  shall  cause  the  displaced  end 
to  retrace  the  course  that  it  has  already  taken,  through  the  rent  in 
the  capsule  to  its  normal  position.  The  shoulder  and  hip  joints  are 
more  amenable  to  this  method  of  treatment  than  hinge  joints.  Anaes- 
thesia will  be  required  in  difficult  cases,  and  especially  in  dislocations 
of  the  shoulder  and  hip  joints.  Chloroform  is  generally  preferred,  as 
inducing  deeper  muscular  relaxation,  but  where  the  patient  is  in  a 
bad  state  for  the  administration — i.e.,  with  his  stomach  full  of  food — 
ether  may  be  preferable.  It  is  only  right  to  draw  attention  to  the 
fact  that  a  large  number  of  fatal  cases  of  chloroform  administration 
have  been  reported  as  occurring  in  the  treatment  of  shoulder  disloca- 
tions ;  this  is  due  mainly  to  two  causes,  viz.,  the  deep  anaesthesia 
required,  and  the  want  of  preparation  of  the  patient.  The  greatest 
care  must  therefore  be  exercised  in  giving  the  anaesthetic. 

Extension  is  employed  to  overcome  muscular  and  other  forms  of 
resistance,  so  as  to  allow  the  bone  to  slip  back  or  be  manipulated 
into  its  original  position.  In  order  to  make  this  effectual,  the  parts 
above  the  dislocation  are  steadied  by  some  cotmter-extending  force 
applied  either  by  the  hands  of  an  assistant,  or  by  a  belt  or  towel,  or 
by  the  knee  or  foot  of  the  surgeon.  Extension  may  be  made  by  the 
hands,  or  a  firmer  grip  may  be  maintained,  and  greater  force  used,  by 
applying  a  bandage  or  a  jack-towel  to  the  limb  by  means  of  a  clove- 
hitch-  In  a  few  cases,  the  force  may  be  exerted  through  some  form 
of  multiplying  pulley,  fixed  at  one  end  to  a  hook  or  staple,  and  at  the 
other  end  to  the  loop  of  a  towel  or  bandage  attached  to  the  limb. 
When  any  such  contrivance  is  employed,  precautions  must  be  taken 
to  prevent  the  soft  tissues  from  being  injured.  A  useful  plan  consists 
in  applying  a  damp  bandage  at  the  point  from  which  traction  is  to  be 
made,  and  over  this  a  thick  skein  of  worsted  in  the  form  of  a  clove- 
hitch,  the  loop  being  attached  to  the  hook  of  the  pulley.  The 
extension  must  be  made  continuously  ;  no  jolting  or  jerking  action  is 
allowable,  or  considerable  mischief  may  ensue.  Since  the  introduction 
of  anaesthetics,  however,  pulleys  have  been  very  rarely  required, 
except  in  dealing  with  old-standing  cases. 

Reduction,  however  produced,  is  usually  accompanied  by  a  sudden 


INJURIES  OF  JOINTS— DISLOCATIONS  ^J^ 

and  distinct  snap  or  suction  sound,  due  to  the  contraction  of  muscles, 
unless  the  patient  is  deeply  under  an  anaesthetic,  and  the  muscles 
are  absolutely  relaxed.  The  limb  is  subsequently  kept  at  rest  for 
some  days,  to  allow  the  rent  in  the  capsule  to  heal,  but  massage  may 
be  started  in  a  day  or  two,  and  passive  movements  after  a  week, 
except  when  there  is  great  tendency  to  recurrence  of  the  displacement. 

The  treatment  of  an  unreduced  dislocation  is  often  a  matter  of  consider- 
able difficulty.  Attempts  at  reduction  may  be  undertaken  up  to 
two  or  three  months,  but  the  greatest  caution  must  be  employed  for 
fear  of  rupturing  adhesions  and  endangermg  the  main  vessels  or 
nerves.  Extension  by  pulleys  has  given  rise  to  so  many  accidents, 
varying  in  severity  from  laceration  of  the  skin  to  actual  avulsion 
of  the  limb,  that  it  is  wise  to  discontinue  such  treatment  if  it  has 
failed  on  its  first  application. 

The  amount  of  mobility  possible  in  an  unreduced  dislocation  varies 
a  good  deal  in  different  cases,  and  the  character  of  the  treatment  is 
mainly  governed  by  this.  If  movement  is  tolerably  free,  and  not 
particularly  painful,  massage  and  manipulation  may  be  undertaken, 
and  a  very  useful  limb  result.  Where,  however,  movement  is  both 
painful  and  limited,  one  or  other  of  the  following  plans  of  operative 
treatment  should  be  undertaken :  (i.)  Reduction  by  an  open  operation. 
The  head  of  the  bone  is  cut  down  on,  and  freed  from  its  adhesions 
to  surrounding  structures,  the  capsule  of  the  joint  being  also  opened 
and  the  cavity  cleared  ;  reduction  may  then  be  possible  by  means  of 
manipulation  or  extension.  A  few  cases  of  successful  treatment  of 
old-standing  dislocations  of  the  shoulder  by  this  means  have  been 
recorded;  but,  as  a  rule,  the  gain  derived  thereby  is  scarcely  commen- 
surate with  the  risks  and  difficulties  of  the  operation,  especially  if  a  con- 
siderable interval  has  elapsed  since  the  accident,  (ii.)  Excision  of  the 
displaced  head  of  the  bone  will  give  the  best  results  in  most  cases.  In 
the  elbow-joint  it  is  often  the  only  practicable  treatment,  and  in  the 
shoulder  and  hip  it  is  usually  better  than  attempting  open  reduction. 

Compound  dislocations  are  always  serious  lesions,  for  not  only  are 
adjacent  vessels  and  nerves  liable  to  injury,  but  unless  efficient 
treatment  is  adopted,  suppurative  arthritis  ensues,  leading  to  dis- 
organization of  the  articulation,  with  subsequent  ankylosis,  or,  in  the 
case  of  larger  joints,  possibly  to  death  from  pyaemia  and  toxic 
poisoning.  The  treatment  consists  in  rigid  antisepsis  to  the  wound, 
together  with  reduction  of  the  dislocation  and  temporary  drainage. 
If  necessary,  the  opening  in  the  skin  must  be  enlarged,  in  order  to 
allow  of  the  replacement  of  the  bone,  and  should  the  latter  structure 
be  much  bruised  or  injured,  it  may  be  advisable  to  resect  it  at  once. 
If,  however,  vessels  and  nerves  are  also  injured,  or  if  the  patient  is 
old  or  debilitated,  amputation  may  be  required. 

Special  Dislocations. 

Dislocations  of  the  Lower  Jaw  forwards  is  not  a  very  common 
accident,  and  usually  results  either  from  muscular  action,  or  from  a 
blow  on  the  chin  when  the  mouth  is  widely  open,  as  in  gaping,  laugh- 


6i6 


A  MANUAL  OF  SURGERi 


ing,  or  attempting  to  take  a  large  bite.  It  has  also  been  produced  in 
dentistry  by  a  violent  strain  during  tooth-drawing,  or  from  digging  out 
roots  with  an  elevator.  In  some  persons  the  accident  happens  with 
the  greatest  ease,  and  constantly  recurs,  owing  probably  to  laxity 
of  the  capsule  or  insufficient  development  of  the  eminentia  articularis. 
The  mechanism  of  the  dislocation  is  as  follows :  When  the  mouth 
is  opened,  the  condyle  of  the  jaw  slips  forwards  on  to  the  eminentia 
articularis,  and  it  requires  very  little  force  to  displace  it  still  further 
into  the  zygomatic  fossa  (Fig.  280).     The  inter-articular  cartilage 

follows  the  condyle,  and  the 
attachment  of  the  external  ptery- 
goid muscle  to  that  structure 
and  to  the  bone  explains  the 
occurrence  of  dislocation  from 
muscular  action. 

The  displacement  may  be 
unilateral  or  bilateral,  more  fre- 
quently the  latter.  The  mouth 
remains  widely  open,  the  teeth 
and  the  jaws  being  separated  by 
an  interval  of  about  an  inch. 
The  lower  jaw  projects  unduly, 
and  is  fixed,  saliva  dribbling 
over  the  lip ;  speech  and  deglu- 
tition are  impaired,  the  pronun- 
ciation of  the  labial  consonants 
being  especially  difficult.  A 
hollow  can  be  detected  immediately  in  front  of  the  tragus,  where 
the  condyle  is  normally  lodged,  and  in  front  of  this  hollow  the  con- 
dyle can  be  felt,  being  recognised  by  the  slight  amount  of  passive 
movement  still  possible.  A  finger  in  the  mouth  may  define  the 
coronoid  process  in  an  abnormal  position  beneath  the  zygoma. 

When  the  dislocation  is  unilateral,  the  symptoms  are  much  less 
marked.  Some  amount  of  movement  of  the  jaw  still  remains,  whilst 
the  chin  is  displaced  towards  the  sound  side. 

Treatment. — Reduction  is  usually  easy.  All  that  is  needed  is  to 
depress  the  condyle  below  the  level  of  the  eminentia  articularis,  when 
the  rnasseter,  temporal,  and  internal  pterygoid  muscles  speedily  draw 
it  back  into  the  glenoid  cavity.  The  patient  is  seated  in  a  chair; 
the  surgeon  standing  in  front  protects  his  thumbs  with  thick  napkins, 
and  introduces  them  into  the  mouth,  pressing  upon  the  lower  molar 
teeth.  Pressure  is  continued  in  a  downward  and  backward  direction 
until  the  condyle  is  free,  and  then  the  chin  is  raised  by  the  fingers  on 
either  side.  The  jaw  is  kept  at  rest  for  a  week  or  ten  days  by  means 
of  a  four-tailed  bandage.     Anaesthesia  is  occasionally  necessary. 

A  few  cases  are  on  record  of  displacement  of  the  condyle  of  the 
jaw  backimrds,  associated  with  fracture  of  the  tympanic  plate  and 
tearing  or  separation  of  the  cartilage  of  the  auricle,  leading  to  bleeding 
from  the  ear.     Displacement  upwards  into  the  cranial  cavity  through 


Fig    280. — Dislocation  of  Jaw. 


INJURIES  OF  JOINTS— DISLOCATIONS  617 

the  roof  of  the  glenoid  fossa  has  also  been  described,  the  patient  in 
one  case  dying  of  meningitis. 

Subluxation  of  the  Temporo-maxillary  Joint  is  due  to  displacement 
of  a  relaxed  interarticular  cartilage,  which  becomes  folded  or  nipped 
on  opening  the  mouth,  the  result  being  a  painful  temporary  fixation 
of  the  jaw  with  a  snap  or  crack  on  freeing  it.  The  condition  is 
associated  with  a  passive  synovial  effusion  into  the  joint,  and  may 
be  dealt  with  by  the  external  application  of  blisters  ;  should  this  fail, 
it  is  justifiable  to  open  the  joint  and  fix  the  cartilage  by  sutures  or 
remove  it. 

Dislocation  of  the  Sternal  End  of  the  Clavicle. — In  spite  of  the 
apparent  weakness  of  this  joint  and  the  great  strams  to  which  it  is 
subjected,  dislocation  is  uncommon,  owing  to  the  strength  of  the 
ligaments  surrounding  it,  particularly  of  the  rhomboid,  the  clavicle 
being  more  easily  broken  than  displaced.  The  cause  of  these  disloca- 
tions is  always  violence  directed  to  the  outer  end  of  the  bone,  and 
since  that  usually  acts  from  in  front,  the  inner  end  of  the  bone  is 
generally  thrown  forwards  Two  other  varieties  are  described, 
however,  m  which  the  displacement  is  backwards  or  upwards. 

In  the  forward  dislocation  the  end  of  the  bone  lies  on  the  anterior 
surface  of  the  manubrium,  where  it  can  be  easily  detected  ;  all  the 
ligaments  of  the  joint  are  torn,  except,  perhaps,  the  interclavicular. 
The  point  of  the  shoulder  is  approximated  to  the  middle  line.  Treat- 
ment.— Reduction  is  effected  by  placing  the  knee  against  the  spme 
between  the  scapulae,  and  drawing  the  shoulders  backwards,  the 
elbow  on  the  affected  side  being  kept  in  front  of  the  mid-axillary  line. 
To  prevent  recurrence,  the  shoulders  are  kept  back  by  handkerchiefs 
passed  round  the  axillae  and  knotted  together  in  the  middle  line 
behind,  as  for  a  fractured  clavicle  (p.  494).  The  elbow  is  then  drawn 
forwards  in  front  of  the  mid-axillary  line,  and  supported  by  a  sling  or 
bandage.  It  is  advisable  to  keep  the  patient  m  bed  for  a  few  days, 
so  as  to  give  the  ligaments  a  better  chance  of  re-uniting,  but  some 
amount  of  forward  displacement  is  very  likely  to  persist.  No  bad 
result  follows,  even  should  the  dislocation  remain  unreduced. 

The  backward  dislocation  is  not  often  seen.  The  head  of  the  bone 
lies  behind  the  upper  part  of  the  sternum,  and  all  the  ligaments  are 
ruptured,  including  the  rhomboid.  The  movements  of  the  head  .and 
neck  are  painful  and  limited,  and  pressure  upon  the  trachea,  oeso- 
phagus, and  vessels  of  the  neck,  gives  rise  to  difficulty  in  breathing 
and  swallowing,  and  to  congestion  of  the  head.  Reduction  and 
after-treatment  are  similar  to  that  suggested  for  the  former  variety. 
If  the  condition  cannot  be  reduced,  and  serious  symptoms  of  pressure 
are  present,  the  head  of  the  bone  should  be  excised. 

The  upward  dislocation  is  one  of  extreme  rarity.  The  head  of  the 
bone  in  front  of  the  trachea  compresses  both  trachea  and  oesophagus, 
especially  when  the  patient  sits  up  or  leans  forwards.  To  effect 
reduction,  the  shoulders  are  drawn  forcibly  backwards,  and  direct 
pressure  applied  to  the  end  of  the  bone,  but  it  is  very  probable  that 
some  amount  of  displacement  will  persist. 


6i8 


A  MANUAL  OF  SURGERY 


Dislocation  of  the  Acromioclavicular  Joint  consists  in  the  acromion 
being  forced  either  above  or  below  the  outer  end  of  the  clavicle,  more 
commonly  the  latter.  The  displacement  is  easily  recognised  by  the 
abnormal  prominence  of  one  or  other  of  the  bones.  It  usually 
results  from  violence  directed  to  the  scapula.  No  difficulty  is 
experienced  in  reduction,  but  the  displacement  is  very  liable  to 
recur,  especially  in  the  more  common  form.  The  elbow  is  then 
flexed  to  a  right  angle,  and  pads  of  lint  or  small  towels  placed  over 
the  acromion  and  beneath  the  elbow;  a  bandage  or  strap,  applied 
over  the  shoulder  and  under  the  elbow,  suffices  to  maintain  the  bone 
in  position.  The  strap  is  kept  from  slipping  by  passing  a  bandage 
under  it  round  the  opposite  side  of  the  chest.  Should  the  displacement 
persist,  and  give  rise  to  pain  or  impair  the  movements  of  the  arm,  the 
bones  may  be  wired  together  after  removing  the  cartilaginous  surfaces. 

Dislocation  of  the  Shoulder  occurs  almost  as  frequently  as  all 
the  other  dislocations  of  the  body  put  together.     The  shallowness  of 


Fig.  281. — Subglenoid  Dislocation 
OF  Shoulder.     (Tillmanns.) 


Fig.  282.— Subcoracoid  Dislocation 
OF  Shoulder.     (Tillmanns.) 


the  glenoid  cavity,  the  size  of  the  head  of  the  humerus,  the  laxity 
of  the  capsule,  the  extent  and  force  of  the  movements  possible,  and 
the  exposed  position  of  the  shoulder,  explain  the  great  frequency  of 
the  accident.  It  usually  results  from  falls  upon  the  hand  or  elbow, 
the  arm  at  the  time  of  the  accident  being  widely  outstretched  to 
enable  the  individual,  if  possible,  to  save  himself.  The  weak  lower 
and  inner  part  of  the  capsule  receives  the  chief  portion  of  the  shock, 
and  yields,  the  head  of  the  bone  being  primarily  displaced  downwards 
into  the  axilla  (subglenoid  variety),  and  then,  according  to  the  direc- 
tion of  the  force,  or  the  character  of  the  subsequent  manipulations, 
the  head  travels  either  forwards  (subcoracoid  or  subclavicular  disloca- 
tion) or  backwards  (subspinous).  Falls  on  the  elbow  or  shoulder 
may,  however,  cause  a  direct  forward  or  backward  displacement. 

The  Signs  of  a  dislocation  of  the  shoulder  are  sufficiently  obvious, 
and  certain  characteristic  features  are  present  in  almost  all  varieties, 
(i)  The  shoulder  looks  flattened,  owing  to  displacement  of  the  head 
inwards  (Figs.  201,  B,  and  283),  and  as  a  result  of  this  the  acromion 


INJURIES  OF  JOINTS— DISLOCATIONS 


619 


.^* 


process  is  unduly  prominent,  and  a  hollow,  felt  below  it,  occupied  by 
the  tense  deltoid.  (2)  The  head  of  the  bone  lies  in  some  abnormal 
position,  and  the  glenoid  cavity  is  empty.  (3)  The  elbow  is  displaced 
away  from  the  side,  and  it  is  impossible  to  make  it  touch  the  chest 
wall  at  the  same  time  that  the  hand  is  placed  on  the  opposite  shoulder 
(Dugas'  test) ;  this  does  not  always  obtain  in  the  subcoracoid  type. 
(4)  The  vertical  measurement  round  the  axilla  is  increased  in  all  the 
varieties  (Callaway's  test)  ;  whilst  inspection  reveals  a  lowering  of 
the  anterior  or  posterior  axillary  fold  (Bryant's  test).  (5)  A  ruler  or 
straight-edge  can  be  made  to  touch  both  the  acromion  process  and 
the  outer  condyle  of  the  elbow  in  most  cases  of  dislocation  (Hamilton's 
ruler  test) ;  this  is  impossible  when  the  head  of  the  bone  is  in  its 
normal  position,  but  can  also  occur  in  fractures  of  the  anatomical 
neck.     At  the  same 

time,  the  usual  signs  ^,  ^  >^ 

of  a  dislocation,  viz., 
rigidity  and  local 
bruising,  are  also 
present.  Stereo- 
scopic radiography 
is,  of  course,  invalu- 
able for  diagnostic 
purposes. 

Subglenoid  Dislo- 
cation (Fig  281)  is 
always  the  primary 
condition  when  due 
to  a  fall  upon  the  out- 
stretched arm,  but  is 
not  often  seen,  since 
further  displacement 
usually  occurs  be- 
fore the  case  comes 
under  observation. 
The  head  of  the  bone 
passes  down  into  the 
axilla,  resting  against  the  outer  border  of  the  scapula  below  the  glenoid 
cavity,  between  the  subscapularis  above  and  the  feres  minor  below, 
with  the  long  head  of  the  triceps  behind.  The  capsular  ligament 
and  muscles  passing  to  the  tuberosities  are  torn,  whilst  the  axillary 
vessels  and  nerves  ma)'  be  seriously  compressed,  leading  to  numb- 
ness of  the  fingers.  The  head  of  the  bone  is  felt  in  the  axilla,  and 
the  anterior  axillary  fold  is  much  lowered  ;  the  elbow  is  directed  away 
from  the  side  and  slightly  backwards  ;  the  arm  is  lengthened,  perhaps 
to  the  extent  of  i  inch,  whilst  the  fore-arm  is  usually  flexed. 

A  few  cases  have  been  recorded  in  which  the  arm  was  abducted 
and  displaced  vertically  upwards,"  although  the  head  of  the  bone  was 
in  the  usual  position  of  a  subglenoid  dislocation.  This  variety  is 
known  as  the  luxatio  erect  a. 


Fig. 


3S3. — Subcoracoid  Dislocation  of  the  Right 
Shoulder. 


620 


A  MANUAL  OF  SURGERY 


Subcoracoid  Dislocation  (Figs.  282  and  283)  is,  without  doubt,  the 
most  common  form.  The  head  of  the  bone  Hes  under  the  coracoid 
process  on  the  anterior  part  of  the  neck  of  the  scapula,  immediately 
in  front  of  the  glenoid  cavity,  the  anatomical  neck  impinging  on  its 
anterior  border.  In  this  position  it  is  above  the  tendon  of  the  sub- 
scapularis,  which  is  either  torn  or  stretched  over  the  neck  as  a  tense 
band,  and  may  considerably  impede  reduction.  Two  forms  of  this 
displacement  are  described  by  Malgaigne,  according  to  whether  the 
muscles  attached  to  the  great  tuberosity  are  intact,  resulting  in 
marked  external  rotation  of  the  limb  (subcoracoid  variety),  or  whether 
they  are  lacerated,  or  even  the  great  tuberosity  itself  pulled  off,  the 
humerus  being  then  rotated  inwards  (intracoracoid  variety).  In  both 
types  the  elbow  is  displaced  backwards  and  outwards,  and  the  head 
of  the  bone  can  be  usually  felt  on  rotation  of  the  arm  under  the 

outer  third  of  the  clavicle.  Compara- 
tively little  alteration  is  produced  in  the 
length  of  the  arm. 

The  Subclavicular  variety  is  uncommon, 
and  merely  an  exaggeration  of  the  sub- 
coracoid. The  head  of  the  humerus  passes 
further  inwards,  and  lies  deeply  under  the 
pectoralis  major,  on  the  second  and  third 
ribs.  The  capsule  and  surrounding  muscles 
are  much  lacerated,  or  perhaps  the  great 
tuberosity  torn  off  ;  the  elbow  is  markedly 
separated  from  the  side  and  directed  a 
little  backwards,  whilst  distinct  shortening 
is  present. 

The  Subspinous  Dislocation  (Fig.  284)  is 
unusual.  The  head  of  the  bone  lies  in  the 
infraspinous  fossa,  immediately  behind  the 
glenoid  cavity,  between  the  infraspinatus  and  teres  minor  muscles, 
the  subscapularis  being  generally  torn.  Malgaigne  states  that  the 
head  of  the  humerus  is  most  commonly  found  resting  on  the  pos- 
terior edge  of  the  glenoid  cavity  immediately  below  the  acromion 
process  (subacromial  variety).  The  elbow  is  displaced  considerably 
forwards,  but  can  be  made  to  touch  the  chest  wall ;  the  arm  is 
rotated  inwards,  so  that  the  hand  is  thrown  across  the  front  of  the 
body.  There  is  usually  a  marked  hollow  in  front  of  the  shoulder, 
whilst  a  distinct  prominence  is  caused  behind  by  the  head  of  the 
bone  in  its  false  position.  The  length  of  the  limb  is  frequently 
unaffected,  or  if  any  change  is  present,  the  arm  is  slightly  lengthened. 
Three  or  four  cases  have  been  described  of  what  is  known  as  a 
Supracoracoid  Dislocation.  The  head  of  the  bone  is  here  displaced 
upwards,  and  either  the  coracoid  or  acromion  process  is  broken,  more 
commonly  the  former.  Replacement  with  crepitus  is  easily  obtained, 
but  the  dislocation  is  liable  to  recur: 

The  Treatment  of  Dislocation  of  the  Shoulder  consists  in  reduction 
by  manipulation  or  extension. 


Fig.  284. — Subspinous  Dis 
location    of    shoulder 

(TlLLMANNS.) 


INJURIES  OF  JOINTS— DISLOCATIONS 


621 


I.  For  reduction  hymanipulation 
an  anaesthetic  is  always  advis- 
able, but  must  be  given  with 
caution.  Many  different  methods 
of  manipulation  have  been  sug- 
gested, of  which  the  following 
are  the  more  important.  Not 
unfrequently,  when  the  muscles 
are  relaxed,  any  slight  rotary 
movement  suffices  to  '  put  the 
bone  in.' 

Kocher's  Method  for  Suhcoracoid 
Dislocations. — The  surgeon  stand- 
ing in  front  of  his  patient,  who 
is  seated  or  reclining,  and  sup- 
ported by  an  assistant,  grasps 
the  elbow  after  flexion  of  the 
fore-arm,  and  presses  it  to  the 
side  and  slightly  backwards. 
With  one  hand  holding  the 
wrist  and  the  other  the  elbow, 
the  arm  is  now  rotated  firmly 
and  steadily,  outwards  as  far  as 
it  will  go,  the  elbow  still  being 
pressed  to  the  side  (Fig.  285). 
Distinct  resistance  will  be  felt 
during  this  movement,  which 
causes  the  head  of  the  humerus 
to  roll  out  beneath  the  acromion, 
and  may  suffice  to  effect  reduc- 
tion. If  the  limb  is  still  dis- 
placed, the  elbow  should  be 
drawn  forwards  and  upwards 
as  far  as  it  will  go,  with  the 
humerus  still  fully  everted 
(Fig.  286),  whilst  finally  the 
arm  is  rotated  inwards  so  as 
to  carry  the  hand  towards  the 
opposite  shoulder,  and  the  elbow 
drawn  across  the  chest  and 
lowered  (Fig.  287).  All  these 
movements  should  be  carried 
out  steadily  and  evenly,  and 
without  undue  force  for  fear  of 
fracturing  the  surgical  neck  of 
the  bone.  The  value  of  this 
plan,  according  to  Kocher,  turns 
on  the  fact  that  '.  .  .  the  pos- 
terior  part  of   the  capsule  and 


Figs.  285,  286,  287. — Kocher's  Method 
OF  Reduction  of  a  Subcoracoid 
Dislocation  of  the  Shoulder. 


622  A  MANUAL  OF  SURGERY 

the  scapular  tendons  inserted  therein  are  usually  untorn  and  stretched 
tightly  across  the  glenoid  fossa.  Rotation  outwards  relaxes  these  , 
structures  and  removes  them  from  the  fossa,  whilst  the  rent  in  the 
capsule  gapes  ;  but  owing  to  the  fact  that  the  upper  and  lower, 
margins  of  the  opening  are  still  tight,  the  head  of  the  humerus 
remains  fixed  against  the  neck  of  the  scapula  until  the  elbow  is 
carried  forwards  and  raised.  The  upper  part  of  the  capsule  then 
relaxes,  and  the  lower  part,  which  remains  tense,  guides  the  head  of 
the  bone  into  the  joint. ' 

Smith's  Method  varies  somewhat  in  its  application,  according  to 
whether  the  head  of  the  bone  is  displaced  anteriorly  or  posteriorly. 
For  anterior  displacements  the  surgeon  stands  in  front  of  the  patient, 
and  grasps  the  shoulder,  using  the  right  hand  for  the  right  shoulder 
and  the  left  for  the  left,  so  that  the  thumb  rests  on  the  head  of  the 
bone,  and  the  fingers  grasp  and  steady  the  scapula.  With  the  other 
hand  he  seizes  the  arm  near  the  elbow  which  has  been  flexed,  and 
raises  it  from  the  side,  extending  and  everting  it.  Having  thus 
raised  it  to  a  right  angle,  the  limb  is  steadily  and  continuouh,ly 
circumducted  inwards,  the  thumb  following  the  head  of  the  bone  and 
assisting  it  to  reach  the  lower  and  under  side  of  the  capsule,  and 
thus  enter  the  socket  through  the  rent.  For  the  subspinous  disloca- 
tion, the  surgeon  stands  behind  the  patient  and  grasps  the  shoulder 
with  one  hand,  raising  the  arm  with  the  other,  and  making  extension 
backwards  combined  with  external  rotation ;  i.e.,  the  limb  is  circum- 
ducted outwards,  and  finally  brought  to  the  side. 

2.  Extension  may  be  applied  in  different  ways,  the  object  being  to 
overcome  the  tension  of  surrounding  ligaments  and  muscles.  It 
may  be  applied  directly  downwards  by  the  surgeon  grasping  and 
pulling  on  the  arm,  whilst  his  unbooted  foot  is  used  as  a  counter- 
extending  force  in  the  axilla,  the  patient  lying  flat  on  a  mattress 
placed  on  the  ground,  and  the  surgeon  sitting  by  ths  side.  Another 
plan  consists  in  using  the  knee  as  a  fulcrum  instead  of  the  heel,  the 
patient  sitting  in  a  chair.  Occasionally  the  foot  has  been  placed 
against  the  thoracic  wall,  and  extension  made  directly  outwards  at 
right  angles  to  the  body,  as  recommended  by  Sir  Astley  Cooper. 
White,  of  Manchester,  suggested  vertical  traction,  the  arm  being 
pulled  directly  upwards,  the  surgeon's  foot  having  been  placed  over 
the  acromion,  the  patient  being  in  the  recumbent  posture.  The 
only  objection  to  this  last  method,  which  may  succeed  when  other 
plans  fail,  is  that  the  axillary  vessels  are  somewhat  exposed  to  injury. 

Dislocations  of  tlie  Elbow-Joint  are  not  very  uncommon,  occur- 
ring particularly  in  young  people,  and  are  due  to  either  direct  or 
indirect  violence.  The  diagnosis  is  often  difficult  from  the  amount 
of  swelling  that  quickly  follows.  A  careful  investigation  of  the 
relative  position  of  the  bony  points  (p.  504),  and  of  the  degree  of 
mobility  of  the  diff'erent  parts  on  each  other,  is  essential  in  order 
to  arrive  at  a  definite  conclusion  as  to  the  exact  nature  of  the 
lesion.     In  cases  of  doubt,  a  skiagram  should  be  taken. 

I.  Dislocation  of  Both.  Bones  may  occur  either  backwards,  forwards^ 
or  laterally. 


INJURIES  OF  JOINTS— DISLOCATIONS 


623 


The  backward  variety  (Fig.  205,  A)  is  that  most  often  met  with ; 
it  usually  occurs  without  either  the  coronoid  process  or  the  olecranon 
being  fractured,  although  occasionally  the  former  is  detached.  If 
the  coronoid  remains  intact,  it  sometimes  becomes  locked  in  the 
olecranon  fossa,  and  renders  the  arm  immobile ;  if,  however,  it  is 
broken,  considerable  mobility  of  both  bones  occurs,  with  crepitus. 
The  fore-arm  is  semi-flexed,  the  hand  held  midway  between  pronation 
and  supination,  and  the  displaced  bones  form  a  considerable  swelling 
at  the  back  of  the  joint,  above  which  is  a  marked  hollow,  crossed  by 
the  triceps.  The  lower  .end  of  the  humerus  projects  in  front,  and 
the  artery  and  the  soft  parts 
are  displaced  forwards.  The 
measurement  from  the  acromion 
process  to  the  external  condyle 
remains  unaltered,  but  that  from 
the  condyle  to  the  styloid  pro- 
cess of  the  radius  is  distinctly 
shortened,  and  the  distance 
between  the  condyles  and  the 
olecranon  process  is  increased. 

Dislocation  forwards  of  both 
bones  rarely  occurs  without 
fracture  of  the  olecranon  pro- 
cess, although  a  few  cases  of 
this  unusual  accident  are  on 
record.  The  displacement  is 
readily  detected,  the  fore-arm 
being  lengthened  perhaps  to  the 
extent  of  an  inch.  The  arm  is 
in  a  condition  of  flexion,  and, 
indeed,  the  accident  can  only 
take  place  from  falling  back- 
wards on  the  point  of  the  elbow 
when  in  this  position.  The 
triceps  muscle  may  be  con- 
siderably lacerated. 

Lateral  dislocations  of  the  fore-arm  are  almost  always  incomplete, 

and   are   not  very   frequent ;   the   bones   may   be   displaced   either 

inwards  or  outwards,  the  latter  being  the  more  common.     They  are 

.  recognised  by  a  careful  examination  of  the  relative  position  of  the 

bony  prominences  and  by  stereoscopic  radiography. 

2.  Dislocation  of  the  Ulna  alone  occurs  only  in  a  backward  direction. 
It  is  very  rare  owing  to  the  position  and  strength  of  the  orbicular 
and  oblique  ligaments  and  of  the  interosseous  membrane.  If,  how- 
ever, the  bones  of  the  fore-arm  are  rotated  backwards  upon  the 
head  of  the  radius  as  a  fulcrum,  and  then  the  fore-arm  adducted,  this 
displacement  can  occur  without  extensive  ligamentous  lacerations, 
which,  indeed,  have  not  been  noted  in  any  of  the  cases  observed. 

In  the  Treatment  of  the  above  dislocations,  all  that  is  necessary  is 


Fig.  288. — Reduction  of  Backward 
Dislocation  at  the  Elbow. 


624  A  MANUAL  OF  SURGERY 

to  unhitch  the  interlocking  bony  prominences,  so  as  to  allow  the 
bones  to  return  to  their  normal  positions  by  muscular  contraction. 
This  is  usually  accomplished  by  the  method  described  by  Sir  Astley 
Cooper.  The  patient  being  in  a  sitting  position,  the  surgeon  presses 
backwards,  with  his  knee  in  the  bend  of  the  elbow,  against  the 
lower  end  of  the  humerus  ;  at  the  same  time  he  grasps  the  patient's 
wrist,  and  slowly  and  forcibly  bends  the  fore-arm  (Fig.  288). 

3.  Dislocation  of  the  Radius  alone  may  occur  either  forwards,  back- 
wards, or  outwards. 

The  forward  dislocation  (Fig.  289)  is  that  usually  seen,  and  results 
from  falls  on  the  hand  when  the  fore-arm  is  in  a  state  of  extreme 
pronation,  or  from  forcible  traction  upon  the  hand,  or  from  direct 
injury  applied  to  the  back  and  outer  side  of  the  elbow.  The  head  of 
the  radius  rests  against  the  lower  end  of  the  humerus  in  the  hollow 
above  the  capitellum,  and  the  most  characteristic  feature  consists 
in  the  inability  of  the  patient  to  flex  his  fore-arm,  owing  to  the  bone 
impinging  against  the  lower  end  of  the  humerus.     It  can  be  readily 

detected  in  this  situation,  rotating 
with  the  movements  of  the  fore-arm, 
whilst  a  deep  hollow  is  felt  behind, 
immediately  below  the  external  con- 
dyle. The  fore-arm  is  somewhat 
flexed,  and  midway  between  prona- 
tion and  supination  ;  the  former  act 
can  be  satisfactorily  accomplished, 
but  supination  cannot  be  carried 
further  than  half-way.  A  marked 
fulness  exists  on  the  anterior  aspect 

„         „        T^  of   the  limb  when  the  arm  is  ex- 

FiG.    280. — Dislocation    of    thh      .       1    1      t-        ,  r  ,1  ,1  •    1 

Radius  Forwards.    (Pick.)  tended.    Fracture  of  the  upper  third 

of  the  ulna  sometimes  accompanies 
this  accident,  especially  when  produced  by  direct  violence.  If  this 
luxation  is  not  reduced,  great  impairment  of  the  mobility  of  the 
limb  results,  flexion  beyond  an  obtuse  angle  becoming  impossible. 
Treatment. — Reduction  is  accomplished  by  traction  from  the  wrist, 
with  the  fore-arm  flexed  to  a  right  angle,  combined  with  pressure 
over  the  head  of  the  bone.  Owing  to  the  fact  that  the  orbicular 
ligament  is  ruptured,  the  deformity  is  likely  to  recur,  and  hence 
active  movements  of  the  limb  rftust  be  interdicted  for  three  or  four 
weeks ;  a  pad  is  placed  anteriorly  over  the  head  of  the  bone,  and  the 
limb  fixed  on  a  splint.  In  old-standing  cases  excision  of  the  head 
of  the  bone  is  desirable. 

Dislocation  backwards  is  less  common.  The  head  lies  behind  the 
external  condyle  on  the  outer  side  of  the  olecranon,  where  it  can  be 
detected  on  rotating  the  limb  (Fig.  290).  The  fore-arm  is  flexed, 
and  the  limb  pronated.  Even  if  left  unreduced,  it  leads  to  but  little 
inconvenience. 

Dislocation  outwards  is  also  rare,  the  head  of  the  bone  being  dis- 
placed to  the  outer  side  of  the  external  condyle,  where  it  can  be 


INJURIES  OF  JOINTS— DISLOCATIONS 


625 


felt,  causing  considerable  impairment  of  movement.  Reduction  is 
accomplished  without  difficulty,  or,  if  necessary,  the  head  may  be 
excised. 

Occasionally  a  rare  form  of  dislocation  is  met  with  in  which  the 
ulna  passes  backwards  and  the  radius  forwards,  resulting  in  great 
deformity. 

A  very  common  accident  in  children  under  four  years  of  age 
consists  of  a  subluxation  of  the  liead  of  the  radius  downwards 
within  the  orbicular  ligament,  so  that  a  fold  of  synovial  membrane 
slips  up  and  becomes  nipped  between  the  head  and  capitellum. 
It  results  from  forcible  traction  of  the  hand,  as  from  pulling  up  a 
child  roughly  after  it  has  fallen,  and  is  a  common  nursery  accident, 
popularly  known  as  pulled  elbow.  The  limb  becomes  fixed  in  a 
position  of  slight  flexion,  and  with  the  hand  pronated,  and  the  child 
cries  out  with  the  pain  ;  it  is  readily  treated  by  completely  flexing  the 
limb,  and  subsequently  extending 
and  fully  supinating  it,  and  leaves 
no  bad  results. 

It  must  not  be  forgotten  that 
here  merely  the  pure  dislocations 
have  been  described.  In  actual 
practice  complications  of  a  serious 
nature  are  frequently  present  in 
the  shape  of  fracture  of  one  or 
both  condyles,  which  lead  to  much 
difficulty  in  diagnosis.  These  frac- 
ture-dislocations give  rise  to  so 
much  haemorrhage  that  diagnosis 
is  often  impossible  without  radio- 
graphy, and  even  then  the  results 
of  treatment  may  be  unsatisfactory. 
Abundant  callus  is  formed,  and  fibrous  adhesions  of  such  strength 
are  developed,  that  considerable  impairment  of  function  is  almost 
certain  to  ensue.  Probably  early  operative  treatment  is  in  these 
cases  the  best. 

Dislocation  of  the  Wrist  is  a  very  uncommon  accident,  and  may 
occur  forwards  or  backtuards.  The  lower  ends  of  the  radius  and 
ulna  project  under  the  skin,  and  the  styloid  processes  retain  their 
relative  positions ;  it  is  thereby  easily  distinguished  from  a  Colles's 
fracture. 

Occasionally  the  radius,  carrying  with  it  the  hand,  is  dislocated 
from  the  lower  end  of  the  ulna,  as  a  result  of  forcible  pronation, 
which  results  in  laceration  of  the  inferior  radio-ulnar  ligaments,  and 
probably  of  the  lowest  portion  of  the  interosseous  membrane.  The 
triangular  fibro-cartilage  is  in  some  of  these  cases  loosened,  and  its 
mobility  may  subsequently  give  rise  to  a  painful  weakness  of  the 
wrist.  The  ulna  projects  backwards,  and  its  reduction  is  easy  ;  but 
some  laxity  of  the  inferior  radio-ulnar  joint  may  persist,  unless  the 
bones  are  kept  firmly  together  by  suitable  bandaging. 

40 


Fig.  290.  —  Dislocation  of  the 
Radius  Backwards.  (Diagram- 
matic.) 


626 


A  MANUAL  OF  SURGERY 


Dislocations  of  various  Carpal  Bones  have  been  described,  and 
skiagraphy  has  demonstrated  that  they  are  by  no  means  uncommon. 
That  which  is  best  known  is  a  displacement  of  the  os  magnum 
backwards.  It  forms  a  rounded  prominence  under  the  skin  in  the 
usual  situation  of  the  bone,  which  becomes  more  prominent  on 
flexion,  and  may  disappear  on  extension.     As  a  rule,  it  is  readily 

reduced,  but   is  very  likely  to 
/~\  recur.    If  troublesome,  the  bone 

may  be  excised. 

Dislocations  of  the  Metacar- 
pal Bones  and  Phalanges  are 
not  unfrequent,  but  need  no 
special  mention,  except  in  the 
case  of  Dislocation  Backwards 
of  the  First  Phalanx  of  the 
Thumb.  The  chief  interest 
here  lies  in  the  difficulty  ex- 
perienced in  reduction,  which 
was  formerly  attributed  to  the 
head  slipping  between  the  two 
portions  of  the  flexor  brevis 
pollicis  and  being  grasped  by 
them,  as  a  button  in  a  button- 
hole. It  has  now  been  shown 
that  there  are  two  much  more 
important  factors,  viz.,  the 
tension  of  the  long  flexor 
tendon,  which  hitches  round 
the  neck  (Fig.  291),  and  the 
arrangement  of  the  glenoid 
ligament.  This  fibro-cartilagi- 
nous  structure  passes  between 
the  two  heads  of  insertion  of  the  short  flexor,  and  is  thus  incorporated 
between  the  two  sesamoid  bones;  whilst  firmly  attached  to  the 
base  of  the  phalanx,  it  is  but  loosely  connected  with  the  head  of  the 
metacarpal  bone,  so  that  it  accompanies  the  phalanx  in  its  disloca- 
tion, and  will  then  be  situated  immediately  behind  the  head  of  the 
metacarpal,  so  as  to  prevent  any  attempts  at  reduction.  Treat- 
ment.— Traction  and  manipulation  are  always  attempted  in  the  first 
instance.  The  thumb  is  grasped  by  a  suitable  apparatus  and 
hyper-extended  to  a  right  angle,  thus  making  the  head  of  the 
metacarpal  project  still  further  through  the  muscular  interspace, 
and,  as  it  were,  enlarging  the  buttonhole.  Still  maintaining  the 
traction,  the  thumb  is  rapidly  flexed  into  the  palm,  the  metacarpal 
bone  being  at  the  same  time  pressed  inwards.  Should  this  fail,  as  it 
often  will,  a  sterilized  tenotome  should  be  inserted  in  the  middle  line 
of  the  thumb  behind,  immediately  above  the  base  of  the  phalanx, 
and   should   be   pushed  on   till   it   reaches  and  divides  the  glenoid 


Fig.  291.  —  Dislocation  of  Thumb, 
SHOWING  Head  of  the  Metacarpal 
Bone  protruding  Forwards  between 
THE  Heads  of  the  Short  Flexor 
Muscle.     (Pick.) 


INJURIES  OF  JOINTS— DISLOCATIONS  627 

fibro- cartilage  between  the  sesamoid  .  bones ;  this  Httle  manoeuvre 
will  at  once  render  replacement  simple. 

Dislocation  of  tlie  Hip,  though  not  very  common,  is  a  condition 
of  extreme  gravity.  The  depth  of  the  socket  in  which  the  femur 
rests,  and  the  strength  of  the  muscles  and  ligaments  surrounding 
the  articulation,  explain  the  comparative  unfrequency  of  the  accident. 
It  always  results  from  violence  applied  to  the  feet  or  knees,  or,  if  the 
legs  be  fixed,  to  the  back.  It  is  rarely  met  with  except  in  young 
people  or  adults,  since  after  the  age  of  forty-five  fractures  of  the 
neck  of  the  bone  are  much  more  likely  to  occur. 

Four  chief  varieties  of  dislocation  are  described,  in  two  of  which 
the  head  of  the  bone  is  displaced  posteriorly,  and  in  two  anteriorly. 
The  two. former  are  known  as  the  Dorsal  and  the  Sciatic  Varieties, 
in  which  the  head  of  the  bone  occupies  some  situation  on  the  dorsum, 
ilii,  determined  by  the  integrity  or  not  of  the  obturator  internus  tendoni 
The  two  anterior  dislocations  are  known  as  the  Obturator  ox  Thyroid, 
and  the  PuUc  ;  in  the  former  the  head  of  the  bone  is  located  in  the 
obturator  notch,  and  in  the  latter  upon  the  pubic  ramus.  The  relative 
frequency  of  these  dislocations  is  as  follows :  About  50  to  55  per 
cent,  of  the  cases  are  of  the  dorsal  type,  20  to  25  per  cent,  sciatic, 
10  to  15  per  cent,  obturator,  and  5  to  10  per  cent,  pubic.  In  addition 
to  these  four  varieties,  many  other  slight  modifications  have  been 
described,  which  it  will  be  unnecessary  further  to  particularize. 

Mechanisnl. — In  considering  these  dislocations,  the  relative  strength 
or  weakness  of  the  different  parts  of  the  capsule  and  its  surrounding 
structures  must  be  remembered.  The  weakest  part  of  the  capsule  is 
placed  below  and  behind,  and  it  is  through  a  rent  in  this  position  that 
the  head  of  the  bone  most  frequently  escapes.  In  front,  the  ilio- 
femoral or  Y-shaped  ligament  of  Bigelow  is  a  structure  of  much 
strength,  on  the  integrity  of  which  depends  the  fact  whether  the ,  dis- 
placed head  of  the  bone  shall  occupy  some  definite  position  or  be 
freely  moveable.  Bigelow,  to  whom  we  owe  so  much  in  the 
elucidation  of  the  mechanism  of  these  dislocations,  has  divided  them 
into  two  classes — the  regular  and  the  irregular — according  to  whether 
this  ligament  is  intact  or  completely  lacerated.  Posteriorly,  the 
plicated  tendon  of  the  obturator  internus  is  the  most  important 
structure,  and  the  position  and  level  of  the  bone  on  the  dorsum  ilii 
depends  in  some  measure  on  whether  it  remains  intact  or  is  ruptured. 
It  must  also  be  remembered  that  the  ligamentum  teres  is  relaxed 
when  the  thigh  is  forcibly  abducted,  and  is  made  tense  by  adduction. 

The  limb  is  usually  in  a  position  of  abduction  at  the  moment  of 
dislocation,  the  head  of  the  bone  escaping  through  a  rent  in  the 
lower  and  back  part  of  the  capsule.  The  type  of  accident  responsible 
for  this  is  a  fall  with  the  legs  widely  separated,  or  when  the  limbs  are 
drawn  forcibly  apart,  as,  for  instance,  when  one  leg  is  placed  on 
a  boat  just  moving  away  from  a  pier  on  which  the  other  is  fixed. 
The  direction  of  the  violence,  or  the  subsequent  manipulations 
performed  by  willing  but  ignorant  friends,  or  the  voluntary  move- 
ments of  the  individual,  determine  what  form  of  dislocation  will  be 


628 


A  MANUAL  OF  SURGERY 


subsequently  produced.  If  the  limb  is  externally  rotated  and 
extended,  or  the  trunk  is  hyper-extended  and  the  limb  remains  fixed, 
the  head  travels  forwards,  and  either  the  pubic  or  obturator  variety 
results.  If,  however,  the  leg  is  inverted  and  flexed,  the  head  of  the 
bone  passes  backwards,  and  either  the  dorsal  or  sciatic  form  is 
produced.  Again,  in  the  posterior  dislocations,  if  the  obturator 
internus  tendon  remains  intact,  it  may  hitch  across  the  front  of  the 
neck,  and  prevent  any  further  upward  displacement  of  the  bone,  thus- 
giving  rise  to  the  so-called  sciatic  variety,  or 
as  Sir  Astley  Cooper  called  it,  the  dorsal  below 
the  tendon ;  but  if  the  tendon  is  ruptured,  or 
if  the  head  of  the  bone  slips  in  front  of  it, 
there  is  no  obstacle  to  its  upward  displace- 
ment on  the  dorsum  ilii. 

Dislocation  may,  however,  also  result  when 
the  limb  is  in  a  position  of  adduction,  a  direct 
dorsal  dislocation  being  thus  produced,  the 
head  of  the  bone  escaping  from  the  capsule 
above  the  tendon  of  the  obturator  internus ; 
such  an  accident  is  sometimes,  but  not  always, 
associated  with  fracture  of  the  posterior  lip  of 
the  acetabulum.  The  type  of  violence  leading 
to  this  occurrence  is  when  a  heavy  weight 
falls  on  the  back  of  a  person  whilst  kneeling, 
or  when,  the  knee  being  flexed,  the  body  is 
thrust  forwards,'  so  that  the  limb  is  forcibly 
inverted.  If,  however,  the  thigh  is  in  a  posi- 
tion of  extreme  flexion,  the  head  may  be 
displaced  below  the  tendon  of  the  obturator 
internus,  and  the  sciatic  variety  will  then 
result. 

I.  Dorsal  Dislocation  (Fig.  292). — The  head 
of  the  bone  in  this  form  is  found  lying  on 
the  dorsum  ilii,  a  variable  distance  above  and 
behind  the  acetabulum,  and  always  above 
the  obturator  internus  tendon.  It  may  be 
detected  on  manipulation  of  the  limb,  although 
in  muscular  subjects  this  is  difficult.  The 
ligamentum  teres  is  necessarily  ruptured,  as 
also  the  capsule,  the  rent  being  situated  either 
below  or  above  the  obturator  tendon,  according  to  whether  the  dis- 
location is  due  to  forcible  abduction  or  adduction.  The  small 
external  rotator  muscles  are  often  lacerated,  and  perhaps  even  the 
glutei  and  the  pectineus.  The  ilio-femoral  ligament  usually  remains 
intact.  The  great  sciatic  nerve  is  sometimes  compressed  or  con- 
tused. The  trochanter  is  raised  above  Nelaton's  line  (p.  535)  and 
approximated  to  the  anterior  superior  spine  ;  the  ilio-tibial  band  of 
fascia  is  therefore  relaxed,  and  there  is  considerable  shortening  of 
the  limb,  amounting  sometimes  to  2  or  3  inches.     The  leg  is  in  a 


Fig.  292. — Dorsal  Dis- 
location OF  THE  Hip. 

(TiLLMANNS.) 


INJURIES  OF  JOINTS— DISLOCATION S 


629 


Fig.  293. — Reduction  of 
Dorsal  Dislocation 
OF  Hip      (Bryant.) 


position  of  flexion,  adduction,  and  inversion,  so  that  the  axis  of  the 
femur  crosses  the  lower  third  of  the  sound  thigh.  The  knee  is  semi- 
flexed, and  the  ball  of  the  great  toe  rests  against  the  opposite  instep  ; 
the  heel  is  somewhat  raised.  A  marked  hollow  is  felt  in  the  upper 
part  of  Scarpa's  triangle,  and  the  main  vessels  of  the  limb  appear  to 
be  unsupported. 

The  Diagnosis  should  be  easy,  the  only  difficulty  being  experienced 
in  distinguishing  it  from  an  impacted  extra- 
capsular fracture.  The  character  of  the 
accident,  the  presence  of  adduction  and 
inversion,  the  increased  breadth  of  the  tro- 
chanter in  the  case  of  fracture,  and  the 
abnormally  placed  head  of  the  bone  in  dis- 
location, are  the  points  to  which  attention 
must  be  directed. 

2.  Sciatic  Dislocation,  or  dorsal  below  the 
tendon,  is  one  in  which  the  head  of  the  bone 
is  prevented  from  travelling  upwards  to  the 
dorsum  ilii  by  the  integrity  of  the  obturator 
internus  tendon.  It  may  occur  either  from 
forced  abduction  of  the  limb,  or  from  extreme 
flexion  in  the  adducted  position.  The  lesions 
of  muscles  and  ligaments  are  practically  the 
same  as  for  the  dorsal  variety.  The  ilio- 
femoral ligament  is  uninjured. 

The  Signs  resemble  those  of  a  dorsal  dislocation,  but  are  less 
marked.  There  is  less  shortening,  often  not  more  than  ^  to  i  inch  ; 
the  Hmb  is  flexed,  adducted,  and  inverted,  but  the  axis  of  the  femur 
is  directed  across  the  opposite  knee,  and  the  great  toe  rests  against 
the  ball  of  the  great  toe  of  the  opposite  side.  The  head  of  the  bone 
is  often  much  less  distinct,  owing  to  the  greater  thickness  of  the 
glutei  muscles  at  the  lower  level. 

Treatment  of  the  Two  Backward  Dislocations  is  effected  in  much 
the  same  way,  whether  the  dorsal  or  sciatic  variety  is  present.  The 
most  usual  method  is  that  of  manipulation  and  rotation,  so  accurately 
worked  out  by  Bigelow.  The  patient  is  anaesthetized,  preferably  on 
a  mattress  placed  on  the  floor.  The  leg  is  first  flexed  on  the  thigh, 
and  the  thigh  on  the  abdomen,  the  position  of  adduction  being  still 
maintained,  so  that  the  knee  extends  beyond  the  middle  line  of  the 
body  (Fig.  293).  This  position  is  maintained  for  some  moments,  and 
then  the  limb  is  freely  circumducted  outwards,  and  brought  rapidly 
down  into  a  position  of  extension  parallel  with  the  other.  By  this 
manoeuvre  the  tense  structures  in  front  of  the  joint  are  relaxed,  and 
then  the  head  of  the  bone  is  made  to  retrace  its  course  towards  the 
rent  in  the  capsule,  and  finally  directed  upwards  into  the  acetabular 
cavty.  These  movements  are  tersely  summarized  in  Bigelow's  words 
— ^ Lift  up,  bend  out,  roll  out.' 

If  this  plan  does  not  succeed,  the  following  method  of  traction  may 
be  employed.     The  patient,  lying  on  his  back,  is  firmly  fixed  by  a 


630 


A   MANUAL  OF  SURGERY 


bandage  or  towel  passed  over  the  pelvis  and  secured  to  two  or  three 
hooks  or  staples  driven  into  the  floor.  The  surgeon  stands  over  the 
patient,  whose  thigh  is  flexed  to  a  right  angle  on  the  abdomen,  as 
also  the  knee  upon  the  thigh.  The  surgeon's  arms  are  passed  under 
the  knee  sufficiently  far  to  enable  him  to  grasp  his  own  elbows,  and 
the  front  of  the  leg  is  steadied  against  the  operator's  perineum.  Direct 
and  forcible  traction  upwards  can  now  be  made,  and  this  is  often 


Fig.  294. — Dislocation  of  the 
Hip  :     Obturator    Variety. 

(TiLLMANNS.) 


Fig.  295. — Dislocation  of  the 
Hip  Forwards:  Pubic 
Variety.     (Tillmanns.) 


sufficient  in  itself  to  lift  the  head  of  the  bone  into  the  acetabulum. 
If  this  is  unsuccessful,  the  movements  described  above  can  be  ener- 
getically repeated  in  this  position.  The  above  plans,  combined  with 
the  use  of  an  anaesthetic,  rarely  fail  in  reducing  a  backward  disloca- 
tion of  the  hip,  and  hence  extension  by  means  of  pulleys  is  rarely  required. 
If,  however,  it  is  needed,  traction  should  always  be  made  in  the  direc- 
tion of  the  displaced  limb,  i.e.,  across  the  other  thigh,  counter-exten- 
sion being  obtained  by  a  jack-towel  passed  between  the  injured  thigh 
and  the  perineum,  and  fixed  to  a  staple  in  the  floor,  close  to  the  head 
of  the  patient,  and  applied  on  the  side  of  the  dislocation.  When  suffi- 
cient force  has  been  apphed,  the  surgeon  rotates  the  limb  outwards 
so  as  to  allow  the  head  of  the  bone  once  more  to  slip  into  its 
socket. 


INJURIES  OF  JOINTS— DISLOCATIONS 


631 


Fig.  296.  —  Reduction  of 
Anterior  Dislocation  of 
THE  Hip,     (Bryant.) 


3.  Thyroid  or  Obturator  Dislocation  (Fig.  294). — The  head  of  the 
bone  in  this  case  passes  downwards  through  a  rent  in  the  lower  part 
of  the  capsule,  and  its  position  is  subsequently  but  little  altered,  a 
slight  forward  and  upward  movement  being  alone  superadded.  The 
ilio-femoral  ligament  is  untorn,  but  the  pectineus  and  adductors  are 
very  tense,  or  may  even  be  lacerated  ;  the  ligamentum  teres  is, 
of  course,  ruptured.  The  head  lies  on  the  obturator  externus 
muscle,   and    can    be   detected    in    the 

perineum.  The  trochanter  is  less  promi- 
nent than  usual,  and,  indeed,  its  normal 
position  may  be  represented  by  a  depres- 
sion. The  limb  is  slightly  abducted  and 
everted,  as  well  as  lengthened,  perhaps 
to  the  extent  of  2  inches,  though  this  is 
more  apparent  than  real.  It  is  also 
flexed,  owing  to  the  tension  of  the  ilio- 
psoas muscle,  and  advanced  before  the 
other,  with  the  toes  pointing  outwards. 
The  adductor  longus  tendon  stands  out 
prominently,  and  much  pain  may  be 
experienced  from  pressure  on  the  ob- 
turator nerve.  If  the  patient  stands, 
the  body  is  bent  forwards,  whilst  it  is 
interesting  to  note  that  if  the  dislocation 
remains  unreduced  the  patient  may  be  able  to  walk  without  much 
pain  or  inconvenience,  though  in  a  more  or  less  stooping  position. 

4.  Pubic  Dislocation  (Fig.  295). — In  this  variety  the  head  of  the 
bone  either  escapes  from  the  joint  below,  or  may  be  forced  out  m 
front  and  to  the  inner  side  of  the  ilio-femoral  ligament  as  a  result  of 
hyper-extension  of  the  trunk.  The  head  lies  on  the  horizontal  ramus 
of  the  pubes,  just  internal  to  the  anterior  inferior  spinous  process  of 
the  ilium,  where  it  can  be  felt  rolling  under  the  finger  on  any  move- 
ment of  the  limb.  The  vessels  are  pushed  inwards,  and  considerable 
pain  may  be  felt  down  the  limb  from  pressure  on  the  anterior  crural 
nerve.  The  ilio-femoral  ligament  is  untorn,  whilst  the  ligamentum 
teres  and  capsular  ligament  are  ruptured  ;  the  small  external  rotator 
muscles,  with  the  exception  of  the  obturator  internus,  are  usually 
torn.  There  is  marked  flattening  of  the  hip,  the  trochanter  being 
approximated  to  the  middle  line  and  raised .  The  limb  is  shortened 
to  the  extent  of  i  inch,  and  there  is  considerable  abduction  and 
eversion,  so  that  the  inner  aspect  of  the  limb  looks  forwards.  The 
thigh  is  slightly  flexed  to  relax  the  ilio-psoas  muscle. 

Treatment  of  the  thyroid  and  pubic  dislocations  is  undertaken  along 
similar  lines  as  for  the  posterior  dislocations.  The  patient  is  anaes- 
■  thetized  ;  the  knee  is  flexed,  as  also  the  thigh  upon  the  abdomen,  but 
in  a  position  of  abduction ;  circumduction  inwards  follows  (Fig.  296), 
and  on  extension  of  the  limb  the  head  again  enters  the  acetabulum. 
The  thyroid  variety  may  sometimes  be  reduced  by  upward  and  out- 
ward traction  when  the  limb  has  been  flexed  to  a  right  angle  in  the 


^32    ■  A  MANUAL  OF  SURGERY 

abducted  position,  the  unbooted  foot  being  placed  against  the  pelvis 
to  steady  it. 

If  extension  by  pulleys  is  required  in  the  thyroid  dislocation,  it 
is  made  transversely  outwards  across  the  upper  part  of  the  thigh, 
counter-extension  being  obtained  by  means  of  a  band  passed  round 
the  abdomen.  The  limb,  at  first  in  a  position  of  abduction,  is  sub- 
sequently adducted  forcibly  by  drawing  the  ankle  inwards,  the  band 
by  means  of  which  extension  is  being  made  acting  as  a  fulcrum  to 
lever  the  head  of  the  bone  into  the  acetabulum.  In  the  pubic  variety 
traction  is  made  downwards,  outwards,  and  backwards,  and  the  head 
of  the  bone  drawn  into  its  socket  by  a  towel  passed  transversely 
across  the  limb. 

After  reduction  of  any  form  of  dislocation  of  the  hip,  the  patient 
should  be  kept  in  bed  with  the  legs  tied  together  for  about  a  fortnight, 
and  then  passive  movement  may  be  commenced,  but  with  consider- 
able caution  ;  voluntary  movements  should  not  be  undertaken  for 
another  week  or  two. 

Should  the  dislocation  recur,  it  may  be  due.  to  fracture  of  the 
posterior  lip  of  the  acetabulum,  or  to  some  involuntary  movements 
of  the  patient,  or  perhaps  to  the  fact  that  the  displacement  has  not 
been  fully  reduced.  Under  such  circumstances  further  attempts  at 
replacement  should  be  undertaken,  and  the  limb  subsequently  kept 
immobilized  for  a  longer  period  than  usual  with  a  weight-extension 
and  a  Listen's  splint. 

Irregular  dislocations  of  the  hip  occur  when  the  Y-shaped  ligament 
is  completely  torn  through,  so  that  the  head  of  the  bone  is  not 
restricted  by  it,  but  can  be  moved  round  the  acetabular  cavity. 
Reduction  is  usually  easy. 

Dislocation  of  the  Patella  may  occur  outwards,  inwards,  or  edgeways. 
A  dislocation  upwards  resulting  from  rupture  of  the  ligamentum 
patellae  is  sometimes  described,  but  it  is  scarcely  to  be  included  in 
the  same  category  as  the  others.  The  displacement  may  be  complete 
or  incomplete  ;  in  the  former  the  capsule  is  always  lacerated  ;  in  the 
latter,  not  necessarily  so 

The  outward  variety  is  much  the  commonest  on  account  of  the 
obliquity  of  the  limb,  and  may  result  from  muscular  action,  especially 
in  people  suffering  from  genu  valgum. ;  it  also  arises  from,  direct 
violence.  In  either  case  it  occurs  most  frequently  when  the  limb  is 
extended,  since  during  flexion  the  bone  is  firmly  lodged  in  the  inter- 
condyloid  notch.  When  completely  displaced,  it  lies  upon  the  outer 
surface  of  the  condyle,  with  its  inner  margin  projecting  forwards. 
In  this  situation  it  is  easily  felt,  whilst  the  knee  appears  flattened 
and  broader  than  usual,  the  intercondyloid  notch  being  plainly  dis- 
tinguishable in  the  position  usually  occupied  by  the  patella.  It  is 
not  unfrequently,  however,  incomplete,  and  then  the  inner  half  of  the 
articular  surface  of  the  patella  lies  in  contact  with  the  cartilaginous 
surface  of  the  outer  condyle,  with  its  outer  border  projecting  forwards. 
Reduction  may  take  place  spontaneously,  but  is  usually  effected  by 
manipulation.     The  ihigh  is  flexed  on  the  abdomen,  and  the  knee 


INJURIES  OF  JOINTS— DISLOCATIONS  633 

extended,  so  as  to  relax  the  quadriceps,  and  then  a  little  pressure  on 
its  outer  margin  causes  the  bone  to  slip  back  into  place.  In  the  in- 
complete form,  where  one  of  the  borders  of  the  bone  is  lodged  in  the 
intercondyloid  notch, reduction  is  sometimes  very  diffi  cult,  and  to 
effect  it  an  open  operation  may  be  required. 

The  inward  dislocation  is  rare,  being  always  due  to  direct  violence. 
In  characters  and  treatment  it  is  the  exact  converse  of  those  met  with 
when  the  bone  is  displaced  outwards. 

A  dislocation  edgeways,  or  Vertical  Rotation  of  the  patella,  is  an 
interesting  condition  in  which  the  bone  is  said  to  be  twisted  vertically 
upon  its  own  axis,  and  even  to  have  been  turned  completely  round. 
Incomplete  rotation  is  practically  identical  with  that  just  described 
as  an  incomplete  lateral  dislocation,  whilst  the  complete  rotation  of 
the  patella  must  indeed  be  a  rare  accident. 

Eecurrent  dislocation  of  the  patella  may  be  associated  with  genu 
valgum,  or  with  laxity  of  the  extensor  muscles  from  paralysis.  In 
the  former  case  it  may  be  cured  by  correcting  the  deformity  by 
means  of  osteotomy  of  the  femur  ;  but  sometimes  the  synovial  mem- 
brane of  the  knee-joint  on  the  inner  side  will  require  to  be  braced  up 
by  excision  of  a  portion  and  suture  of  the  margins  of  the  defect.  In 
the  paralytic  variety,  when  the  extensor  muscle  is  slack,  it  may 
suffice  to  pleat  up  the  rectus  or  to  shorten  it  by  a  plastic  operation. 

Dislocations  of  tlie  Knee  may  occur  laterally,  as  also  forwards  or 
hachjvavds.  When  due  to  disease  of  the  joint,  the  backward  disloca- 
tion is  commonest ;  but  when  arising  from  traumatic  causes,  the 
lateral  is  the  most  frequent. 

The  lateral  displacements  are  rarely  complete,  and  are  usually 
associated  with  a  certain  amount  of  rotation  ;  the  leg  is  partially 
flexed.     Reduction  is  effected  without  difficulty. 

Dislocation  of  the  tibia  forwards  is  more  common  than  displace- 
ment backwards.  It  is  generally  complete,  the  lower  end  of  the 
femur  projecting  into  the  popliteal  space,  and  compressing  the 
vessels,  so  that  gangrene  not  unfrequently  follows.  The  upper  end 
of  the  tibia,  carrying  with  it  the  patella,  lies  in  front,  forming  a  well- 
marked  swelling  with  a  hollow  above  it.  There  is  usually  consider- 
able shortening  of  the  limb  if  the  articular  surfaces  overlap. 

Dislocation  of  the  tibia  backwards  is  a  much  rarer  accident,  and  is 
also  usually  complete  (forty  out  of  fifty-five  cases  were  complete).* 
The  signs  are  exceedingly  characteristic,  the  pressure  effects  upon 
the  popliteal  vessels  and  nerves  often  resulting  in  gangrene  (ten  cases 
out  of  fifty-five). 

Reduction  of  either  of  these  conditions  is  easily  accomplished  by 
traction  on  the  limb,  whilst  the  thigh  is  flexed,  combined  with 
manipulation  in  order  to  guide  the  head  of  the  tibia  into  its  normal 
position.  The  limb  must  subsequently  be  kept  at  rest  on  a  splint  for 
two  or  three  weeks. 

Displacement  or  Rupture  of  a  Semilunar  Cartilage  {Syn. :  Subluxa- 
tion of  the  Knee,  Internal  Derangement  of  the  Knee-Joint)  is  a  condi- 

*  Sheldon,  Annals  of  Surgery,  January,  1903. 


6J4  A   MANUAL  OF  SURGERY 

tion  frequently  met  with,  resulting  from  sprains  and  strains 
associated  with  torsion.  In  any  rotary  movement  of  the  knee, 
which  is  only  possible  when  the  limb  is  flexed,  the  pressure  of  the 
condyles  always  tends  to  modify  the  position  of  the  cartilages,  which, 
moreover,  are  relaxed  and  mora  freely  moveable  on  the  upper  surface 
of  the  tibia  in  flexion  than  in  extension.  Displacement  of  a  cartilage 
is  almost  always  due  to  a  sudden  strain  or  wrench  of  a  rotary  type, 
e.g.,  turning  quickly  round  in  such  games  as  tennis  or  football,  or 
slipping  off  the  kerb  with  the  knee  bent.  The  inner  cartilage  is  much 
more  frequently  affected  than  the  outer,  and  the  character  and  extent 
of  the  lesion  varies  much  in  different  cases.  Sometimes  its  anterior  or 
posterior  tibial  attachment  is  torn  through,  thereby  permitting  con- 
siderable lateral  mobility  ;  but  more  frequently  the  cartilage  is  broken 
across  the  middle  or  split  longitudinally,  thereby  detaching  a  hinged 
portion  from  its  free  border,  which  slips  in  or  out  of  position,  and  not 
uncommonly  gets  nipped  between  the  bones,  or  may  even  be  doubled 
over.  It  subsequently  becomes  inflamed  and  swollen,  and  unless 
properly  treated  the  displacement  is  likely  to  be  repeated. 

The  Symptoms  produced  by  this  accident  are  a  sudden  sickening 
pain  of  much  severity,  located  in  the  knee,  which  becomes  partially 
locked  in  a  position  of  flexion,  with  inability  to  extend  it.  The  patient 
may  be  able  to  '  wriggle '  his  joint  free,  or  the  limb  may  remain  stiff 
for  some  hours,  or  even  a  day  or  two,  when  movement  suddenly 
returns  more  or  less  spontaneously,  a  snap  being  at  the  same  time 
felt  within  the  joint.  An  attack  of  subacute  synovitis  usually  follows. 
In  other  cases  the  cartilage  remains  out  of  place,  until  reduced  by  the 
surgeon,  with  or  without  an  anaesthetic.  If  the  case  is  not  correctly 
treated,  the  displacement  is  liable  to  recur,  the  cartilage  constantly  slip 
ping  in  and  out,  and  getting  nipped  between  the  bones ;  as  time  goes 
on,  this  becomes  more  and  more  easy,  owing  to  the  ligaments  of  the 
joint  being  relaxed  from  the  recurrent  attacks  of  synovitis.  In  fact, 
the  limb  may  pass  into  such  a  state  of  chronic  weakness  as  to  inter- 
fere seriously  with  the  patient's  comfort.  There  is  usually  a  spot  of 
localized  pain  in  the  front  of  the  joint,  corresponding  to  the  upper 
surface  of  the  tibia  ;  possibly  there  may  be  some  amount  of  lateral 
mobility  of  the  leg',  and  movement  of  the  cartilage  may  be  detected 
on  flexing  and  extending  the  knee. 

The  Diagnosis  is  not  always  easy,  as  the  symptoms  may  be 
simulated  by  other  conditions,  such  as  a  loose  foreign  body  in  the 
joint  (p.  674),  or  a  fringe  of  synovial  membrane  thickened  and 
swollen  protruding  backwards  and  getting  caught  between  the  bones, 
or  perhaps  pushed  backwards  by  enlargement  of  the  bursa  beneath 
the  ligamentum  patellae.  The  definite  history  of  a  traumatic  onset  is 
an  important  element  in  the  diagnosis  of  a  torn  or  loose  meniscus. 
Inflammation  of  a  semilunar  cartilage  {meniscitis)  also  needs  to  be 
considered ;  it  usually  results  from  a  heavy  fall  on  the  foot  or  heel, 
whereby  the  cartilage  is  bruised  ;  painful  limitation  of  movement 
results,  and  especially  pain  on  standing ;  there  are  usually  no  sudden 
attacks  of  painful  locking  of  the  joint,  but  the  cartilage  is  tender,  and 
can  perhaps  be  felt,  though  it  is  not  moveable. 


INJURIES  OF  JOINTS— DISLOCATIONS 


635 


The  Treatment  in  the  early  stages  consists  in  replacement  of  the 
cartilage  by  manipulation.  The  limb  is  fully  flexed  and  then 
suddenly  extended,  pressure  being  applied  at  the  same  time  in  the 
neighbourhood  of  the  displaced  cartilage,  which  often  returns  into 
position  with  a  distinct  snap.  The  limb  is  subsequently  kept  at  rest 
on  a  back-splint,  and  cooling  lotions  are  applied  until  the  inflamma- 
tion has  subsided  ;  it  is  then  further  im- 
mobilized for  some  weeks  in  plaster  of 
Paris  or  water-glass,  so  as  to  allow  the 
lacerated  ligaments  to  reunite  and  con- 
solidate. At  the  expiration  of  six  or  eight 
weeks  after  the  accident  an  elastic  knee-cap 
is  applied,  massage  is  employed,  passive 
movements  are  permitted,  followed  by 
active  movements,  and  finally  the  patient 
is  again  allowed  to  walk. 

When  the  cartilage  has  become  loose 
and  is  constantly  slipping  out  of  place, 
immobilization  of  the  limb,  with  pressure 
by  an  elastic  knee-clip,  or  by  a  knee-truss 
(Fig,  297),  may  be  useful.  Should  this  not 
prove  satisfactory,  operative  proceedings 
must  be  undertaken. 

The  knee-joint  is  opened  by  a  curved 
incision  on  the  appropriate  side  of  the 
patella,  and  the  condition  of  the  cartilage 
ascertained.  If  of  normal  shape  and 
merely  loose  and  moveable,  it  may  perhaps  be  stitched  to  the  peri- 
osteum over  the  head  of  the  tibia,  so  as  to  keep  it  from  again  slipping 
between  the  bones  ;  this  is  sometimes  best  accomplished  by  splitting 
the  cartilage  diagonally  into  two  portions,  and  securing  each  of  these 
by  two  or  three  stitches.  If,  however,  the  anterior  end  is  doubled 
over  on  itself,  or  deformed,  or  if  fixation  seems  impracticable,  it  may 
be  removed  ;  it  is  astonishing  how  well  patients  get  on  after  such  an 
operation. 

For  general  considerations  concerning  intra-articular  operations, 
see  p.  640. 

Rupture  of  the  Crucial  Ligaments  is  another  form  of  internal 
derangement,  resulting  from  great  violence.  The  integrity  and 
strength  of  the  joint  are  much  impaired,  and  abnormal  lateral 
and  antero- posterior  movements  are  possible.  Should  the  con- 
dition persist,  the  joint  may  be  freely  opened,  and  the  ligaments 
sutured.* 

Dislocations  of  the  Ankle-joint  may  occur  in  the  following  direc- 
tions :  outwards,  inwards,  backwards,  forwards,  and  upwards,  this  being 
the  order  of  their  frequency.  Owing  to  the  fact  that  the  astragalus 
is  wedged  like  a  block  into  the  mortice  formed  by  the  lower  ends  of 


Fig.  297.  —  Knee  Truss 
FOR  Dislocated  In- 
ternal  or  external 
Semilunar  Cartilages, 
orforChronic  Disloca- 
tions OF  THE  Patella. 


•  Mayo  Robson,  Annals  of  Surgery,  May,  1903. 


636 


A   MANUAL  OF  SURGERY 


the  tibia  and  fibula,  it  is  obvious  that  fractures  of  these  bones  are  fre- 
quently met  with  as  complications. 

The  lateral  dislocations  are  in  reality  fracture -dislocations,  and 
have  been  already  described  in  the  chapter  on  fractures  (p.  556). 

Although  the  upper  articular  surface  of  the  astragalus  is  broader  in 
front  than  behind,  dislocation  of  the  foot  backwards  is  a  more  common 
accident  than  displacement  forwards.  It  results  from  falls  on  the  feet 
while  running  or  jumping,  or  by  sudden  violence  applied  to  the  limb 
when  the  foot  is  fixed.  Usually  both  malleoli  are  fractured,  and  the 
articular  surface  of  the  astragalus  is  thrown  behind  the  lower  end  of 
the  tibia.     The  heel  projects  unduly  backwards,  and  the  articular 


Fig.  298. — Dislocation  of  the  Astragalus  Forwards. 


surface  of  the  tibia  usually  rests  upon  the  neck  of  the  astragalus,  the 
scaphoid,  or  even  the  cuneiform  bones. 

Dislocation  forwards  is  very  uncommon,  and  may  occur  without 
any  associated  fracture  of  the  bones  of  the  leg.  The  foot  is  appar- 
ently lengthened,  and  the  tibia  rests  upon  the  posterior  part  of  the 
upper  surface  of  the  os  calcis,  behind  the  astragalus.  The  prominence 
of  the  heel  and  of  the  tendo  Achillis  is  lost,  and  the  normal  depression 
in  front  of  the  latter  structure  is  occupied  by  the  lower  ends  of  the 
bones  of  the  leg. 

The  treatment  of  antero-posterior  dislocations  consists  in  reduction 
by  traction.  The  leg  is  flexed  upon  the  thigh,  so  as  to  relax  the 
tendo  Achillis,  or,  if  necessary,  this  structure  is  divided.  The  ankle 
is  subsequently  commanded  by  a  pair  of  Cline's  side-splints,  care 
being  taken  to  keep  the  foot  at  right  angles  to  the  leg,  and  the 
articular  surfaces  of  the  astragalus  and  tibia  exactly  in  apposition, 
thus  preventing  displacement  of  the  heel  backwards  or  forwards. 


INJURIES  OF  JOINTS— DISLOCATIONS  637 

A  dislocation  upwards  has  been  described  in  which  the  astragalus, 
together  with  the  foot,  is  carried  up  between  the  tibia  and  fibula, 
owing  to  a  rupture  of  the  inferior  tibio-fibular  ligament  and  the  lower 
end  of  the  interosseous  membrane.  The  displacement  is  very  marked, 
and  the  character  of  the  lesion  very  evident. 

Dislocations  of  tlie  Astragalus  alone  are  by  no  means  common. 
They  consist  in  a  partial  or  complete  detachment  of  the  bone  from  all 
its  normal  connections,  both  to  the  bones  of  the  leg  and  of  the  foot, 
and  its  displacement  from  under  the  tibio-fibular  arch.  It  may  travel 
backwards  or  forwards  with  or  without  lateral  rotation,  and  be  complete 
or  incomplete. 

Dislocation  forwards  (Fig.  298)  is  much  the  more  common  variety, 
and  is  usually  associated  with  partial  rotation,  the  displacement 
occurring  more  frequently  outwards  than  inwards.  When  complete, 
the  bone  is  entirely  detached  from  its  connections,  and  lies  upon  the 
upper  surface  of  the  scaphoid  and  cuneiform  bones,  the"  skin  of  the 
dorsum  being  tightly  stretched  over  it,  or  even  torn.  The  limb  is 
shortened,  and  the  malleoli  are  approximated  to  the  sole,  the  lower 
end  of  the  tibia  resting  on  the  upper  surface  of  the  os  calcis. 

In  the  complete  variety,  the  head  of  the  astragalus  impinges 
either  upon  the  scaphoid  on  the  inner  side,  or  the  cuboid  on  the 
outer,  whilst  the  lower  end  of  the  tibia  rests  on  the  posterior  half  of 
the  articular  surface  of  the  astragalus. 

Dislocation  backwards  is  almost  always  complete,  and  may  or  may 
not  be  associated  with  rotation  of  the  bone,  which  can  easily  be  felt 
between  the  tendo  Achillis  and  the  malleoli. 

Treatment. — Reduction  is  only  possible  in  the  incomplete  forms  of 
dislocation.  The  patient  is  anaesthetized,  the  knee  flexed  to  relax  the 
muscles  or  the  tendo  Achillis  divided,  and  traction  upon  the  foot 
established,  so  as  to  enable  the  surgeon  to  apply  pressure  upon  the 
displaced  bone  in  a  suitable  direction.  In  the  complete  variety  re- 
duction is  impracticable,  owing  to  the  fact  that  the  os  calcis  is  drawn 
up  into  contact  with  the  malleolar  arch.  In  such  cases  manipulation 
is  useless,  and  excision  of  the  bone  is  necessary.  Comparatively  little 
impairment  in  the  function  of  the  foot  results  from  this  operation. 

Subastragaloid  Dislocation. — By  this  term  is  meant  a  displacement 
of  all  the  bones  of  the  foot  from  below  the  astragalus,  which  retains 
its  normal  position  between  the  malleoli.  It  is  due  to  some  violent 
strain  or  wrench  of  the  foot.  Displacement  may  occur  either  for- 
wards or  backwards,  but  in  the  great  majority  of  cases  it  is  either 
backwards  and  inwards  or  backwards  and  outwards.  The  luxation  is 
rarely  complete  as  regards  the  calcaneo-astragaloid  joint,  but  the 
articular  surfaces  of  the  head  of  the  astragalus  and  scaphoid  are 
completely  separated,  the  former  structure  lying  on  the  dorsal  surface 
of  the  latter  bone.  The  foot  is  greatly  deformed,  the  anterior  portion 
being  shortened,  the  heel  projecting,  and  the  toes  pointing  down- 
wards. The  head  of  the  astragalus  forms  a  rounded  globular 
swelling  under  the  tense  skin.  In  a  compound  dislocation  of  this 
nature  examined  post-mortem,  the  inner  edge  of  the  under  surface  of 


638  A  MANUAL  OF  SURGERY 

the  astragalus  had  burst  through  the  skin  ;  the  vessels  and  nerves 
were  torn  or  stretched,  and  even  when  the  wound  in  the  skin  had 
been  enlarged,  reduction  was  impossible  owing  to  the  tendons  which 
were  caught  around  the  neck  of  the  astragalus.  In  such  a  case 
removal  of  the  astragalus  would  have  been  the  only  practicable 
treatment. 

In  the  inward  displacements,  the  foot  is  somewhat  inverted,  so 
that  the  outer  malleolus  is  unduly  prominent,  and  the  inner  malleolus 
is  lost  in  a  deep  depression  caused  by  the  lateral  displacement  of  the 
OS  calcis ;  the  foot  is  thus  in  a  position  somewhat  simulating  talipes 
equino-varus.  In  the  outward  dislocations  the  foot  is  everted,  the 
inner  malleolus  prominent,  and  the  outer  buried,  a  position  of  talipes 
equino-valgus  being  thus  assumed.  In  both  forms  the  tendo  Achillis 
is  curved,  with  its  concavity  towards  the  displacement.  Treatment 
consists  in  reduction  by  manipulation,  which  is  sometimes  readily 
accomplished,  but  may  be  a  matter  of  the  greatest  difficulty,  pro- 
bably from  the  tibial  tendons  becoming  hitched  around  the  neck  of 
the  astragalus.  Section  of  the  tendo  Achillis  is  occasionally  needed. 
In  difficult  cases  excision  of  the  astragalus  may  be  required,  and 
when  there  is  much  associated  injury  to  the  soft  parts  amputation. 


CHAPTER  XXII. 

DISEASES  OF  JOINTS. 

General  Considerations.  —  A  careful  study  of  the  anatomy  and  physiology  of 
joints  is  required  in  order  to  appreciate  the  many  problems,  mechanical  and 
pathological,  which  confront  the  surgeon  in  the  treatment  of  their  diseases. 
Limitations  of  space  prevent  us  from  discussing  these,  but  we  would  remind 
students  that  the  exposed  ends  of  the  bones  entering  into  a  joint  are  covered  with 
articular  cartilage,  and  in  young  people  are  separated  from  the  shafts  by  the 
intervention  of  epiphyses,  which  protect  the  joint  in  many  cases  from  the  spread 
of  disease  from  the  diaphyses.but  in  some  cases  are  a  source  of  danger  in  that  the 
junction  cartilages  are  intra-articular.  Holding  the  bones  together  is  a  com- 
plicated series  of  ligaments,  of  varying  strength  and  density,  usually  inserted 
into  the  epiphyses  in  young  people,  and  arranged  so  as  to  resist  the  various 
forms  of  strain  to  which  the  particular  joint  is  exposed.  Lining  the  under  side 
of  the  ligaments,  and  more  or  less  closely  attached  to  them,  is  the  synovial 
membrane,  a  thick,  smooth  structure  which  secretes  a  glairy  fluid  for  lubricating 
purposes  ;  it  extends  as  far  as  the  margins  of  the  articular  cartilages.  Where  it 
is  not  in  close  proximity  to  the  ligaments,  as  in  the  knee-joint,  the  interspaces  are 
■  padded  with  fat,  which  may  occasionally  prove  a  source  of  trouble.  On  the  inner 
aspect  of  the  membrane  are  a  number  of  small  villi,  which  sometimes  develop  to 
a  considerable  size. 

Inflammatory  affections  of  joints  are  of  the  most  diverse  character,  and  are 
brought  about  by  injury,  infection,  or  general  constitutional  conditions,  such  as 
gout.  The  trouble  may  be  limited  mainly  to  the  synovial  membrane,  constituting 
merely  a  synovitis,  or  may  spread  to  or  involve  the  other  articular  structures, 
such  as  ligaments,  cartilages,  ends  of  the  bones,  etc.,  thereby  constituting  an 
arthritis. 

Effusion  into  a  joint  occurs  in  most  of  the  various  manifestations, 
the  exudate  varying  with  the  cause.  The  phenomena,  however,  are 
similar  in  all  the  diverse  conditions,  and  it  would  be  well  to  note 
them  here.  Shoulder  :  The  curvature  of  the  shoulder  is  increased, 
and  the  deltoid  expanded  by  a  fluid  swelling  beneath  it,  which  is 
especially  noticeable  at  its  anterior  border  along  the  bicipital  groove, 
and  sometimes  posteriorly ;  in  the  axilla  a  painful  intumescence  may 
also  be  felt.  These  symptoms  may  be  somewhat  simulated  by 
inflammation  of  the  multilocular  subdeltoid  bursa,  but  the  latter 
condition  is  recognised  by  the  absence  of  any  axillary  swelling,  by 
its  not  encroaching  on  the  anterior  and  posterior  borders  of  the 
deltoid,  and  by  the  fact  that,  although  when  the  patient  voluntarily 
moves  his  arm  pain  is  produced,  yet  when  the  surgeon  gently  mani- 
pulates it,  so  as  to  press  the  head  of  the  bone  against  the  glenoid 
cavity,  there  may  be  none.     Elbow  :  The  hollows  on  either  side  of 

639 


640  A  MANUAL  OF  SURGERY 

the  olecranon  and  tendon  of  the  triceps  are  replaced  by  soft  fluid 
swellings,  the  outer  of  which  also  extends  down  to,  and  masks,  the 
head  of  the  radius ;  there  is  usually  a  little  general  pufhness  in  front 
of  the  joint.     It  is  readily  distinguished  from  inflammation  of  the 
olecranon  bursa  by  the  fact  that  in  the  latter  condition  there  is  a 
central  fluid  prominence  over  the  bone,  whilst  in  the  former  the 
swellings  are  placed  on  either  side  of  and  above  the  bony  projection. 
Wrist :  There  is  a  general  fulness  around  the  joint,  most  marked  on 
the  anterior  and   posterior  aspects,  but  also  noticeable  below  the 
styloid  processes.     The  tendons  in  their  sheaths  are  lifted  up  back 
and  front,  and  deep  fluctuation  may  be  detected  beneath  them.     It 
is  distinguished  from  a  teno-synovitis  by  the  facts  that  the  swelling 
is  limited  more  or  less  to  the  joint  line,  and  does  not  extend  up  and 
down  in  the  direction  of  the  tendons ;  there  is  also  no  limitation  of 
movement  of  the  fingers,  and  the  characteristic  crepitus  of  teno- 
synovitis is  absent.     Effusion  into  the  Hip-Joint  cannot  be  easily 
detected  by  digital  examination.     There  may  be  a  little  fulness  and 
tenderness  in  the  gluteal  region,  or  in  the  upper  and  outer  part  of 
Scarpa's  triangle.     The  rhost  characteristic  feature,  however,  is  the 
position  of  flexion,  abduction,  and  eversion  taken  by  the  limb,  whilst 
limitation  of  movement  is  equally  marked.    The  Knee,  when  distended 
with  fluid,  presents  a  rounded  outline,  in  which  all  the  nornial  hollows, 
especially  those  on  either  side  of  the  patella  and  ligamentum  patellae, 
have  disappeared.      There  is  also  a  swelling  corresponding  to  the 
subcrural  pouch,*  more  marked  on  the  inner  than  the  outer  side,  and 
extending  for  3  or  4  inches  above  the  patella.     Fluctuation  can  be 
readily  detected  when  one  hand  is  placed  above  the  patella,  and  the 
fingers  of  the  other  hand  compress  the  tissues  on  either  side  of  the 
ligamentum  patellae  below,  or  by  alternate  pressure  on  either  side  of 
the  rectus  tendon.     When  the  effusion  is  considerable,  the  patella  is 
felt  to  float,  and  on  pressing  it  sharply  backwards  can  be  made  to  tap 
against  the  intercondyloid  notch  of  the  femur  (patellar  tap).    A  smaller 
effusion  is  recognised  by  pressing  the  fluid  downwards  from  the  sub- 
crureal  pouch  with  the  knee  fully  extended,  when  the  patellar  tap  can 
usually  be  demonstrated.    Enlargement  of  the  bursa  patellae  is  recog- 
nised by  the  swelling  being  central  and  in  front  of  the  patella,  so 
that  its  outline  is  obscured.     Ankle  :  The  hollows  between  the  tendo 
Achillis  and  the  malleoli  are  replaced  by  fluctuating  swellings,  whilst 
the    dorsal   tendons  are  displaced   forwards,  and   a   fluid  swelling 
appears  in    front   of   each  malleolus.      Enlargement  of  the   bursa 
beneath  the  tendo  Achillis  is  so  obviously  confined  to  the  back  of  the 
joint  that  it  should  never  be  mistaken  for  true  synovitis  of  the  ankle. 
Finally,  it  must  be  noted  that  joints  are  peculiarly  liable  to  bacterial 
invasion,  especially  from  without.     Any  breach  of  strict  aseptic  pre- 
cautions is  only  too  likely  to  be  followed  by  an  infection  which  will 
have  disastrous  results,  endangering  both  the  utility  of  the  limb  and 
also  the  life  of  the  patient.      Hence  the  most  minute  care  must  be 
taken  in  all  operations  which  involve  the  opening  of  joints.     Pro- 
longed sterilization  of  the  skin  must  be  insisted  on  when  possible,  and 


DISEASES  OF  JOINTS  641 

ail  needless  introduction  of  fingers  into  the  wound  should  be  avoided. 
No  antiseptics  are  allowed  to  enter  the  joint,  as  they  are  always 
somewhat  irritating,  and  may  cause  a  considerable  synovial  effusion 
which  becomes  a  suitable  nidus  for  the  development  of  bacteria,  if 
such  happen  to  be  present.  Owing  to  the  frequent  presence  of 
streptococci  in  articular  infections,  attempts  at  immunization  by  the 
antecedent  injection  of  antistreptococcic  serum  have  been  made. 
Greater  confidence  in  our  aseptic  technique  has,  however,  to  a  large 
extent  banished  this  precautionary  measure.  At  the  conclusion  of 
the  intra-articular  manipulation,  the  joint  must  be  carefully  closed  by 
buried  sutures,  which  involve  seriatim  the  synovial  membrane,  the 
ligaments,  the  overlying  muscular  or  aponeurotic  structures,  and 
finally  the  superficial  parts ;  exact  co-aptation  of  each  of  these  struc- 
tures is  necessary  if  good  functional  repair  is  to  be  obtained,  free 
from  weakness.  Drainage  may  or  may  not  be  necessary ;  as  a 
general  rule,  the  patient's  comfort  is  increased  by  introducing  a 
drainage-tube  for  twenty-four  hours,  since  there  is  often  a  good  deal 
of  oozing  from  divided  ligaments.  The  joint  is  usually  kept  at  rest  for 
a  week  or  ten  days,  perhaps  on  a  splint,  and  then  movements  are 
cautiously  permitted,  at  first  passive,  then  active,  and  finally  active 
against  resistance,  and  all  these  advisably  before  the  patient  strains 
the  joint  (if  a  knee)  by  bearing  upon  it  the  weight  of  the  body. 
Massage  to  the  surrounding  muscles  will  of  course  be  employed  as 
soon  as  the  wound  is  securely  healed. 

Acute  Synovitis. 

In  this  affection  the  inflammation  is  limited  almost  entirely  to  the 
synovial  membrane,  the  ligaments  and  other  structures  of  the  joint 
being  but  little  affected. 

The  Causes  are  local  and  general.  Local  conditions  include  cold 
and  injury ;  general  or  constitutional  comprise  rheumatism,  gout, 
syphilis,  and  gonorrhoea. 

Pathological  Anatomy. — Acute  synovitis  is  characterized  by  hyper- 
aemia  of  the  synovial  membrane,  and  exudation  of  plasma  and 
leucocytes,  firstly  into  the  substance  of  the  membrane,  causing  it  to 
be  thickened  and  spongy,  and  subsequently  into  the  joint ;  the 
endothelium  also  proliferates,  and  is  shed.  In  the  early  stages  the 
effusion  consists  of  synovia,  diluted  with  blood  plasma,  and  often 
discoloured  with  blood  in  traumatic  cases,  and  hence  on  removal  is 
sometimes  spontaneously  coagulable ;  after  a  time  the  plasma  may 
coagulate,  depositing  lymph  upon  the  articular  surface,  whilst  serum 
remains.  This  lymph  may  either  be  removed  by  a  natural  process 
of  absorption  when  the  inflammation  comes  to  an  end,  or  it  may 
organize,  so  as  to  form  adhesions.  In  some  varieties,  especially  if 
repair  is  not  quickly  established,  a  certain  amount  of  peri-synovial 
inflammation  follows,  resulting  in  the  ligaments  becoming  congested, 
infiltrated,  and  perhaps  somewhat  relaxed. 

The  Clinical  Signs  of  acute  synovitis  consist  in  the  joint  becoming 
painful  and  distended,  whilst  if  the  articulation  is  superficial,  as  in 
ihe  knee,  a  sense  of  heat  may  be  imparted  to  the  hand,  and  the 

41 


e-4&  A  Manual  of  surgfrv 

surface  may  even  be  red  and  hyperaemic.  The  limb  is  maintained 
by  muscular  spasm  in  that  position  which  gives  the  most  ease — viz., 
that  in  which  its  capacity  is  the  greatest,  and  this  is  usually  one  of 
slight  flexion.  If  the  condition  is  neglected,  the  flexion  may  increase 
considerably,  and  the  limb  become  more  or  less  fixed  in  an  undesir- 
able position,  whilst  the  muscles  governing  the  movements  of  the 
joint  undergo  rapid  atrophy.  The  phenomena  resulting  from  effusion 
into  various  joints  have  been  already  noted  (p.  639). 

When  the  acute  stage  has  passed,  the  joint  is  usually  left  in  a 
somewhat  weak  and  relaxed  condition,  with  a  little  passive  effusion, 
or  perhaps  some  adhesions.  The  adhesions  which  follow  acute  syno- 
vitis are  usually  slight  in  character,  if  the  case  has  been  properly 
treated ;  they  result  from  the  union  of  patches  of  lymph  on  opposing 
surfaces  of  synovial  membrane  or  bone,  which  become  organized  into 
loose  fibro-cicatricial  tissue,  containing  a  few  delicate  bloodvessels, 
and  covered  by  endothelium  extending  over  them  from  the  adjacent 
serous  membrane.  The  characteristic  signs  of  such  a  condition  are 
painful  limitation  of  movement  in  some  particular  direction,  and 
possibly  a  little  soft  crepitus. 

The  Treatment  of  acute  synovitis  consists  in  so  immobilizing  the 
joint  as  to  give  the  patient  the  greatest  amount  of  ease,  whilst,  should 
ankylosis  result,  the  limb  is  left  in  as  favourable  a  position  as  possible 
for  subsequent  utility.  Thus  the  shoulder  should  be  bandaged  to  the 
side,  and  the  hand  kept  in  a  sling  ;  the  elhow  is  placed  on  an  internal 
angular  splint,  and  flexed  to  a  little  more  than  a  right  angle,  whilst 
the  hand  is  midway  between  pronation  and  supination  ;  for  the  wrist 
all  that  is  needed  is  to  apply  a  palmar  splint  to  the  fore-arm ;  the 
hip  is  immobilized  by  the  application  either  of  a  Thomas's  splint 
or  of  a  Liston's  long  splint,  or  by  placing  the  limb  between  sand- 
bags and  adjusting  an  extension  apparatus;  the  knee  is  put  on  a 
back-splint,  perhaps  slightly  flexed ;  whilst  the  ankle  is  best  kept  at 
rest  by  applying  what  is  known  as  a  Roughton's  splint,  i.e.,  an  external 
splint  with  a  foot-piece.  Necessarily,  in  all  severe  cases  of  acute 
synovitis  the  patient  should  be  confined  to  bed  and  the  limb  elevated. 
In  the  early  stages  cold  should  be  applied  to  the  joint  by  means  of 
evaporating  lotion,  an  icebag  or  Leiter's  tubes,  but  this  is  not  advis- 
able in  old  people.  In  the  later  stages  fomentations  give  greater 
relief,  whilst  the  application  of  a  few  leeches  may  also  be  beneficial. 
When  the  distension  is  considerable,  removal  of  some  of  the  fluid  by 
a  carefully  purified  aspirator,  or  trocar  and  cannula,  may  diminish 
pain  and  hasten  recovery. 

In  the  subacute  stage,  when  the  joint  is  weak  and  relaxed,  massage 
or  friction  with  stimulating  liniments  should  be  employed,  whilst  in 
tha  later  stages  elastic  pressure  is  often  of  the  greatest  value.  If  the 
case  has  been  neglected  and  the  limb  has  assumed  a  vicious  position, 
the  patient  should  be  anaesthetized  and  the  deformity  corrected; 
or  gradual  extension  is  made  by  means  of  a  weight  and  pulley,  until 
the  correct  position  is  attained. 

If  adhesions  are  present,  they  should  be  carefully  broken  down 


DISEASES  OF  JOINTS 


643 


under  chloroform  ;  the  limb  is  subsequently  kept  at  rest  for  a  few 
days  upon  a  splint,  whilst  passive  movements  and  massage  are 
afterwards  adopted.  In  bad  cases  it  may  be  desirable  not  to  do  too 
much  at  a  time,  as  a  good  deal  of  inflammatory  reaction  is  thereby 
lighted  up ;  the  manipulation  may  be  repeated  more  than  once  with 
a  few  days'  interval. 

Chronic  Synovitis. 

This  affection  follows  an  acute  attack,  or  may  be  lighted  up  by 
some  injury  or  condition  insufficient  to  determine  a  more  violent  form 
of  inflammation.  The  synovial  membrane  becomes  thick  and  infil- 
trated, whilst  the  effusion  is  sometimes  relatively  less  than  in  the 
acute  form,  sometimes  excessive. 

Three  varieties  have  been  described  :  [a)  Chronic  Serous  Syno- 
vitis (Fig.  299)  is  a  condition  in 
which  effusion  is  the  most 
prominent  factor.  It  results  from 
many  causes,  which  throw  strain 
upon  the  joint,  or  is  sometimes  in- 
explicable. It  isnot  unfrequently 
associated  with  some  condition 
such  as  a  loose  cartilage,  osteo- 
arthritis, etc.,  and  in  its  most 
aggravated  form  constitutes  a  con- 
dition of  hydrarthrosis  or  hydrops 
(p.  645).  It  is  not  unfrequently 
seen  affecting  the  knees  after 
rising  from  a  prolonged  stay  in 
bed.  The  fluid  is  often  clear  and 
limpid,  and  the  changes  in  the 
structure  of  the  membrane  are 
but  slight.  The  pain  is  usually 
not  severe,  being  replaced  by  a 
sense  of  uselessness  and  weak- 
ness. It  is  interesting  to  note 
that,  in  cases  where  the  eff"usion 
is  well  marked,  the  bunag  com- 
municating with  the  joint  fre- 
quently become  distended ;  they 
are  prevented  from  participating 
in  the  acute  forms  of  inflammation 
by  the  fact  that  the  apertures  of 

communication  with  the  interior  of  the  joint  are  narrow  and  slit-like, 
and  thus  readily  become  occluded  by  the  swelling  of  the  membrane. 

{b)  Chronic  Synovitis  with  Thickening  of  the  Synovial  Membrane  is 
always  a  suspicious  condition,  as  it  may  be  a  precursor  of  tuberculous 
disease,  if  it  lasts,  or  an  outcome  of  a  syphilitic  infection.  There 
is  but  little  effusion,  and  the  membrane  may  possibly  be  palpable. 
Crepitus  is  sometimes  met  with  in  this  condition,  possibly  from  a 
roughening  of  the  articular  surfaces  on  which  lymph  has  been 
deposited,  or  between  which  fibrous  adhesions  have  formed. 


Fig.  29c. — Chronic  Serous  Synovitis 
OF  Knee,  with  Distension  of  the 

SUBCRUREAL    PoUCH.         (ErOM     COL- 
LEGE OF  Surgeons'  Museum.) 


644 


A  MANUAL  OF  SURGERY 


(c)  Chronic  Papillary  Synovitis. — Occasionally  the  synovial  fringes 
and  the  villi  of  the  synovial  membrane  become  hypertrophied, 
giving  rise  to  a  condition  somewhat  similar  to  that  described  under 
osteo-arthritis  (p.  665).  The  overgrown  villi  usually  spring  from  the 
reflections  of  the  synovial  membrane  close  to  the  bone,  and  may  be 
loaded  with  fat,  constituting  a  condition  known  as  '  Lipoma 
arborescens.'  In  the  knee-joint  the  fringes  may  be  felt  rolling  under 
the  fingers,  and  painful  symptoms  may  be  caused  by  the  loose  ends 
being  caught  and  nipped  between  the  bones. 

Treatment  varies  somewhat  in  the  different  varieties,  but  in  all 
commences  by  keeping  the  joint  at  rest  in  a  suitable  position,  and 
applying  counter- irritation  and  pressure;  Scott's  dressing  and  blisters 
are  especially  useful  in  this  affection.     At  a  somewhat  later  stage 


Fig.   300. — Baker's  Cysts  from  Back  of  Knee.     (Howard  Marsh.) 

elastic  pressure  by  a  Martin's  bandage  may  be  employed,  together 
with  friction  with  stimulating  liniments,  or  even  hot-air  baths. 
When  effusion  is  marked  and  resists  these  methods  of  treatment, 
removal  of  some  of  the  fluid  by  aspiration  and  subsequent  compres- 
sion may  do  good  ;  but  if  the  effusion  re-appears,  the  best  procedure 
consists  in  opening  the  joint,  washing  it  out  with  sterile  saline 
solution,  and  draining  it  for  a  few  days. 

In  the  chronic  fibroid  form  iodide  of  potassium,  or  iodolysin*  may 
be  useful  in  addition  to  the  above-mentioned  methods,  but  as  a  rule? 
one  has  to  rely  on  prolonged  massage,  radiant-heat  baths,  the  intro- 
duction of  iodine  by  ionic  medication,  or  Spa  treatment. 

Should  enlarged  villi  be  present  and  give  rise  to  trouble,  the  joint 
should  be  opened,  and  if  they  are  limited  in  their  distribution  they 

*  lodolysin  is  a  5  per  cent,  solution  of  the  ethyl-iodide  of  thiosinamin  ;  20  to  6n 
minims  may  be  given  by  the  mouth  three  times  a  day. 


DISEASES  OF  JOINTS  645 

may  be  clipped  away,  or  the  synovial  membraBe  from  which  they 
grow  dissected  out.  When  very  extensive,  so  that  removal  would 
involve  total  excision  of  the  synovial  membrane  and  consequent 
stiffness,  it  may  be  wise  to  wash  out  and  drain,  in  the  hope  that 
they  may  become  fixed,  before  undertaking  complete  extirpation  of 
the  membrane. 

Hydrarthrosis  (Hydrops  Articuli)  is  the  term  applied  to  any  condition  of  a 
chronic  nature  in  which  the  joint  is  much  distended  with  fluid.  It  may  arise 
from  at  least  five  different  affections  :  {a)  Chronic  serous  synovitis  ;  {b)  in  osteo- 
arthritis, a  very  common  cause ;  (c)  in  Charcot's  disease ;  {d)  in  secondary 
syphilitic  synovitis  ;  and  (e)  occasionally  in  tuberculous  disease.  It  must  be 
remembered  that  it  is  but  a  symptom,  and  not  a  disease  sui  generis,  and  treatment 
necessarily  varies  with  the  cause. 

Baker's  Cysts. — This  condition,  first  described  by  the  late  Mr.  Morrant  Baker, 
consists  in  a  hernial  protrusion  of  the  synovial  membrane  of  a  joint  through  an 
aperture  in  its  fibrous  capsule  (Fig.  300).  It  is  usually  due  to  some  chronic 
affection  of  the  articulation,  especially  osteo-arthritis  or  tuberculous  disease, 
whereby  the  intra-articular  pressure  is  increased,  and  not  uncommonly  several 
such  sacs  are  connected  with  the  same  joint.  They  vary  much  in  size,  contain 
synovial  fluid,  and,  though  at  first  communicating  with  the  joint  cavity,  have  a 
tendency  to  travel  away  from  it,  burrowing  along  muscular  and  fascial  planes, 
and  coming,  perhaps,  to  the  surface  at  a  distance  from  their  origin,  the  aperture 
of  communication  with  the  joint  having  in  some  instances  been  shut  off.  If 
causing  no  troublesome  symptoms,  there  is  no  necessity  to  interfere  ;  but  if  they 
become  inconvenient  or  painful,  it  is  best  to  dissect  them  out,  closing  where 
necessary  by  ligature  or  suture  the  narrow  neck  which  leads  into  the  joint.  Of 
course,  the  strictest  asepsis  must  be  maintained  in  all  such  proceedings,  and  the 
causative  affection  must  not  be  forgotten. 

Acute  Arthritis. 

Causation. — Acute  arthritis  is  nearly  always  due  to  infection  of  the 
joint  cavity  with  pyogenic  bacteria,  which  reach  it  either  from  within 
or  without  the  body,  (i.)  It  may  be  due  to  the  entrance  of  cocci 
through  a  punctured  or  valvular  wound  of  the  joint,  or  during 
operations.  It  is  interesting  to  note  how  extremely  prone  to  in- 
flammation is  the  synovial  membrane  when  opened,  even  after  the 
most  careful  antiseptic  precautions.  The  micro-organisms  most 
commonly  present  are  the  Pneumococcits  and  the  Streptococctis  pyogenes, 
but  various  other  pathogenic  organisms  have  also  been  found  in 
special  cases,  (ii.)  It  may  arise  in  a  manner  exactly  analogous  to 
that  in  which  acute  infective  osteo-myehtis  is  produced,  viz.,  by 
auto-infection.  A  slight  injury  {e.g.,  a  sprain  or  strain  occurring  in 
a  weakly  child,  convalescent  from  measles  or  scarlet  fever)  may  result 
in  this  affection,  which  is  then  commonly  due  to  the  pneumococcus. 
(iii.)  It  may  be  produced  by  the  lodgment  of  a  pyaemic  embolus,  and 
in  a  similar  way  it  not  unfrequently  follows  as  a  sequela  of  fevers, 
such  as  enteric  or  pneumonia,  by  direct  transmission  of  some  infective 
material,  (iv.)  It  is  sometimes  met  with  as  a  result  of  gonorrhoea, 
and  may  then  run  its  course  with  or  without  suppuration,  (v.)  It  may 
be  lighted  up  as  a  result  of  the  extension  of  inflammation  from  the 
end  of  a  neighbouring  bone,  or  from  the  bursting  of  a  subcutaneous 
or  bursal  abscess  into  the  joint.  Acute  arthritis  of  the  hip-joint  is 
commonly  due  to  the  former  of  these  conditions,  being  consecutive 


646  A  MANUAL  OF  SURGERY 

to  an  acute  infective  osteo-myelitis  of  the  upper  end  of  the  femur 
(yi.)  It  is  occasionally  observed  as  a  result  of  rheumatism,  ihe  inflarn- 
mation  running  a  very  acute  course,  and,  leading  to  disorganization 
of  the  joint,  though  without  suppuration.  Such  attacks  are  un- 
doubtedly bacterial  in  origin. 

Course  of  the  Case. — In  the  early  stages  acute  arthritis  maijifests 
itself  as  a  hyperacute  synovitis,  combined  with  severe  pain  and  fever. 
The  pain  is  often  so  intense  that  the  patient  cannot  bear  the  part  to 
be  touched  or  the  bed  shaken,  and  indeed  the  slightest  jar  of  the 
limb  is  so  exquisitely  painful  that  the  patient  may  scream  with 
agony.  The  joint  itself  is  distended  with  a  turbid  effusion,  which 
rapidly  becomes  purulent,  and  the  tissues  around  are  hyperaemic,  and 
cedematous.  The  patient  naturally  places  himself  in  that  position 
in  which  the  limb  obtains  the  greatest  ease,  and  therefore  usually 
semiflexes  the  joint  and  fixes  it  by  muscular  contraction. 

As  the  disease  progresses,  pus  is  formed  within  the  capsule, 
but  in  time  bursts  through  it,  and  either  travels  directly  to  the  surface, 
or  burrows  deeply  into  the  substance  of  the  limb,  and  spreads  along 
the  muscular  planes ;  thus,  in  the  knee  an  enormous  abscess  may- 
collect  beneath  the  vasti  muscles,  stripping  them  from  the  bone  for 
a  considerable  distance.  The  pain  increases  whilst  the  abscesses  are 
forming,  and  becomes  especially  distressing  at  night,  the  patient  being 
often  waked  by  a  painful  start  just  as  he  has  fallen  asleep.  This 
condition  usually  indicates  that  the  articular  cartilages  are  becoming 
affected,  and  is  explained  by  the  fact  that  just  as  the  patient  loses 
consciousness,  the  muscles  which  fix  the  joint  are  relaxed,  and  allow 
the  inflamed  surfaces  to  shift  their  position  slightly,  exciting  severe 
pain  and  a  sudden  spasmodic  contraction  of  the  muscles.  Gradually 
the  deformity  becomes  more  and  more  obvious,  whilst  the  infiltration 
and  relaxation  of  the  ligaments  sometimes  allow  of  abnormal  move-^ 
ments — e.g.,  of  lateral  mobility  in  the  knee-joint ;  the  ends  of  the 
bones  become  carious,  and  absolute  displacement  or  dislocation  may 
follow.  Sinuses  may  open  in  all  directions,  and  the  patient  suffer 
from  recurrent  rigors,  caused  by  toxaemia  or  the  onset  of  pyaemia.  The 
constitutional  effects  are  always  severe,  consisting  of  high  fever,  and 
rapid  exhaustion  from  the  pain,  sleeplessness,  and  absorption  of  toxins. 

The  terminations  of  this  affection  are  as  follow :  (a)  Recovery, 
rarely  with  a  moveable  joint,  and  then  only  after  active  interference;- 
m  most  cases  ankylosis  in  a  good  or  bad  position,  according  to  the 
treatment,  is  the  best  result  that  can  be  expected,  (b)  During  the 
acute  stage  the  patient  may  die  of  pyaemia,  or  acute  toxaemia  and 
exhaustion,  {c)  If  he  survive  the  acute  stage,  chronic  suppuration 
may  ensue,  and  symptoms  of  hectic  and  amyloid  degeneration  of  the 
viscera  may  supervene.  In  such  cases  sinuses  leading  down  to 
carious  bones  exist,  and,  unless  efficient  measures  are  taken  to  obtain 
asepsis,  or  to  remove  the  diseased  structures,  perhaps  by  amputation, 
the  patient  is  likely  to  die  from  exhaustion  or  chronic  sapraemia. 

Pathological  Anatomy. — The  synovial  membrane,  at  first  merely 
infiltrated  and  hyperaemic,  soon  becomes  converted  from  within  out- 


DISEASES  OF  JOINTS 


647 


wards  irto  granulation  tissue,  exuding  an  abundance  of  pus.  The 
ligaments  in  turn  are  sodden  and  relaxed  by  the  presence  of  a  plastic 
exudation  between  the  fibres,  rendering  them  soft  and  oedematous, 
so  that  the  tonic  contraction  of  the  muscles  easily  stretches  them 
and  brings  about  displacement.  The  articular  cartilages  are  dis- 
integrated and  destroyed  in  various  ways  according  to  the  acuteness 
of  the  inflammation  and  the  amount  of  pressure  to  which  they  are 
exposed.  In  acute  cases  they  early  lose  their 
normal  bluish-white  appearance,  and  become 
opaque  and  slightly  yellow.  The  central  parts, 
which  are  exposed  to  pressure  between  the  ends 
of  the  bones,  soon  disappear,  whilst  the  peri- 
pheral portions  are  eroded  by  the  growth  of  the 
granulation  tissue  developing  from  the  synovial 
membrane.  When  once  the  cartilage  has  been 
perforated  at  any  one  spot,  the  suppurative 
inflammation  speads  along  its  under  surface, 
stripping  it  from  the  bone,  and  thus  inducing 
necrosis,  as  a  result  of  which  isolated  portions 
of  dead  cartilage  may  be  found  lying  in  the 
joint.  The  interarticular  cartilages  are  affected 
in  a  very  similar  manner,  and  quickly  disappear. 
The  ends  of  the  hone  pass  into  a  condition  of 
acute  osteitis,  resulting  in  the  transformation  of 
the  medulla  into  granulation  tissue,  absorption 
of  the  bony  cancelli  with  or  without  suppuration, 
and  sometimes  necrosis  of  small  portions  of  the 
cancellous  tissue  {caries  necrotica).  The  veins 
within  the  cancelli  become  thrombosed,  and 
hence  pyaemia  may  result.  The  periosteum 
covering  the  ends  of  the  bones  is  also  inflamed 
and  hyperEemic,  in  consequence  of  which  spicu- 
lated  or  stalactitiform  osteophytes  are  produced 
(Fig.  301).  The  tnuscles  in  the  neighbourhood 
of  the  joint  undergo  rapid  atrophy  and  fatty 
degeneration. 

Treatment. — In  the  early  stages  the  limb 
must  be  elevated,  absolutely  immobilized,  and 
put  into  such  a  position  that,  if  ankylosis  subse- 
quently obtains,  it  may  be  of  some  use  to  the 
patient.  Weight  extension  is  sometimes  de- 
sirable in  order  to  keep  the  inflamed  articular 
ends  from  rubbing ;  but  as  light  a  weight  as 
possible  must  be  used,  or  the  inflamed  and  softened  ligaments  may 
be  stretched.  Fomentations  or  an  icebag  may  be  applied  temporarily, 
but  as  soon  as  the  symptoms  point  to  suppuration,  the  joint  should 
be  freely  opened  in  one  or  two  places,  washed  out  with  some  sterile 
or  antiseptic  solution,  and  drainage-tubes  inserted,  whilst  necessarily 
any  peri-articular  abscesses  are  dealt  with  in  the  same  way.    Openings 


^^ 


Fig.  301. — Ends  of 
THE  Bones  after 
Acute  Arthritis 
OF  Elbow,  show- 
ing THE  Carious 
Surfaces  Devoii. 
OF  Cartilage, 
and  the  De- 
velopment OF 
Stalactitiform 
Osteophytes. 
(From  King's  Col- 
lege Hospital 
Museum.) 


6a8  A   MANUAL  OF  SURGERY 

should  preferably  be  made  on  opposite  sides  of  the  joint,  so  as  to 
allow  the  cavity  to  be  flushed  out  frequently,  or,  if  considered  desir- 
able, for  continuous  irrigation  of  the  joint  with  some  mild  antiseptic 
{e.g.,  weakboracic  lotion,  or  sublimate  solution,  i  in  8,000),  or  prefer- 
ably some  bland  unirritating  fluid,  such  as  sterilized  normal  saline 
solution.  The  fixation  of  the  limb  is  maintained,  and  the  general 
health  attended  to.  Irrigation  should  be  continued  until  all  signs  of 
inflammation,  pain,  heat,  and  startings  of  the  limb  have  passed  away. 
Under  such  a  regime  it  is  sometimes  possible  to  obtain  a  moveable 
joint,  but  more  frequently  ankylosis  must  be  expected.  Excision  may 
be  required  in  order  to  prevent  or  remedy  faulty  ankylosis,  or  to  place 
the  limb  in  a  good  position :  it  is  also  undertaken  in  some  cases  of 
chronic  suppuration,  with  caries  of  the  ends  of  the  bones  or  displace- 
ment, but,  as  a  rule,  not  until  all  acute  symptoms  have  passed  away. 
If  the  patient  is  suffering  from  severe  toxaemic  or  pyaemic  symptoms 
threatening  life,  amputation  may  be  required,  as  also  for  exhaustion 
from  long-standing  suppuration  and  hectic  fever. 

Acute  Arthritis  of  Special  Joints. 

In  the  Shoulder,  infection  sometimes  occurs  through  the  axilla 
where  the  capsule  is  weak  and  easily  invaded  by  organisms,  as  after 
an  axillary  cellulitis ;  more  frequently  it  follows  a  penetrating  injury. 
Severe  pain  is  caused  by  any  movement  of  the  arm  affecting  the 
joint,  and  if  abscesses  form,  they  will  come  to  the  surface  in  front 
of  or  behind  the  deltoid,  or  in  the  axilla.  It  may  suffice  to  open 
the  articulation  anteriorly,  and  flush  it  out,  but,  if  possible,  a 
counter  opening  should  be  made  behind  by  cutting  down  on  a  pair 
of  dressing-forceps  pushed  backwards  through  the  capsule.  In 
many  instances  the  patient's  condition  will  not  improve  until  the 
head  of  the  bone  has  been  excised.  The  subsequent  results  as  regards 
movement  and  power  of  the  arm  are,  on  the  whole,  very  satisfactory. 

In  the  Elbow,  there  are  no  points  requiring  special  mention  as  to 
clinical  history  or  results,  although  it  must  be  remembered  that  the 
superior  radio-ulnar  articulation  is  necessarily  involved,  and  hence 
the  power  of  pronation  and  supination  of  the  hand  is  threatened.  As 
to  treatment,  incisions  should  be  made  on  either  side  of  the  olecranon, 
the  ulnar  nerve  being  avoided.  The  limb  is  then  placed  on  a  rect- 
angular splint,  and  with  the  hand  midway  between  pronation  and 
supination  ;  of  course,  the  patient  is  kept  in  bed,  with  the  arm  raised 
on  a  pillow.  In  an  adult  excision  may  be  undertaken  as  soon  as  the 
acute  stage  has  passed,  in  order  to  obtain  a  moveable  elbow ;  but 
in  children,  where  the  growth  is  incomplete,  it  is  better  to  allow 
ankylosis  to  occur,  and  excise,  if  need  be,  at  a  later  date. 

The  Wrist  may  be  infected  secondarily  to  septic  conditions  follow- 
ing operations  on  ganglia  in  the  neighbourhood  or  through  direct 
injury.  The  essential  treatment  consists  in  free  incisions  parallel 
with  the  tendons,  and  avoiding  the  sheaths.  Ankylosis  usually 
results,  and  excision  is  not  resorted  to  except  when  the  disease  has 
become  very  chronic,  with  extensive  car'es  of  the  carpus. 


DISEASES  OF  JOINTS  G^q 

Acute  arthritis  of  the  Hip-joint  is  usually  a  sequela  of  acute  infec- 
tive osteo-myelitis  attacking  the  upper  end  of  the  shaft  of  the  femur, 
and  involving  the  joint,  owing  to  the  epiphyseal  cartilage  being  intra- 
capsular ;  it  also  results  from  pyaemia,  and  rarely  from  penetrating 
injuries.  The  symptoms  are  similar  to  those  of  the  first  stage  of 
ordinary  tuberculous  disease  (p.  679),  but  much  more  acute.  There 
is  high  fever,  together  with  intense  pain,  marked  flexion  and  eversion 
of  the  limb,  early  suppuration,  and  rapid  disorganization  if  not 
properly  treated ;  indeed,  where  nothing  is  done,  and  the  patient  lives 
long  enough,  the  head  of  the  bone  may  be  entirely  absorbed,  or  is 
detached,  and  remains  as  a  sequestrum  in  the  disorganized  articular 
cavity.  As  soon  as  the  capsule  gives  way,  the  pus  may  come  to  the 
surface  in  any  of  the  usual  localities  for  hip-joint  abscesses.  In 
treating  these  cases,  the  joint  should  be  freely  laid  open  in  the  situa- 
tion which  appears  most  favourable.  The  anterior  incision  is  more 
suitable  for  the  early,  and  the  posterior  for  the  later,  stages,  when 
the  head  of  the  bone  is  either  dislocated,  or  remains  in  situ  and 
separated  from  the  shaft.  A  double  opening  may  sometimes  be 
utilized  with  advantage. 

The  Knee-joint  is  more  frequently  involved  by  this  disease  than  any 
other,  and  is  usually  infected  from  without.  The  symptoms  are  ex- 
ceedingly typical :  the  pain  is  very  acute,  and  the  joint  hot  and  dis- 
tended to  its  utmost  capacity,  the  limb  lying  semiflexed  and  on  its 
outer  side.  Left  to  itself,  the  capsule  gives  way,  and  suppuration 
rapidly  extends  upwards"  beneath  the  vasti  or  downwards  into  the  leg, 
the  pus  ultimately  finding  its  way  to  the  surface.  The  deformity 
gradually  increases,  until  in  the  worst  forms  the  tibia  slips  behind 
the  condyles  of  the  femur,  the  leg  is  flexed  to  a  right  angle  and 
rotated  outwards,  and  if  the  limb  has  long  rested  on  its  outer  side, 
considerable  lateral  displacement  may  also  occur.  Early  and  efficient 
treatment  will  usually  prevent  such  a  disaster.  The  joint  should  be 
freely  incised  on  each  side  of  the  patella,  so  as  to  open  up  the  sub- 
crureal  pouch,  and  the  whole  articular  cavity  well  washed  out.  In 
some  cases  a  counter-opening  may  be  made  with  advantage  and  a 
drainage-tube  inserted,  by  passing  a  pair  of  sinus  forceps  through  the 
outer  portion  of  the  posterior  ligament  of  Winslow,  and  cutting 
down  on  it  to  the  inner  side  of  the  biceps  tendon  and  clear  of  the 
external  popliteal  nerve.  By  this  means  more  efficient  drainage  of 
the  articular  cavity  is  obtained. 

When  the  Ankle-joint  is  involved,  amputation  has  often  to  be 
resorted  to,  in  consequence  of  the  difficulty  of  securing  good  drainage, 
although  excision  of  the  astragalus  will  sometimes  cut  short  the 
disease  and  lead  to  a  good  result. 

Special  Forms  of  Synovitis  and  A  rthritis. 

Rheumatic  Synovitis  is  met  with  in  the  course  of  acute  rheumatism, 
or  as  a  chronic  affection  from  the  commencement.  In  the  former 
one  joint  after  another  is  involved;  complete  resolution  usually 
follows,  but  there  may  be  some  thickening  of  ligaments  and  con- 


6SO  A  MANUAL  OF  SURGERY 

sequent  impairment  of  mobility.  If  the  disease  is  limited  to  one 
joint,  absolute  disorganization,  though  without  suppuration,  may 
ensue  (acute  rheumatic  arthritis).  There  can  now  be  little  question 
that  this  disease  is  of  bacterial  origin  and  due  to  a  diplococcus 
(Poynton,  Paine). 

The  chronic  variety  is  characterized  by  swelling  of  the  joints,  due 
partly  to  effusion,  partly  to  thickening  of  the  synovial  membrane  and 
of  the  capsular  and  other  ligaments.  If  neglected,  it  may  produce 
fixity  of  the  joint,  due  mainly  to  ligamentous  changes,  but  also 
resulting  from  the  development  of  intra-articular  adhesions  ;  but  there 
is  never  any  lipping  of  the  cartilages  or  new  formation  of  bone,  as  in 
osteo-arthritis.  Not  unfrequently  other  evidences  of  rheumatism  may 
be  present,  such  as  chorea,  erythema,  etc.,  whilst  rheumatic  nodules* 
{i.e.,  new  growths  of  fibrous  tissue  beneath  the  skin,  perhaps  attaining 
the  size  of  a  walnut,  but  more  often  much  smaller)  may  also  develop. 

The  Treatment  of  the  acute  form  is  medical  rather  than  surgical, 
and  general  rather  than  local.  The  affected  joints  must  be  kept  at 
rest  in  good  position,  and  wrapped  in  warm  cotton-wool,  or,  perhaps 
better,  soda  fomentations  may  be  applied.  Should  the  inflammation 
resist  such  measures,  it  is  quite  justifiable  to  open  and  wash  out  the  joint, 
which  is  found  to  be  occupied  by  a  greenish,  semi-puriform  effusion. 

In  the  more  chronic  forms  anti-rheumatic  drugs  have  less  power, 
and  more  attention  must  be  paid  to  diet.  Butcher's  meat,  sweets, 
and  rich  dishes  should  be  avoided,  and  as  far  as  possible  a  '  white 
diet '  obtained.  Alkaline  mineral  waters  are  valuable,  and  a  visit 
to  a  suitable  home  or  Continental  spa  may  be  desirable.  Locally, 
massage  and  stimulating  embrocations  do  good,  but  in  bad  cases 
counter-irritation  by  repeated  blisters,  or  even  by  applying  the  actual 
cautery,  maybe  required.  Malposition  should  be  corrected  under  an 
anaesthetic  or  by  weight  extension.  Localized  or  general  hot-air  baths 
(Sheffield-Tallerman  system,  or  Dowsing's  radiant  electric  heat)  do 
good  in  most  cases,  as  also  ionic  medication  (p.  47)    with  iodine. 

Grouty  Artliritis  is  characterized  by  certain  well-marked  features. 
It  often  attacks  the  metatarso-phalangeal  articulation  of  the  great  toe 
(podagra),  or  the  metacarpo-phalangeal  joint  of  the  thumb  (cheiragra). 
Its  onset  is  usually  sudden,  and  it  frequently  commences  in  the 
middle  of  the  night.  The  tissues  around  the  joint  become  swollen, 
red,  shiny,  and  oedematous,  whilst  the  superficial  veins  are  prominent. 
The  attack  is  exceedingly  painful,  and  the  skin  exquisitely  tender. 
These  symptoms  pass  oiT  in  the  course  of  a  few  days,  leaving  the 
articulation  swollen  and  sensitive. 

Even  a  single  attack  results  in  a  slight  deposit  of  bi-urate  of  soda 
in  acicular  crystals  in  the  matrix  of  the  articular  cartilage  close  to  the 
surface ;  but  when  the  joint  has  been  several  times  inflamed,  the  whole 

*  Dr.  Bannatyne's  opinion  as  to  the  diagnostic  value  of  fibrous  or  bony  sub- 
cutaneous nodules  connected  with  articular  lesions  is  as  follows  :  '  Muscular 
swellings  are  most  often  due  to  rheumatism,  small  subcutaneous  nodules  also  to 
rheumatism,  larger  ones  to  rheumatoid  arthritis,  bursal  enlargements  to  chronic 
gout,  rheumatoid  arthritis,  or  rheumatism,  and  bony  nodes  (of  the  Heberden 
type)  to  chronic  gout  or  chronic  rheumatoid  arthritis. ' 


DISEASES  OF  JOINTS  651 

thickness  of  the  cartilage  may  be  invaded  by  this  chalky  deposit, 
whilst  the  ligaqients  and  ends  of  the  bones  are  also  infiltrated.     In 
the  smaller  joints  it  may  increase  to  such  an  extent  as  to  form  well- 
marked  swellings,  or  '  tophi,'  similar  in  character  to  those  so  com- 
monly seen  in  the  external  ear  ;  the  skin  sometimes  gives  way  over 
them,  and  a  chalky  discharge  results.     In  some  cases  the  cartilages 
are  eroded,  and  eburnation  of  the  exposed  bone  may  follow,  as  in 
osteo-arthritis.      The  treatment   of  acute  gout    consists   in    foment- 
ing the  parts  or  applying  glycerine  of  belladonna,  whilst  colchicum, 
citrate  of  lithia,  and  alkaline  purgatives  are  administered.     In  the 
more  chronic  forms  iodides  may  be  given,  and  the  diet  and  drink 
are  carefully  regulated.     Probably  some  form  of  hydro-therapeutic 
treatment  will  be  required,  and  if  the  patient  cannot  go  to  a  suitable 
spa  much  may  be  done  at  home  by  getting  him  to  drink  a  large  cup 
of  hot  water  half  an  hour  before  each  meal. 
.  Pysemic  Synovitis  is  due  to  embolic  infection  from  some  suppurating 
focus.    The  joint  becomes  rapidly  distended  with  pus,  and  often  with- 
out pain.     If  the  joint  is  promptly  opened,  washed  out  and  drained, 
its  disorganization  may  be  in  many  cases  prevented  {vide  Pyemia, 
p.  88) ;_  otherwise  destructive  changes  will  quickly  follow. 
-  Typhoid  Disease  of  Joints. — i.  A  simple  synovitis  occurs  in  one  or 
more  joints,  with  but  slight  effusion  and  little  inflammatory  disturb- 
ance.    It  is  somewhat  resistant  to  treatment,  and  hence  may  cause 
hmitation  of  movement.     Possibly  it  is  due  to  the  action  of  toxins 
rather  than  of  the  living  organism.     2.  The  true  typhoid  arthritis,  due 
to  the  B.  typhosus,  is  characterized  by  a  marked  inflammatory  effusion 
into  one  or  more  joints,  and  is  liable  to  end  in  spontaneous  disloca- 
tion, especially  in  the  hip-joint.     Suppuration,  however,  is  rare,  and 
the  prognosis  favourable,  provided  the  limb  is  kept  in  a  good  position. 
The  presence  of  a  large  effusion  indicates  aspiration.     3.  A  mixed 
pyogenic  diXid.  typhoid  infection  results  in  active  suppuration  within  the 
joints,  the  B.  typhosus  playing  quite  a  subsidiary  part.     4.  A  pure 
pyogenic  infection.     In  these  latter  two  varieties  the  ordinary  symp- 
toms of  acute  suppurative  arthritis  occur,  and  the  treatment  for  that 
affection  must  be  instituted. 

Pneumococcal  Arthritis. — In  the  course  of  an  acute  pneumonia  the 
pneumococcus  is  occasionally  disseminated  through  the  body,  and  is 
then  very  likely  to  attack  a  joint  which  has  been  already  damaged, 
giving  rise  to  a  suppurative  arthritis  with  an  effusion  of  thick  creamy 
pus,. or  sometimes  to  a  milder  form  of  synovitis.  Males  are  more 
often  affected  than  females,  and  the  upper  rather  than  the  lower 
extremity.  Occasionally  more  than  one  joint  is  involved,  and,  with 
the  exception  of  the  hip,  the  larger  joints  are  attacked  rather  than 
the  smaller.  There  are  no  special  peculiarities  in  the  disease,  but 
since  it  is  merely  part  of  a  general  infection,  a  high  mortality  is  asso- 
ciated with  it.  Suppuration  usually  occurs,  and  its  onset  is  always 
an  indication  for  incising,  washing  out,  and  draining  the  joint. 

It  may  also  occur  primarily  and  apart  from  any  other  obvious 
pneumococcal  lesion.     The  symptoms  are  then  those  of  a  subacute 


652  A   MANUAL  OF  SURGERY 

arthritis  with  effusion,  which  may  be  so  resistant  to  treatment  as  to 
require  arthrotomy.  Some  limitation  of  movement  is  likely  to  follow. 
Gonorrhoeal  Disease  of  Joints  is  always  due  to  infection  with  the 
gonococcus,  transmitted  by  the  blood  from  the  primary  focus  of  mis- 
chief. It  is  sometimes  associated  with  pyogenic  organisms,  and  then 
the  prognosis  is  decidedly  worse.  In  the  later  stages  the  pus  or 
seram  from  the  joint  is  sometimes  found  to  be  sterile,  the  gonococci 
having  died  after  causing  the  inflammation.  Such  an  occurrence  is 
always  suggestive,  as  sterile  pus  is  rarely  found  in  an  acute  abscess 
due  to  ordinary  pyococci.  Whilst  usually  seen  in  connection  with 
gonorrhoeal  urethritis  in  males,  it  has  been  known  to  follow  ophthal- 
mia neonatorum,  and  has  been  lighted  up  by  passing  a  full-sized 
bougie  on  a  patient  with  gleet.  It  generally  commences  after  the 
third  week  of  the  gonorrhoeal  attack,  when  the  discharge  is  becoming 
subacute,  but  may  sometimes  appear  at  a  much  later  period.  It  may 
involve  one  or  many  joints,  the  knee,  ankle,  and  wrist  being  most 
frequently  affected,  and  perhaps  on  both  sides  of  the  body.  Two 
distinct  types  of  trouble  may  manifest  themselves,  but  they  are  not 
unfrequently  combined.  In  one,  the  synovial  membrane  is  mainly 
affected,  and  the  effusion  is  chiefly  intra-articular,  so  that  the  con- 
dition closely  resembles  an  ordinary  attack  of  acute  traumatic  syno- 
vitis, except  that  it  is  more  severe,  more  painful,  and  more  persistent. 
•In  the  other,  which  is  more  frequent,  the  peri-articular  structures 
bear  the  brunt  of  the  mischief  ;  and  there  is  at  first  but  little  effusion 
in  the  joint,  but  much  around  it,  the  parts  even  becoming  cedematous 
and  reddened ;  the  ligaments  are  infiltrated  and  softened,  so  that  dis- 
placement readily  occurs  ;  surrounding  muscles  atrophy  rapidly  ;  the 
patient  suffers  from  severe  pain  and  fever,  so  that  he  becomes  thin 
and  worn.  In  the  worst  cases  the  intra-articular  effusion  increases, 
and  is  sero-purulent,  yellowish-green  in  colour,  and  contains  flakes  of 
lymph  ;  sometimes  it  becomes  frankly  purulent.  Both  forms  are  very 
chronic  and  resistant  to  treatment,  and  hence  ankylosis,  with  or  with- 
out disorganization,  is  very  liable  to  follow.  Treatment  is  not  very 
satisfactory.  The  urethral  discharge  must  be  arrested  as  soon  as 
possible,  whilst  the  affected  joints  are  kept  at  rest ;  moderate  pressure 
and  counter-irritation,  as  by  Scott's  dressing,  are  useful  appliances, 
but  Bier's  treatment  is,  peirhaps,  of  more  value,  or  ionic  medication 
with  iodine  preparations.  Iodide  of  potassium,  mercury,  and  quinine 
may  be  administered  internally.  Should  the  local  phenomena  be  at 
all  severe,  the  joint  must  be  opened  and  irrigated,  and  if  undertaken 
sufficiently  early  ankylosis  may  be  prevented.  Anti-streptococcic, 
and  even  anti- diphtheritic,  serum,  given  per  recttim,  has  proved  of 
value  in  some  of  these  cases,  probably  by  increasing  the  general 
resisting  power  of  the  body.  In  most  cases  a  gonococcal  vaccine 
(p.  27)  may  be  employed  with  advantage. 

Tuberculous  Disease  of  Joints. 

Tuberculous  Arthritis  (Syn,:  Pulpy  Degeneration  of  the  Synovial 
Membrane,  White  Swelling,  etc.)  may  commence  either  in  the  synovial 


Diseases  of  joints  653 

membrane  or  in  the  articular  end  of  the  adjacent  bone  (tuberculous 
epiphysitis,  p.  582)  ;  or  it  may  spread  to  the  synovial  membrane 
from  the  periosteum,  as  a  result  of  a  tuberculous  periostitis,  or  from 
a  neighbouring  bursa.  There  is  some  slight  difference  of  opinion  as 
to  the  relative  frequency  of  the  synovial  and  osseous  varieties ;  it 
is  probable,  however,  that  in  children  the  disease  commences  most 
frequently  in  the  epiphyses,  whilst  in  adults  it  may  start  either  in 
membrane  or  bone  with  about  equal  frequency,  but  considerable 
variation  occurs  according  to  the  particular  joint  affected. 

The  Causes  may  be  summed  up  as  follows :  The  individual  is  pre- 
disposed to  the  development  of  tuberculous  disease,  usually  as  the 
result  of  an  inherited  tendency,  a  family  history  of  tubercle  being  often 
obtainable ;  the  general  health  of  the  patient  may  also  be  at  fault. 
Some  slight  injury,  of  which  but  little  notice  is  taken,  may  lead  to 
the  actual  deposit  of  the  B.  tuberculosis,  which  has  probably  been 
lying  latent  in  the  bronchial  or  mesenteric  glands,  or  is  present  in  an 
active  state  in  the  lungs.  Severe  articular  lesions,  such  as  dislocations, 
are  less  likely  to  induce  tuberculous  disease,  partly  because  their 
gravity  demands  efficient  treatment,  partly  because  the  activity  of 
the  reparative  process  is  capable  of  dealing  with  the  organisms,  even 
if  they  are  brought  to  the  spot. 

Pathological  Anatomy. — The  synovial  menihrane  becomes  thickened, 
pulpy,  and  oedematous,  and  in  the  early  stages,  on  naked-eye  examina- 
tion, may  be  found  to  be  studded  with  small  gelatinous  nodules,  about 
the  size  of  a  pin's  head,  situated  immediately  beneath  the  serous 
lining ;  later  on,  these  may  amalgamate  into  caseous  masses,  which 
burst  and  discharge  into  the  joint,  leaving  ulcerated  surfaces.  Finally, 
the  synovial  membrane  is  changed  into  a  so-called  pyogenic  mem- 
brane, consisting  of  granulation  tissue  similar  to  that  lining  the  cavity 
of  a  chronic  abscess,  and  more  or  less  closely  attached  to  the  surround- 
ing structures,  which  are  transformed  into  oedematous  fibro-cicatricial 
tissue,  whilst  the  superficial  parts  undergo  fatty  or  necrotic  changes. 
Fringes  of  the  synovial  membrane,  swollen  and  succulent,  spread 
over  the  margins  of  the  articular  cartilage,  and  as  they  increase  in  size 
become  adherent  to  it,  just  as,  according  to  Billroth's  classical 
description,  ivy  creeps  along  a  wall.  On  lifting  the  edges  of  these 
fringes,  the  underlying  cartilage  is  found  hollowed  out  and  eroded. 
As  soon  as  the  whole  thickness  is  destroyed  at  any  one  spot,  the 
cancellous  tissue  at  the  end  of  the  hone  becomes  invaded  by  the  tuber- 
culous disease,  and  the  granulations  spread  along  under  the  cartilage, 
cutting  it  off  from  its  nutritive  supply,  and  thus  large  flakes  of 
necrosed  cartilage  may  be  shelled  off  (Fig.  302).  As  a  result  of  the 
hypersemic  condition  of  the  end  of  the  bone,  especially  when  pyogenic 
infection  is  superadded,  a  new  formation  of  subperiosteal  osteophytes, 
stalactitiform  in  character,  sometimes  takes  place,  but  not  to  such  an 
extent  as  in  a  true  pyococcal  arthritis.  Occasionally  the  periosteum 
itself  is  involved  in  the  tuberculous  process,  and  the  disease  may  then 
extend  some  distance  from  the  joint. 

When   the    bone  becomes   involved,    either   primarily   or    secon- 


654 


A   MANUAL  OF  SURGERY 


■X"" 


darily,  any  of  the  manifestations  of  tuberculous  disease  described  in 
Chapter  XX.  may  be  met  with,  and  thus  it  is  not  uncommon  to  find 
sequestra  in  connection  with  tuberculous  arthritis.  When  it  originates 
in  the  bone  in  adults,  the  tissue  directly  contiguous  to  the  articular 
cartilage  is  often  that  primarily  attacked  ;  but  in  children  it  more 
frequently  starts  in  connection  with  the  epiphyseal  cartilage.  The 
joint  is  usually  infected  by  extension  of  the  disease  through  the 
articular  cartilage;  but  when  the  synovial  membrane  extends  along 
the  bone  beyond  the  cartilage,  as  in  the  hip-joint,  it  may  become  in- 
volved without  any  cartilaginous  lesion.  In  the  early  stages-a  simple 
,^  -  -,  _.  synovial  effusion  may  occur,  but 
gives  place  to  the  more  typical 
manifestations  when  irifection  has 
followed.  Occasionally  a  tubercu- 
lous abscess  of  the  bone  or  surround- 
ing parts  bursts  into  a  joint ;  acute 
symptoms  supervene,  but  gradually 
quiet  down,  and  the  usual  chronic 
phenomena  subsequently  develop. 
More  commonly  the  infection  is 
slow  and  gradual,  and  the  onset  of 
the  articular  symptoms  is  of  a  similar 
character.  The  extent  of  the  mis- 
chief in  the  bones  may  sometimes 
be  ascertained  by  radiography. 

Clinical  History.  —  The  disease 
usually  commences  in  a  most  in- 
sidious manner.  It  may  be  dated  back 
to  some  injury,  but  as  often  as  not 
no  such  occurrence  has  been  noted. 
Slight  impairment  of  movement,  to- 
gether with  some  pain,  especially 
when  the  limb  is  jarred  or  twisted, 
is  perhaps  the  first  sign,  causing  the 
patient  to  limp  if  one  of  the  lower  ex- 
tremities is  involved.  This  limitation 
of  movement  is  usually  manifested 
in  all  directions,  and  this  will  often 
assist  in  diagnosing  it  from  the  fixity  due  to  the  presence  of  adhe- 
sions in  a  simple  chronic  synovitis.  The  amount  of  rigidity  varies 
much ;  in  a  purely  synovial  lesion  the  movements  may  at  first  be 
painless  and  but  little  impaired,  although  the  whole  region  of  the 
joint  may  be  puffy  and  swollen  ;  when,  however,  the  bone  is  affected, 
either  primarily  or  secondarily,  the  limitation  of  movement  is  con- 
siderably increased.  The  position  of  the  limb  is  that  which  will  give 
the  greatest  amount  of  comfort,  and  varies  in  different  joints  (q.v.). 
On  inspection  a  superficial  joint,  like  the  knee,  looks  white,  smooth, 
and  rounded,  the  swelling  being  more  apparent  on  account  of  the 
wasting  of  adjacent  muscles.     On  palpation,  the  part  is  found  to  be 


Fig.  302. — Tubercular  Disease 
OF  Head  and  Neck  of  the 
Femur. 

The  disease  evidently  started  on 
the  under  side  of  the  neck, 
which  has  been  eroded,  and 
spread  into  the  head  ;  the 
articular  cartilage  is  loose,  and 
necrotic  fragments  of  it  have 
been  stripped  up  off  the  bone. 


DISEASES  OF  JOINTS 


(>S5 


hotter  than  that  on  the  opposite  side  of  the  body,  whilst  fluctuation 
is  not  readily  detected,  there  being  but  httle  fluid  in  the  joint,  though 
the  affected  tissues  are  elastic  and  puffy.  In  a  few  cases,  where 
the  synovial  membrane  is  widely  involved,  the  affection  commences 
with  considerable  serous  exuda- 
tion, giving  rise  to  the  condition 
known  as  tuberculous  hydrops ; 
after  persisting  for  a  while,  the 
usual  manifestations  of  the  disease 
show  themselves.  In  this  type 
fibrinous  melon-seed  bodies  are 
sometimes  found,  and  a  cyto- 
logical  examination  of  the  exu- 
dation indicates  an  excess  of 
lymphocytes. 

From  time  to  time  exacerba- 
tions of  pain  and  increase  of 
swelling  occur,  which  subside 
after  resting  for  a  few  days,  but 
leave  the  joint  more  and  more 
crippled.  Starting  pains  at  night 
develop  when  the  cartilages  are 
becoming  eroded,  together  with 
slight  fever  and  malaise.  Sooner 
or  later  an  abscess  forms,  with 
increased  local  and  general  dis- 
turbance. When  it  bursts  or  is 
opened,  temporary  relief  is  ex- 
perienced ;  but  fresh  abscesses  are 
liable  to  form.  If  pyogenic  in- 
fection supervenes,  the  patient 
develops  a  hectic  temperature ; 
amyloid  degeneration  of  the 
viscera  may  follow;  the  limb  be- 
comes more  and  more  deformed ; 
and  finally  the  patient,  exhausted 
partly  by  the  discharge,  partly  by 
the  pain,  and  partly  by  want  of 
sleep,  becomes  emaciated,  and 
may  even  die,  unless  prompt 
measures  are  taken  for  his  relief. 

Results.  —  {a)  If  seen  in  the 
early  stages,  and  suitably  treated, 
the  disease  may  be  entirely  cured, 
and  a  moveable  joint  result. 
{h)  More  frequently  the  articular  structures  are  so  severely  damaged, 
that  a  cure  can  only  be  established  by  means  of  ankylosis.  Unless 
measures  have  been  adopted  to  maintain  the  limb  in  a  satisfactory 
position,  permanent  deformity  may  ensue,    {c)  If  pyogenic  organisms 


Fig.  303. — Bones  entering  into  For- 
mation OF  Knee-joint,  which  has 
BEEN  Disorganized  by  Tuberculous 
Disease.  (From  College  of  Sur- 
geons' Museum.) 

The  cartilage  is  almost  entirely  de- 
stroyed, and  the  exposed  bone  is 
carious  and  eroded. 


656  A  MANUAL  OF  SURGERY 

have  been  admitted,  the  patient  will  probably  develop  hectic  or 
amyloid  disease  from  chronic  toxaemia,  and  to  this  he  may  succumb. 
On  the  other  hand,  in  a  few  instances  he  may  survive  such  dangers, 
the  sinuses  alternately  drying  up  and  discharging,  although  he 
remains  a  permanent  invalid,  and  the  joint  is  crippled,  (d)  Acute 
miliary  tuberculosis  is  occasionally  met  with  as  a  complication  of 
this  affection,  or  tuberculous  disease  of  the  lungs,  brain,  kidneys,  or 
other  viscera,  may  be  lighted  up. 

The  Diagnosis  is  by  no  means  easy  in  all  cases,  although  sometimes 
it  is  tolerably  obvious.  One  can  never  insist  too  often  on  the  impor- 
tance of  comparing  the  diseased  joint  with  the  healthy  whenever 
possible,  observing  the  differences  in  contour,  colour,  temperature, 
and  mobility.  The  history  of  the  case  must  be  carefully  noted,  the 
amount  and  character  of  the  effusion,  and  whether  or  not  lympho- 
cytes predominate  in  a  cytological  examination;  the  amount  of  move- 
ment must  be  ascertained  and  whether  the  limitation  is  general  or  par- 
ticular. The  opsonic  index  to  the  tubercle  bacillus  may  also  throw  light 
on  the  case,  and  the  degree  and  character  of  the  reaction  after  a  tuber- 
culin injection.  Finally,  radiography  may  help,  and  particularly  in 
distinguishing  a  sarcoma  of  the  cancellated  tissue  of  one  or  other  of 
the  bones  forming  the  joint.  A  mistaken  diagnosis  in  such  a  condi- 
tion may  result  in  loss  of  life,  and  not  merely  in  crippling  or  loss  of 
the  limb,  and  has  been  made  many  a  time  with  disastrous  results  by 
unqualified  (so-called)  bone-setters. 

The  Prognosis  is  mainly  influenced  by  the  condition  of  the  in- 
dividual and  his  surroundings.  In  children  of  the  better  classes, 
where  every  hygienic  and  medical  assistance  can  be  given,  recovery 
generally  follows,  unless  there  is  a  strong  counterbalancing  hereditary 
tendency.  Amongst  the  poorer  classes,  and  especially  in  '  slum  chil- 
dren,' the  outlook  is  correspondingly  serious.  Moreover,  the  extremes 
of  life  are  unfavourable  :  babies  resist  tuberculous  invasion  badly, 
and  patients  over  fifty  have  comparatively  little  recuperative  power. 

TJie  Treatment  of  tuberculous  joints  varies  not  only  with  the 
articulation  affected,  but  also  with  the  type  of  patient,  and  the 
extent  to  which  the  disease  has  advanced. 

I.  Hygienic  Treatment. — Localized  tuberculosis  can  often  be  cured 
in  the  early  stages  by  suitable  local  and  constitutional  treatment. 
The  limb  must  be  kept  absolutely  at  rest  by  means  of  splints, 
plaster  of  Paris,  etc.,  and  elevated  if  there  is  much  pain.  Rest  should 
include  freedom  not  only  from  mobility,  but  also  from  pressure,  and 
therefore  in  the  lower  extremity,  if  the  patient  is  allowed  to  walk, 
the  limb  must  be  kept  from  the  ground  by  putting  a  patten  on  the 
other  boot.  An  endeavour  should  be  made  at  the  same  time  to  correct 
any  faulty  position  of  the  limb  by  gradual  weight  extension,  made 
at  first  in  the  direction  of  the  displaced  limb,  and  with  only  just  suffi- 
cient energy  to  keep  the  joint  surfaces  at  rest  and  counteract  the 
tonic  muscular  contraction  which  is  tending  to  produce  a  fixed  de- 
formity. Tenotomy  may  be  necessary  to  assist  in  this  proceeding; 
but  any  form  of  apparatus  which  depends  upon  a  screw  mechanism  to 


DISEASES  OF  y 01  NTS  657 

straighten  out  a  limb  is  certain  to  increase  intra-articular  tension, 
and  therefore  is  not  to  be  used.  The  sudden  appHcation  of  force 
under  an  anaesthetic  is  usually  unadvisable,  since  tuberculous  material 
may  thereby  be  disseminated  through  the  system.  Counter-irrita- 
tion, combined  with  pressure,  in  the  form  of  Scott's  dressing,  is 
often  useful  in  promoting  repair.  The  general  health  should  be 
improved  by  sending  the  child  to  a  suitable  sanatorium  or  the  seaside, 
giving  plenty  of  good  food,  and  administering  cod-liver  oil  and  syrup 
of  the  iodide  of  iron.  The  process  of  cure  is  slow,  and  the  patient's 
friends  must  be  warned  as  to  the  necessary  length  of  the  treatment. 

2.  As  accessories  to  this  hygienic  treatment  the  following  plans 
may  be  adopted : 

.  (a)  Parenchymatous  injections  of  iodoform  suspended  in  glycerine 
into  the  articular  cavity,  or  into  the  substance  of  the  synovial 
membrane,  have  been  much  employed  and  have  apparently  done 
good;  10  parts  of  iodoform  are  mixed  with  20  of  sterilized  water, 
and  made  up  to  100  with  sterilized  glycerine.  A  suitable  quantity 
of  this  fluid  carefully  sterilized  is  injected  into  the  joint  cavity,  or 
smaller  quantities  are  scattered  through  the  surrounding  tissues.  An 
inflammatory  reaction  usually  follows,  but  when  this  has  subsided 
— after  perhaps  a  fortnight — the  injection  may  be  repeated.  It  is 
perhaps  of  most  value  when  there  is  a  definite  effusion  into  the  joint. 
(b)  Bier's  plan  of  induced  hyperaemia  is  decidedly  useful,  and, 
indeed,  was  first  introduced  in  the  treatment  of  tuberculous  joints 
(p.  46).  The  process  was  based  on  the  observation  that  phthisis 
rarely  develops  in  association  with  mitral  regurgitation,  whereby 
pulmonary  engorgement  is  induced ;  whilst  if  the  cardiac  lesion 
supervenes  in  a  phthisical  subject,  the  lung  symptoms  improve.  It 
will  probably  be  wise  to  see  that  the  opsonic  index  is  in  the  positive 
phase  before  applying  this  treatment ;  and,  if  need  be,  the  patient 
must  be  treated  with  tuberculin  (TR)  in  order  to  improve  his  con- 
dition. It  should  not  be  employed  when  septic  sinuses  are  present, 
as  it  aggravates  the  trouble  by  providing  increased  pabulum  for  the 
micro-organisms.  The  method  employed  consists  usually  in  the 
application  of  a  rubber  bandage  both  above  and  below  the  joint  for 
such  a  length  of  time  as  can  be  tolerated  by  the  patient ;  at  first, 
probably,  he  will  not  stand  it  for  longer  than  half  an  hour,  but  by 
degrees  the  length  of  the  application  can  be  increased  until,  perhaps, 
it  can  be  borne  for  twenty  hours  a  day. 

3.  Abscesses  should  be  dealt  with  sufficiently  early  and  in  such  a 
manner  as  to  obviate  the  need  for  drainage.  To  this  end  they  ought 
never  to  be  left  until  the  skin  and  subcutaneous  tissues  are  involved, 
but  as  soon  as  a  collection  can  be  detected,  it  should  be  tapped  by  a 
large  trocar  and  cannula,  the  cavity  well  irrigated,  and  injected  with 
iodoform  emulsion.  It  is  wise  to  incise  the  skin  with  a  knife,  and 
not  to  puncture  it  with  the  trocar ;  the  irregular  wound  made  by  the 
latter  does  not  heal  quickly  ;  a  stitch  closes  the  incision  and  assists 
satisfactory  healing. 

Of  course,  when  the  skin  is  tbm  and  reddened,  and  the  pus  sub- 

42 


658  A   MANUAL  OF  SURGERY 

cutaneous,  the  abscess  must  be  incised  and  drained  in  the  usual 
manner,  any  thin  and  undermined  skin  being  snipped  away. 

4.  If  hygienic  treatment  cannot  be  carried  out  satisfactorily,  or  if 
the  disease  progresses  in  spite  of  such  measures,  operation  may  be 
necessary ;  but  it  is  remarkable  how  rarely  operation  is  required  at 
the  present  day.  Two  chief  plans  need  consideration — viz.,  arthrec- 
tomy  and  excision ;  but  it  must  be  remembered  that  each  joint 
presents  peculiar  features,  and  that  considerations  referable  to  one 
do  not  necessarily  hold  good  for  another. 

Arthrectomy  or  erasion  of  the  joint  consists  in  laying  open  the 
cavity  and  removing  all  the  diseased  tissues  that  can  be  reached. 
The  synovial  membrane  is  cut  away ;  diseased  foci  of  bone  are 
gouged  out,  and  the  resulting  cavities  disinfected  by  carbolic  acid 
and  packed  with  sterilized  iodoform.  Ankylosis  is  the  usual,  though 
not  invariable,  result.  It  is  obvious  that  this  proceeding  is  not 
equally  applicable  to  all  joints.  Thus,  in  the  hip  the  opening  is 
usually  made  from  the  front,  and  unless  there  is  great  laxity  of  the 
capsule  and  some  increase  in  size  of  the  acetabulum,  the  back  and 
upper  part  of  the  joint  cannot  be  reached.  The  knee,  ankle,  and 
elbow  are  perhaps  the  most  favourable  situations  for  this  operation. 
The  chief  advantages  over  excision  are  that  it  interferes  neither  with 
the  immediate  length  nor  with  the  subsequent  growth,  whilst  there 
are  no  extensive  sections  of  bone. 

Excision  of  a  joint  is  a  more  radical  measure,  but  has  the  disad- 
vantage of  removing  healthy  as  well  as  diseased  tissues ;  whilst  the 
fact  that  in  children  it  encroaches  on  the  epiphyseal  structures 
renders  it  undesirable  as  a  routine  procedure.  The  chief  conditions 
for  which  it  is  now  employed  in  tuberculous  disease  are  as  follows : 
(a)  For  complete  disorganization  of  the  joint,  or  when  extensive  bone 
mischief  is  present ;  (b)  to  prevent  ankylosis  in  certain  joints,  such 
as  the  elbow  and  temporo-maxillary ;  (c)  to  determine  a  rapid  and 
radical  cure  with  synostosis  in  such  a  joint  as  the  knee,  as  soon  as  it 
is  evident  that  the  natural  result  of  the  disease  must  be  an  ankylosed 
limb.  Surgical  art  often  produces  a  more  efficient  cure  than  Nature 
under  these  circumstances,  since  all  foci  can  be  removed.  A  natural 
cure  often  leaves  many  tuberculous  foci  encapsuled,  and  these  may 
subsequently  cause  pain  and  lead  to  recurrent  attacks  of  inflammation. 
(d)  Deformity  with  or  without  ankylosis  may  also  need  excision. 

Amputation  is  required  in  cases  which,  in  spite  of  every  care,  are 
steadily  going  from  bad  to  worse,  and  where  the  patient's  health  and 
strength  are  being  sapped  by  the  disease.  It  is  needed  not  unfre- 
quently  in  old  people,  and  where  the  mischief  in  the  bones  and  soft 
parts  is  very  extensive.  It  is  indicated  in  patients  where  excision 
has  been  undertaken  and  failed,  either  from  the  limb  becoming  subse- 
quently flail-like  or  useless,  or  from  recurrence  owing  to  incomplete 
eradication,  or  from  the  advent  of  sepsis.  Lastly,  if  the  disease  is 
present  in  two  joints  at  one  time,  or  in  a  joint  and  some  other  organ, 
neither  of  which  is  improving,  total  removal  of  one  focus  of  mischief 
will  often  induce  a  rapidly  favourable  change  in  the  other. 


DISEASES  OF  JOINTS  659 

The  choice  of  operation  in  any  particular  case  is  not  always  an 
easy  matter,  and  before  reaching  a  decision  several  factors  must  be 
taken  into  consideration:  (i.)  The  age  of  the  patient.  As  already 
mentioned,  the  fact  that  typical  excisions  encroach  on  the  growing 
ends  of  bones  renders  them  undesirable  in  children.  Even  if  growth 
is  not  stopped  thereby,  it  may  be  rendered  irregular,  and  subsequent 
deformity  may  ensue.  In  the  knee,  however,  it  is  possible  to  remove 
a  thin  slice  of  articular  cartilage,  so  as  to  gain  synostosis  of  the  two 
epiphyses  without  interfering  with  the  growth.  As  regards  advanced 
age,  opinions  differ  somewhat,  but  the  shoulder  and  knee  may  be 
excised  satisfactorily  at  a  much  greater  age  than  the  elbow,  wrist, 
and  ankle.  Probably  forty  to  forty-five  years  would  be  looked  on  as 
the  age  limit  for  the  latter,  but  excellent  results  have  been  obtained 
from  excising  the  knee  and  shoulder  at  a  much  later  period  of  life 
(ii.)  The  general  health  and  vitality  of  the  individual  must  be  fairly 
good  if  either  erasion  or  excision  is  to  be  undertaken.  In  weakly 
individuals  amputation  is  often  the  better  practice,  as  also  when 
hectic  fever  is  pronounced  and  amyloid  disease  of  the  viscera 
advanced,  (iii.)  The  extent  of  the  bone  mischief.  If  this  is  slight, 
erasion  may  be  undertaken ;  if  more  extensive,  excision  ;  but  if  the 
bone  trouble  is  so  exaggerated  that  the  removal  of  the  diseased  tissue 
would  leave  a  flail  like,  useless  limb,  then  amputation  is  required, 
(iv.)  It  is  useless  to  attempt  erasion  where  there  is  much  invasion  of 
the  soft  tissues ;  excision  may  even ,  be  impracticable  under  these 
circumstances,  and  amputation  may  be  the  only  hope,  (v.)  Where 
septic  sinuses  are  present,  and  especially  if  any  subacute  or  acute 
sepsis  exists,  free  incisions  should  be  made  to  give  relief  to  tension 
and  allow  the  inflammatory  disturbance  to  quiet  down  before  any 
conservative  operative  measures  are  considered. 

Tiiberculoiis  Disease  of  Special  Joints. 

The  Shoulder -joint  is  but  rarely  affected  in  children,  and  not  very 
commonly  in  adults.  The  disease  usually  starts  in  the  head  of  the 
humerus,  affecting  subsequently  the  synovial  membrane,  and  perhaps 
also  the  glenoid  cavity.  Not  unfrequently  it  results  in  ankylosis 
without  suppuration.  If  abscesses  form,  they  are  likely  to  point 
either  in  front  of  or  behind  the  deltoid,  in  the  former  case  extending 
along  the  synovial  membrane  lining  the  bicipital  groove.  Patho- 
logical dislocation  of  the  head  of  the  bone  forwards  and  upwards 
may  occur  at  a  late  stage,  somewhat  resembling  an  unreduced 
subcoracoid  dislocation.  In  the  traumatic  variety,  however,  the 
fixity  is  greatest  at  first,  and  the  movements  subsequently  improve; 
in  the  tuberculous  form,  the  limitation  of  movement  gradually 
increases  until  complete  ankylosis  supervenes.  Excision  of  the 
head  of  the  bone  is  almost  always  required  if  ankylosis  is  to  be 
avoided. 

In  the  Elbow  (Fig.  304)  the  disease  is  most  common  in  young 
adults,  and  is  often  primarily  osseous,  commencing  in  the  olecranon 
or  outer  condyle  of  the  humerus.    In  children  the  synovial  membrane 


66o 


A  MANUAL  OF  SURGERY 


is  first  affected,  especially  that  of  the  superior  radio-ulnar  articu- 
lation. The  swollen  synovial  membrane  bulges  on  either  side  of  the 
olecranon  and  tendon  of  the  biceps,"  and  can  often  be  felt  over  the 
head  of  the  radius.  Sinuses  form  by  the  side  of  the  olecranon,  or 
an  abscess  may  burrow  upwards  along  the  ulnar  nerve  and  open  on 
the  inner  aspect  of  the  arm.  Prolonged  immobilization,  followed,  if 
need  be,  by  incision  and  partial  removal  of  the  synovial  membrane, 
often  suffices  in  children,  leaving,  however,  a  stiff  elbow,  which  must 
be  left  alone  until  growth  is  completed.  In  adults  excision  is  often 
the  best  practice,  and  the  results  are  very  satisfactory,  provided  that 
a  sufficient  amount  of  bone  is  removed,  and  the  muscular  attach- 
ments are  interfered  with  as  little  as  possible.  If  expectant  treatment 
is  adopted,  the  arm  should  be  flexed  to  a  right  angle,  and  with  the 

hand    midway    between 
■     -        ,     ^^ ,  pronation    and    supina- 

\  .         ,-  tion,  so  that,  if  ankylosis 

V  follows,   the    limb    may 

be  in  the  m^ost  useful 
position.  Arthrectomy 
is  occasionally  adopted, 
and  is  best  accom- 
plished by  means  of  an 
H -shaped  incision  over 
the  olecranon,  which  pro- 
cess of  bone  is  divided 
at  its  base  and  turned 
upwards,  so  as  to  expose 
thoroughly  the  interior 
of  the  articulation.  After 
removing  all  diseased 
tissue,  the  olecranon  is 
replaced  and  wired  to 
the  shaft  of  the  ulna. 

In  the  Wrist  diffuse 
disease  of  the  synovial 
membrane  and  bones  is 
met  with,  starting  most 
frequently  from  the  former  structure  ;  if  primarily  osseous,  it  usually 
commences  in  the  lower  end  of  the  radius.  It  may  also  extend  from 
a  tuberculous  affection  of  the  adjacent  tendon  sheaths.  A  character- 
istic doughy  swelling  forms  over  the  dorsum,  displacing  the  extensor 
tendons,  whilst  the  palmar  aspect  of  the  wrist  is  also  puffy.  Sinuses 
develop  most  frequently  on  the  dorsal  aspect  or  by  the  side  of  the  flexor 
carpi  radialis  tendon.  Conservative  measures  may  bring  about  a  cure, 
and  every  effort  should  be  made  to  avoid  excision,  since  the  result  of 
this  proceeding  is  almost  always  the  production  of  a  weak  and  flail- 
like hand,  so  that  the  constant  use  of  a  leather  support  is  essential 
after  healing  has  occurred.  In  elderly  people  amputation  is  often 
the  only  resource. 


Fig. 


304- 


Tuberculous  Disease  of  the  Left: 
Elbow-joint. 


DISEASES  OF  JOINTS 


66 1 


Diseases  of  the  Hip-joint  and  of  the  Sacro-iliac  Articulation  are 
separately  considered  (pp.  678  and  687). 

The  Knee-joint  is,  perhaps,  more  often  affected  with  tuberculous 
disease  than  any  other  articulation.  It  appears  to  start  in  the 
synovial  membrane  or  bone  with  almost  equal  frequency ;  if  the 
bones  are  first  affected,  the  primary  focus  is  usually  situated  on  the 
inner  aspect  of  either  the  femur  or  the  tibia.  Sequestra  are  found  in 
nearly  one-half  of  the  cases  in  which  the  bone  is  affected,  becoming 
more  frequent  as  the  age  advances.  The  disease  runs  a  typical 
course,  and  needs  no  special  comment.  When  the  joint  has  become 
disorganized,  the  tibia  is  liable 

to   be  displaced   horizontally  ' 

backwards,  flexed,  and  ex- 
ternally rotated,  and  ankylosis 
in  this  position  is  difficult  to 
remedy,  even  by  operation. 

In  the  more  active  stages, 
where  the  joint  is  painful  and 
perhaps  deformity  present, 
the  patient  must  be  kept  m 
bed,  and  weight  extension  em- 
ployed. In  the  later  and  more 
chronic  stages,  immobiliza- 
tion in  plaster  of  Paris  or  the 
application  of  Thomas's  knee- 
splint  (Fig.  306)  will  prevent 
movement,  and  the  use  of  a 
patten  on  the  other  foot  and 
crutches  will  obviate  the 
harmful  effects  of  pressure 
from  the  weight  of  the  body. 
The  patient  is  then  allowed 
to  walk  about,  and  is  placed 
in  suitable  hygienic  condi- 
tions. Venous  engorgement 
and  perhaps  iodoform  injec- 
tions must  also  be  employed, 
if  thought  desirable.  Ab- 
scesses are,  of  course,  dealt  with  in  the  usual  way.  If  in  spite  of 
such  measures  symptoms  persist  and  the  case  is  progressive,  a 
modified  arthrectomy  may  be  undertaken  in  children  where  growth 
is  still  continuing,  and  to  carry  it  out  an  incision  should  be  made 
across  the  front  of  the  joint  from  condyle  to  condyle,  as  for  an  excision, 
dividing  either  the  ligamentum  patellae,  or  perhaps  the  patella,  which 
is  subsequently  wired  together.  The  whole  of  the  synovial  membrane 
is  then  dissected  away,  special  attention  being  directed  to  the  sub- 
crureal  pouch  and  the  back  of  the  joint.  A  thin  slice  should  be 
removed  from  the  surfaces  of  both  tibia  and  femur,  and  if  the 
epiphyseal  cartilages  are  not  encroached  upon,  the  growth  of  the 


Fig    305. — Tuberculous  Disease  of  the 
Knee  in  an  Advanced  State. 

The  joint  is  flexed,  and  displacement  back- 
wards of  the  tibia  is  commencing  ;  the 
smooth  swollen  condition  of  the  articula- 
tion is  very  characteristic. 


662 


A  MANUAL  OF  SURGERY 


limb  is  not  impaired  to  any  great  extent,  although  it  may  become 
irregular  and  lead  to  some  deformity — e.g.,  well-marked  flexion,  or 
genu  recurvatum  (p.  448).  In  adults,  where  the  bones  are  not  too 
extensively  involved,  so  that  on  section  broad  healthy  surfaces  can 
be  apposed,  excision  is  a  most  satisfactory  operation,  provided,  of 
course,  that  the  synovial  disease  is  also  removed.  As  soon  "as  it 
becomes  evident  that  the  only  possible  natural  cure  is  by  ankylosis, 
and  this  evidence  would  be  given  by  fixation  of  the  patella  to  the 
femur,  or  by  severe  starting  pains  at  night,  excision  is  justifiable  and 
advisable.  It  cuts  short  the  disease,  and  provides  a  quicker  and 
more  radical  cure  than  Nature  can  possibly  effect.  Incomplete 
removal  of  the  disease,  either  in  the  synovial  membrane  or  bone, 
may  determine  recurrence ;  if  this  cannot  be 
dealt  with  effectively,  amputation  may  be  re- 
quired, and  then  a  long  posterior  flap  is  the  only 
healthy  tissue  available  for  covering  the  bone. 
Under  other  circumstances  the  ordinary  supra- 
condyloid  amputation  can  be  adopted. 

The  Ankle-joint. — Tuberculous  disease  of  this 
joint  usually  commences  in  the  synovial  mem- 
brane rather  than  in  the  bone.  If  primarily 
osseous,  the  astragalus  is  more  frequently  affected 
than  the  lower  end  of  the  tibia.  The  whole 
region  becomes  occupied  by  a  pulpy  swelling, 
which  first  pushes  forwards  the  extensor  tendons 
and  bulges  in  front  of  the  malleoli,  and  subse- 
quently appears  on  either  side  of  the  tendo 
A  chillis.  The  foot  is  maintained  in  a  position  of 
slight  plantar-flexion  so  as  to  bring  the  narrower 
portion  of  the  upper  surface  of  the  astragalus 
into  the  tibio-fibular  mortice.  Flexion  and  ex- 
tension of  the  foot  are  usually  limited  or  lost, 
but  with  care  the  lateral  movements  (inversion 
and  eversion)  which  occur  at  the  mid-tarsal  and 
sub-astragaloid  joints  can  be  undertaken  without 
pain.  In  the  early  stages  prolonged  rest  and 
immobilization  in  plaster  of  Paris  are  required. 
Operative  treatment  is  not  very  satisfactory. 
Arthrectomy  can  be  undertaken,  but  removal  of 
the  astragalus  and  of  all  available  synovial  membrane  is  probably 
a  better  course  to  adopt.  When,  however,  the  astragalus  is  involved, 
it  is  often  difficult  to  eradicate  the  disease,  which  has  probably 
spread  to  the  articulations  and  bones  beneath  it,  and  amputation 
may  then  be  required.  Where  the  disease  also  involves  the  tibia 
and  fibula,  a  supra-malleolar  amputation  of  the  foot  will  probably  be 
necessary. 

For  diseases  of  the  Bones  and  Joints  of  the  Foot,  see  p.  580. 


u 


Fig.  305. — Thomas's 
Knee  -  splint  ap- 
plied. 


DISEASES  OF  JOINTS  663 

Syphilitic  Diseases  of  Joints. 

Although  syphilitic  disease  of  joints  is  rare  in  proportion  to  the 
prevalence  of  syphilis,  yet  several  varieties  have  been  differentiated 
and  recognised,  (i)  In  the  later  stage  of  the  secondary  period  a 
chronic  form  of  synovitis  occurs,  evidenced  by  passive  effusion  into  the 
joint,  with  or  without  pain,  and  usually  persisting  for  some  time. 
Any  joint  may  be  attacked  in  this  way,  perhaps  the  knee  most 
commonly,  and  the  affection  is  often  symmetrical  in  its  distribution. 
The  effusion  may  be  only  slight,  but  is  frequently  very  considerable 
(hydrarthrosis),  and  a  marked  feature  in  the  condition  consists  in  the 
rapid  variations  in  the  amount  of  swelling,  even  from  day  to  day.  In 
some  few  cases  this  affection  resists  all  treatment,  and  leads  to 
ultimate  disorganization.  (2)  Gummatous  inflammation  of  the  peri- 
synovial  fibrous  tissue,  which  may  or  may  not  extend  to  the  adjacent 
bone,  is  met  with  in  the  tertiary  period.  It  either  appears  as  a 
locaUzed  hard  nodule,  resembling  in  measure  a  fibrous  tumour,  and 
then  causing  but  little  trouble  beyond  a  sense  of  painful  weakness  in 
the  articulation  ;  or  it  is  more  diffuse  in  its  distribution,  leading  to  a 
moderate  effusion,  and  later  on  to  much  thickening  and  infiltration 
of  the  capsular  and  other  ligaments,  and  resulting  in  considerable 
impairment  of  its  movements  from  cicatricial  contraction.  Some  of 
these  gummatous  nodules  may  break  down  and  ulcerate.  (3)  A 
diffuse  gummatous  infiltration  of  the  synovial  membrane  itself  is  also  seen, 
usually  in  children.  It  closely  simulates  a  tuberculous  synovitis, 
from  which  it  is  often  impossible  to  distinguish  it,  except  by  the  rapid 
onset,  the  absence  of  pain,  the  greater  amount  of  effusion,  and  the 
symmetry  which  is  sometimes  present.  It  may  occur  apart  from 
other  evidences  of  congenital  syphilis.  (4)  A  chondro -arthritis  de- 
scribed originally  by  Virchow,  is  the  syphilitic  analogue  of  osteo- 
arthritis. It  commences  by  fibrillation  of  the  matrix  of  the  cartilage, 
and  proliferation  of  the  cells.  The  cartilage  softens,  and  becomes 
eroded  by  friction  of  the  articular  surfaces.  The  bone  thus  exposed 
is  worn  away,  and  curiously  'pitted'  or  excavated.  It  is  distinguished 
from  osteo-  arthritis  by  the  facts  that  there  is  usually  but  little  or  no 
pain ;  that  the  eburnation  of  the  exposed  bone  is  less  extensive,  and 
therefore  crepitus  is  but  httle  marked ;  whilst  the  typical  osteophytic 
outgrowths  and  '  lipping '  of  the  joint  margins  are  absent.  The 
eroded  areas,  moreover,  do  not  correspond  with  the  sites  of  intra- 
articular pressure,  and  are  more  rounded  and  punched  out,  and  not 
arranged  in  linear  grooves,  as  in  the  latter  disease.  It  is  not  uncom- 
monly associated  with  a  gummatous  thickening  of  the  synovial 
membrane,  and,  indeed,  the  hollows  or  pits  above  mentioned  may  be 
filled  with  caseous  material,  derived  from  degeneration  of  this  tissue. 

The  Treatment  in  the  early  manifestation  consists  in  the  adminis- 
tration of  mercury,  and  the  judicious  application  of  pressure  with  or 
without  immobilization,  according  to  the  requirements  of  the  case 
and  the  joint  affected.  In  the  tertiary  forms  iodide  of  potassium  in 
gradually   increasing  doses  has   a  rapidly  beneficial  action,  which 


664  ^  MANUAL  OF  SURGERY 

confirms  the  diagnosis ;  it  may  be  occasionally  combined  with  a 
small  amount  of  mercury,  either  given  internally,  or  applied  locally 
if  any  ulcerative  lesion  exists.  In  the  most  pronounced  cases,  where 
the  pain  is  severe  and  disorganization  of  the  joint  has  occurred, 
excision  may  be  necessary,  and  the  results  are  often  very  satisfactory. 

Osteo-Arthritis. 

Although  this  disease  is  extremely  common  in  this  country  and 
has  well-marked  characteristics,  its  nature  is  still  obscure,  as  is 
evident  from  the  number  of  names  applied  to  it,  such  as  chronic 
rheumatoid  arthritis,  rheumatic  gout,  arthritis  deformans,  arthritis  senilis, 
arthritis  sicca,  etc.  There  is  not  the  slightest  doubt  that  several 
types  of  disease  have  been  confounded  together  under  this  title,  and 
although  rheumatic  and  gouty  conditions  are  now  excluded,  yet  it  is 
probable  that  we  are  still  including  more  than  one  type  of  chronic 
articular  trouble. 

Under  these  circumstances  it  is  a  little  difficult  to  speak  dogmatic- 
ally as  to  iEtiology.  i.  Infection  plays  an  important  part  in  the 
production  of  certain  types  of  the  disease.  The  organisms  find  their 
way  into  the  joints  from  some  other  focus  of  infection,  and  in  this 
connection  it  is  interesting  to  note  the  statement  that  in  a  large  series 
of  cases  55  per  cent,  were  preceded  by  some  other  infective  disease, 
such  as  influenza  (Bannatyne).  The  bacteria  develop  in  the  joints, 
and  produce  toxic  bodies  which  act  locally  by  inducing  destructive 
phenomena  of  a  special  type,  whilst  by  their  general  absorption 
various  trophic  and  nervous  symptoms  are  caused,  whose  existence 
has  been  constantly  noted,  but  for  which  hitherto  there  had  been  no 
adequate  explanation.  Such  an  origin  will  also  explain  the  enlarge- 
ment of  the  spleen  and  of  lymphatic  glands  in  the  neighbourhood 
of  some  of  the  affected  articulations  (Still).  Several  observers  have 
found  bacteria  within  the  joints,  and  Bannatyne  amongst  others  has 
described  a  short  bacillus,  the  ends  of  which  stain  deeply,  whilst  the 
intervening  portion  remains  unstained,  causing  it  to  look  like  a 
diplococcus. 

2.  Auto -intoxication  is  another  probable  cause  of  many  cases.  It 
has  been  already  pointed  out  that  the  absorption  of  toxins  from 
the  mouth  or  elsewhere  may  lead  to  chronic  osteitis  and  arthritis 
(pp.  76  and  598),  and  it  is  probable  that  other  forms  of  intoxication 
may  suffice  to  determine  the  onset  of  osteo-arthritis.  It  may  be 
noted  that  the  affection  has  been  often  associated  with  uterine  and 
ovarian  disease,  and  with  various  forms  of  indigestion. 

3.  Exposure  to  damp  and  cold  is  an  important  aetiological  factor, 
especially  in  elderly  people,  as  also  worry,  fatigue,  depressing  nervous 
and  mental  conditions,  deficient  food,  and  bad  hygiene.  It  is  quite 
possible  that  many  of  these  conditions  act  by  producing  some  form 
of  toxaemia,  perhaps  of  intestinal  origin. 

4.  Traumatism  is  frequently  responsible  for  a  chronic  inflammation 
of  joints,  which  may  be  known  as  chronic  traumatic  arthritis;  the 
changes  are  practically  identical  with  those  of  osteo-arthritis.     The 


DISEASES  OF  jfOINTS 


665 


dimensions    that 
through  the  skin, 
finger ;    they  are 
succulent   during 


injury  may  be  shght  in  nature,  such  as  a  sprain  or  strain,  or  more 
severe,  such  as  a  fracture  or  dislocation  involving  the  articular 
surface  ;  thus,  it  is  not  uncommon  to  see  it  following  Colles's  fracture 
or  one  of  the  cervix  femoris.  Abnormal  pressure  maintained  for  a 
long  time  also  causes  changes  of  a  similar  type,  and  thus  many  of 
the  joints  of  labouring  men  are  deformed  in  a  peculiar  fashion, 
according  to  the  special  type  of  work  and  the  particular  joints  that 
are  exposed  to  strain.  To  this  variety  the  term  arthritis  deformans 
may  well  be  applied. 

5.  Lastly,  senile  degeneration  also  seems  to  produce  articular 
lesions  of  a  very  similar  character. 

Pathological  Anatomy. — The  disease  may  commence  either  in  the 
synovial  membrane  or  in  the  articular  cartilage,  but  perhaps  more 
frequently  in  the  former,  particularly  in  the  acute  and  subacute 
varieties.  In  the  early  stages  the 
synovial  membrane  becomes  vascular 
and  thickened,  and  the  villi  pro- 
liferate so  that  the  surface  becomes 
shaggy  or  villous  in  appearance. 
Sometimes  the  villi  reach  such 
they  can  be  felt 
rolling  under  the 
red,  vascular,  and 
life,  but  after  re- 
moval and  preservation  in  spirit  they 
look  shrunken  and  insignificant.  At 
times  there  is  a  considerable  develop- 
ment of  fat  in  these  villi,  constitut- 
ing the  condition  known  as  lipoma 
arbovescens,  and  often  associated  with 
an  added  element  of  gout.  Occa- 
sionally cartilaginous  nodules  are 
found  in  the  villi,  and  these  may  sub- 
sequently undergo  ossification ;  if  de- 
tached, they  may  constitute  one  form  of  loose  body  in  a  joint.  When 
the  disease  develops  along  these  lines  with  marked  synovial  changes, 
effusion  is  usually  considerable  and  early  ;  in  other  cases  there  is  often 
but  little  effusion,  so  that  the  affection  has  been  termed '  arthritis  sicca.' 

The  changes  in  the  cartilage,  whether  primary  or  secondary, 
consist  in  a  breaking  up  of  the  matrix  into  fibres,  the  so-called 
'  fibrillation,'  so  that  the  surface  becomes  rough  like  the  pile  on 
carpet  or  velvet  (Fig.  307).  Meanwhile  the  cartilage  cells  are 
arranged  in  longitudinal  rows  between  the  fibrillae  and  proliferate 
within  their  capsules,  which  become  distended  and  burst  into  the 
joint.  The  cartilage  thus  softened  is  readily  worn  av/ay  by  the 
movements  of  the  articulation,  and  the  surface  of  the  bone  is  ex- 
posed. Concurrently  with  this  destruction  hyperplasia  is  taking 
place  at  the  margins  of  the  articular  cartilage,  resulting  in  the 
production    of    irregular    overgrowths    (ecchondroses),   which    have 


Fig.  307. — Patella  from  Early 
Case  of  Osteo- Arthritis,  show- 
ing Fibrillation  of  Cartilage. 
(Howard  Marsh.) 


666 


A  MANUAL  OF  SURGERY 


r 
t 


been  likened  to  the  gutterings  of  a  candle.  In  them  ossification 
occurs  secondarily,  and  when  such  overgrowths  have  been  produced 
more  or  less  evenly  around  the  joint  margin,  a  characteristic  lipping 
of  the  edge  of  the  articular  surface  results  (Fig.  308).  Sometimes 
these  osteophytes  attain  considerable  dimensions,  and  by  interlocking 
may  lead  to  ankylosis  of  the  joint. 

The  bone  exposed  by  the  destruction  of  the  articular  cartilage 
is  altered  as  the  result  of  the  movements  of  the  joint.     The  chronic 

irritation  causes  it  to 
become  hard,  sclerosed, 
and  polished  like  ivory 
(eburnat  ion).  This 
usually  occurs  in  certain 
definite  directions  ;  in 
hinge  joints  the  surfaces 
become  grooved  longi- 
tudinally, whereas  in  ball- 
and-socket  joints  like  the 
hip  the  head  is  eburnated 
in  a  circular  manner. 
This  condensed  tissue 
does  not  extend  very 
deeply,  and  immediately 
beneath  it  the  bone  is  of 
a  more  open  texture  than 
usual  and  filled  with  fatty 
medulla.  In  spite  of  the 
sclerosis  the  articular  end 
of  the  bone  is  being  con- 
stantly worn  away,  and 
this  may  progress  to  such 
an  extent  as  to  lead  to 
actual  shortening  of  the 
limb. 

Clinical  History. — 
Three  chief  types  of 
this  disease  may  be  de- 
scribed : 

I.  The  chronic  monarticular  variety  is  that  most  frequently  seen  by 
surgeons,  and  is  constantly  brought  about  by  injury.  Pain  and 
creaking  of  the  joint  on  movement  are  the  early  symptoms.  There 
may  be  very  little  swelling,  unless  effusion  is  present,  but  pain, 
especially  at  night,  is  most  troublesome,  being  usually  increased  on 
changes  of  weather,  particularly  if  rain  is  threatening.  The  pain 
and  stiffness  are  most  marked  after  keeping  the  parts  at  rest,  and 
diminish  when  the  limb  is  used.  As  the  disease  progresses,  the 
movements  become  more  and  more  impaired,  and  the  creaking  may 
be  transformed  into  a  true  bony  crepitus  ;  the  ends  of  the  bones  are 
felt  to  be  enlarged  and  lipped,  and  deformity  soon  becomes  obvious 


Fig.  308.— Late  Stage  of  Osteo-Arthritis  of 
Knee,  showing  Destruction  of  the  Articu- 
lar Cartilage,  and  Eburnation  of  the 
Exposed  Bone  in  Longitudinal  Grooves. 
(From  College  of  Surgeons'  Museum.) 

The  margins  of  the  cartilages  are  distinctly  lipped. 


DISEASES  OF  JOINTS  667 

Exacerbations  in  the  symptoms  occur  from  time  to  time,  resultino-  in 
increased  crippling.  Finally,  the  limb  may  become  absolutely  use- 
less, partly  from  the  pain  and  partly  from  the  limitation  of  movement 
produced  by  the  osteophytes.  Wasting  of  the  adjacent  muscles  is 
also  a  marked  feature. 

This  variety  is  usually  seen  in  elderly  people,  and  may  supervene 
quickly  after  an  accident,  such  as  fracture  or  bruising  of  the  cervix 
femoris,  and  then  the  destructive  phenomena  may  progress  at  a 
rapid  rate.  When  it  appears  in  younger  people,  the  osseous  lesions 
are  much  less  evident. 

2.  The  chronic  polyarticular  variety  arises  independently  of  trau- 
matism, and  is  most  commonly  seen  in  females  of  middle  life.  It 
may  commence  in  one  joint  and  spread  to  others,  or  it  may  appear 
in  many  joints  simultaneously.  Most  frequently  one  or  more  of  the 
phalangeal  articulations  is  the  starting-point,  particularly  the  terminal 
ones,  and  then  it  may  be  the  result  of  an  injury.  The  joints  become 
stiif  and  swollen,  are  tender,  and  in  the  milder  cases  small  nodular 
bony  outgrowths  develop  at  the  bases  of  the  phalanges,  which  are 
known  as  Heberden's  nodosities.  The  trouble  gradually  spreads  to 
other  joints,  and  although  there  are  often  remissions,  yet  the  con- 
dition progresses  steadily  until  the  patient  may  be  entirely  crippled 
thereby.  Well-marked  overgrowth  of  bone  and  eburnation  of  the 
articular  ends  are  characteristic  features  of  this  type.  Sometimes 
there  is  considerable  effusion,  accompanied  by  overgrowth  of  the 
synovial  villi,  but  this  is  unusual. 

3.  The  acute  polyarticular  variety  does  not  often  come  to  the  surgeon 
for  treatment,  at  any  rate  in  the  early  stages.  It  usually  attacks 
young  or  comparatively  young  people,  and  females  rather  than 
males,  frequently  following  some  infective  trouble,  such  as  influenza, 
scarlatina,  tonsillitis,  etc.  It  is  often  ushered  in  by  a  distinct  febrile 
attack  with  persistent  increase  in  the  rate  of  the  heart-beat ;  trophic 
and  vasomotor  phenomena  are  often  co-existent,  such  as  patches  of 
pigmentation,  clammy  cold  hands,  and  rapid  muscular  atrophy.  The 
smaller  joints  of  the  hands  and  feet  are  mainly  affected,  and  that  more 
or  less  symmetrically,  although  the  terminal  interphalangeal  articula- 
tions often  escape.  The  capsules  are  distended  with  a  certain  amount 
of  effusion,  causing  the  joints  to  look  spindle-shaped,  and  at  first  there 
is  but  little  osseous  mischief.  In  not  a  few  cases  a  very  characteristic 
deformity  in  the  shape  of  ulnar  adduction  of  all  the  fingers  occurs. 
Gradually  the  trouble  spreads  to  other  and  larger  joints,  and  osseous 
manifestations  appear ;  but  the  progress  is  slow,  and  may  be  to  a 
large  extent  arrested  by  treatment.  Neighbouring  lymphatic  glands 
may  be  enlarged  in  the  early  stages. 

The  peculiarities  of  this  affection,  as  it  involves  children,  have  been 
emphasized  by  Dr.  Still.  Girls  are  more  often  attacked  than  boys ; 
many  joints  are  implicated,  and  neighbouring  lymphatic  glands  are 
enlarged.  The  cartilage  is  but  little  altered,  and  bony  outgrowths 
are  absent.  The  spleen  is  also  enlarged,  and  there  may  be  peri- 
cardial and  pleural  adhesions. 


668  A  MANUAL  OF  SURGERY 

It  is  important  to  note  that  gouty  and  rheumatic  troubles  may  be 
associated  with  osteo-arthritis  :  the  rheumatic  affections  may  precede, 
the  gouty  usually  follow. 

The  Diagnosis  of  osteo-arthritis  per  se  is  not  often  difficult  in  a  well- 
marked  case,  the  crepitus,  pain,  and  enlargement  of  the  ends  of  the 
bones,  together  with  the  slight  amount  of  effusion,  constituting  a 
tolerably  characteristic  picture.  Radiography  may  show  the  charac- 
teristic lipping  of  the  articular  ends,  and  the  thinning  of  the  bony 
substance  beneath  the  cartilage.  From  simple  chronic  synovitis  it  may 
be  known  by  the  history  and  smaller  amount  of  effusion,  and  by  the 
pain  and  rigidity  being  frequently  more  marked  after  rest,  and  dimin- 
ishing after  the  joint  has  been  actively  used.  There  is  more  difficulty 
in  distinguishing  the  form  associated  with  increased  effusion  and  en- 
largement of  the  synovial  villi ;  careful  examination  may,  however, 
enable  the  surgeon  to  make  out  these  villi  moving  to  and  fro  in  the 
joint  under  his  hand,  whilst  possibly  the  ends  of  the  bone  may  be 
lipped.  For  diagnosis  from  chronic  rheumatism  and  Charcot's  disease, 
see  pp.  650  and  671. 

The  Prognosis  is  usually  unfavourable.  The  fact  that  many  joints 
are  affected  is  an  indication  that  there  is  a  considerable  constitutional 
element  in  the  evolution  of  the  disease,  and  although  it  may  be 
temporarily  combated  with  success,  still,  sooner  or  later,  the  patient 
is  almost  certain  to  be  crippled  by  it.  The  affection  of  only  one  joint 
often  points  to  a  traumatic  origin,  and  the  outlook  is  correspondingly 
brighter  ;  but  where  the  disease  attacks  several  parts  of  the  body, 
there  is  but  little  hope  of  checking  it,  and  indeed  cases  are  known  in 
which  every  joint  has  successively  become  implicated,  the  patient 
dragging  on  a  weary  existence,  never  free  from  pain,  and  usually  in 
a  cramped  or  sitting  posture,  until  death  from  exhaustion  supervenes. 

Treatment. — For  this  troublesome  complaint  there  is,  unfortu- 
nately, little  that  can  be  effected  in  the  way  of  cure,  although  much 
can  be  done  to  alleviate.  Locally,  the  articulations  should  be  pro- 
tected from  cold  and  injury  by  being  swathed  in  flannel,  whilst 
stimulating  embrocations  and  sedative  applications  may  be  bene- 
ficially employed.  It  is  not  advisable  to  maintain  the  joints  absolutely 
at  rest,  otherwise  their  mobility  is  likely  to  become  seriously  limited 
at  an  unnecessarily  early  date.  Moreover,  it  is  often  found  that  the 
more  a  joint  is  moved,  the  easier  and  less  painful  do  the  movements 
become,  and  hence  regular  massage  is  desirable.  Hydrotherapy, 
electrotherapy,  and  treatment  by  the  local  application  of  heat 
(radiant  heat,  etc.)  have  a  large  field  of  usefulness  in  this  affection. 
As  to  general  treatment,  the  individual  is  warned  against  exposing 
himself  to  cold  and  damp,  and  since  the  disease  is  often  considered 
to  be  due  to  perverted  or  diminished  nervous  activity,  all  possible 
sources  of  irritation  and  worry  should  be  removed.  At  the  same 
time  the  nutrition  must  be  improved,  and  plenty  of  good  food,  cod- 
liver  oil,  etc.,  administered.  A  large  number  of  different  drugs  have 
been  tried  for  this  complaint,  but  none  of  them  are  very  satisfactory. 
Perhaps  the  best  is  iodide  of  sodium  combined  with  some  alkalme 


DISEASES  OF  JOINTS  669 

purgative  and  hepatic  stimulant,  such  as  sulphate  of  soda.  Natural 
mineral  waters  and  baths  are  often  beneficial,  those  of  Bath  and 
Buxton  in  this  country  being  most  frequently  recommended. 
Arsenic  is  sometimes  useful. 

Occasionally  operative  treatment  in  the  shape  of  excision  may  be 
undertaken  in  this  complaint,  but  only  when  the  disease  is  limited  to 
one  joint,  and  when  it  has  progressed  to  such  a  stage  as  seriously  to 
cripple  the  patient's  usefulness,  as  in  the  knee-joint,  elbow,  or  the 
shoulder,  or  when  the  act  of  mastication  is  impaired,  owing  to  an 
affection  of  the  temporo-maxillary  articulation.  In  suitable  cases 
excellent  results  are  obtained. 

The  hip-joint  is  not  uncommonly  the  seat  of  osteo-arthritis  in  old 
people,  and  it  always  causes  a  considerable  amount  of  pain,  especially 
on  flexion  of  the  limb,  rendering  sitting  difficult  and  walking  uncom- 
fortable, whilst  the  movements  become  more  and  more  curtailed. 
The  limb  appears  at  first  to  be  slightly  increased  in  length,  but  later 
on  becomes  shortened  from  erosion  of  the  head  and  atrophy  of  the 
neck  of  the  bone  ;  the  trochanter  is  also  much  thickened  and  more 
prominent  than  usual,  on  account  of  the  associated  atrophy  of  neigh- 
bouring muscles.  Well-marked  crepitus  is  obtained  on  moving  the 
thigh.  The  acetabular  cavity  is  increased  in  size  owing  to  the 
formation  of  a  projecting  rim  or  lip.  If  a  patient  falls  on  the  affected 
hip,  some  difficulty  may  be  experienced  in  making  a  diagnosis  from 
fracture  of  the  neck  of  the  thigh-bone.  The  previous  history  and  the 
facts  that  the  trochanter  rotates  around  its  normal  centre,  and  is 
unduly  prominent  rather  than  approximated  to  the  median  line,  and 
that  the  ilio-tibial  band  is  not  relaxed,  as  in  fractures,  should  suffice 
to  prevent  mistakes,  whilst  X-ray  examination  can  make  the  diagnosis 
certain. 

When  the  temporo-maxillary  Joint  is  affected,  the  condyle  of  the  jaw 
becomes  larger  than  usual  and  somewhat  flattened  ;  the  eminentia 
articularis  is  partially  absorbed  and  the'  glenoid  cavity  increased  in 
size,  so  that  the-  condyle  is  liable  to  slip  forwards  owing  to  the  action 
of  the  external  pterygoid  muscles.  If  only  one  joint  is  affected,  the 
bone  is  carried  towards  the  sound  side,  but  when  both  are  involved 
the  chin  becomes  prominent  owing  to  a  forward  displacement  of  the 
whole  bone.  Pain  and  crepitus  are  experienced  on  opening  the 
mouth,  rendering  mastication  difficult,  and  even  impracticable.  If 
ordinary  treatment  fails  to  give  relie;,  the  affected  condyle  of  the  jaw 
should  be  excised. 

Neuropathic  Artliritis  {Syn.  :  Charcot's  Disease). 

This  disease,  bearing  the  name  of  the  late  Professor  Charcot,  is  a 
peculiar  affection  of  joints  met  with  in  the  course  of  locomotor  ataxy. 
It  is  slightly  more  common  in  women  than  men,  and  is  almost  always 
an  early  manifestation,  occurring  usually  between  the  lightning-like 
pains  and  the  onset  of  the  ataxic  symptoms.  The  most  typical  form 
is  lighted  up  by  some  slight  injury — eg.,  a  strain  or  sprain — and  is 


670 


A  MANUAL  OF  SURGERY 


characterized  by  a  rapid  painless  distension  of  the  joint  with  a  light- 
coloured  serum,  which  may  also  extend  into  the  communicating 
bursae  ;  there  is  some  amount  of  effusion  into  the  surrounding  cellular 
tissue,  although  without  cedema.  This  distension  may  be  so  rapid 
that  abnormal  mobility  or  even  dislocation  may  occur  at  the  end  of  a 
few  hours.  The  joints  most  frequently  affected  are  the  knee,  hip, 
and  shoulder;  occasionally  more  than  one  articulation  is  involved. 
The  course  of  the  case  varies ;   in  some  few  instances  the  fluid  is 


Fig.  309. — Hypertrophic  Variety  of 
Charcot's  Disease  of  Knee-joint. 
(From  College  of  Surgeons'  Mu- 
seum. ) 

The  patella  (pat.) can  be  seen  poised  on 
the  top  of  a  mass  of  new  bone  formed 
by  the  welding  together  of  a  number 
of  smaller  portions  formed  in  the  peri- 
synovial  tissues. 


Fig.  310. — Atrophic  Variety  of 
Charcot's  Disease  of  Knee- 
joint.  (From  College  of 
Surgeons'  Museum.) 

The  bones  are  cleanly  eroded,  and 
no  new  formation  is  present. 
The  patella  is  reduced  to  a  mere 
shell,  one-eighth  of  an  inch 
thick. 


gradually  absorbed  and  the  joint  returns  to  its  normal  size  and  shape, 
although  somewhat  weakened.  Sometimes  the  attacks  of  distension 
recur,  and  after  each  the  joint  becomes  more  and  more  crippled.  Two 
chief  types  of  the  affection  are  described  :  (i)  In  the  atrophic  variety, 
the  more  common,  the  bones  become  eroded  to  a  considerable  extent, 
the  hgaments  stretched,  and  a  weak,  flail-like  articulation  remains, 
in  which  the  ends  of  the  bones  are  atrophied  and  displaced  (Figs.  310 
and  311).    (2)  In  the  hypevlrophic  form  new  osseous  formations  occur 


DISEASES  OF  JOINTS 


671 


here  and  there  under  the  synovial  membrane,  especially  in  cases 
where  there  is  much  distension,  so  that  on  compression  of  the  swelling 
between  the  hands  a  sensation  is  produced  similar  to  that  imparted 
by  grasping  a  bag  of  bones.  After  a  time  these  osseous  masses 
become  welded  together,  giving  rise  to  large  overgrowths,  which 
lead  subsequently  to  fixation  of  the  joint  (Fig.  309).  The  disease 
sometimes  runs  a  more  chronic  course,  and  then  closely  resembles 
osteo-arthritis,  since  there  is  but  little  effusion,  whilst  the  ends  of  the 
bones  become  eroded,  and  osteophytes,  perhaps  of  great  size,  form 
around  the  edges  of  the  cartilages,  leading  to. defective  mobility  and 
crepitus. 

The  Diagnosis  of  Charcot's  disease  from  osteo-arthritis  is,  as  a  rule, 
readily  made  if  one  remembers  the  following  points :  Charcot's 
disease  is  usually  characterized  by  a  rapid  onset,  limitation  to  one 
joint,  considerable  effusion,  absence  of  articular  pain,  atrophy  of  the 


Fig.  311. — Charcot's  Disease  of  Left  Knee  and  Shoulder. 
The  great  atrophy  of  the  ends  of  the  bones,  and  the  resulting  dislocations,  are 

clearly  evident. 

ends  of  the  bones,  and  a  tendency  to  the  production  of  a  weak,  flail- 
like joint,  whilst  the  early  general  signs  of  tabes  are  also  observed, 
especially  the  lightning  pains  and  the  Argyll- Robertson  pupil.  Osteo- 
arthritis, on  the  other  hand,  comes  on  slowly,  often  affects  many 
joints,  has  but  little  effusion,  is  very  painful,  and  is  attended  with 
marginal  overgrowth  or  lipping  of  the  cartilages.  In  the  more 
chronic  cases  the  distinguishing  features  are  much  less  evident. 

As  to  pathological  anatomy,  the  changes  observed  are  practically 
identical  with  those  seen  in  osteo-arthritis,  except  that  the  erosion  is 
more  rapid,  the  effusion  greater,  and  the  formation  of  osteophytes 
less  constant. 

The  Treatment  of  Charcot's  disease  consists  in  keeping  the  limb  at 
rest  on  a  splint  and  applying  elastic  pressure.  The  effusion,  when 
considerable,  may  be  removed  by  an  aspirator,  but  is  very  likely  to 
re-collect.  Ionic  medication  with  salts  of  iodine  may  be  of  use.  In 
the  later  stages,  where  the  joint  is  entirely  disorganized,  some  form 


672  A  MANUAL  OF  SURGERY 

of  tixed  apparatus,  such  as  a  carefully  moulded  splint,  may  be  applied 
to  render  the  limb  more  useful,  and  it  is  remarkable  how  well  a 
patient  can  get  on  in  this  way  with  a  badly- affected  joint.  In  the 
worst  cases,  however,  amputation  may  be  required. 

The  same  type  of  articular  lesion  occurs  in  Syringomyelia,  a  disease  which 
consists  in  a  gliomatous  development  in  the  spinal  cord,  and  usually  in  the 
cervico-dorsal  region.  It  is  characterizod  by  loss  of  the  senses  of  pain,  and  of 
heat  or  cold,  but  tactile  and  muscular  sensibility  persists.  Atrophy  of  various 
muscles  of  the  hand  or  forearm  also  occurs,  whilst  trophic  lesions — e.g.,  whitlow, 
perforating  ulcer,  etc. — are  common.  Joint  troubles  are  observed  in  at  least  one- 
third  of  the  cases,  mainly  in  the  upper  extremity,  tabes  generally  affecting  the 
lower.  Either  atrophic  or  hypertrophic  phenomena  are  developed,  and  the 
course  is  identical  with  that  of  Charcot's  disease,  except  that  suppuration  is  a 
little  more  likely  to  follow,  owing  to  the  frequent  presence  of  septic  sores. 

Somewhat  similar  in  nature  to  Charcot's  disease  is  the  chronic  arthritis  met 
with  in  many  conditions  where  the  nervous  supply  to  a  limb  is  impaired  as  a 
result  of  central  or  peripheral  disease  of  the  nervous  system.  Thus,  it  may 
follow  spina  bifida,  hemi-  or  para-plegia  of  cerebral  or  spinal  origin,  or  may  be 
secondary  to  a  peripheral  neuritis,  due  to  either  injury,  syphilis,  gout,  diabetes, 
leprosy,  etc.  The  terminal  articulations  of  fingers  or  toes  are  those  most  often 
affected  (acro-arthritis),  although  larger  joints  may  be  involved.  They  become 
swollen  and  painful,  and  after  a  time  ankylosis  ensues. 

Haemopliilic  Diseases  of  Joints. 

In  haemophilia  ''p.  296)  any  injury  to  a  joint,  such  as  a  sprain  or 
wrench,  may  lead  to  a  copious  effusion  of  blood  into  the  articular 
cavity,  which  becomes  suddenly  swollen,  distended,  and  evidently  full 
of  fluid.  There  is  some  pain  on  movement,  the  part  becoming  hot 
and  tender,  whilst  when  coagulation  has  taken  place  it  is  hard  and 
firm.  Total  recovery  may  ensue,  or  the  joint  be  left  weak  and 
liable  to  recurrence  of  haemorrhage  and  inflammation.  The  effects 
on  the  articular  surfaces  are  curious  :  the  cartilages  usually  retain 
their  normal  colour,  but  become  thin,  worn,  and  rough,  especially  at 
the  points  of  greatest  pressure ;  fibrillar  degeneration  of  the  matrix 
may  occur,  and  in  some  cases  the  cartilage  has  been  found  totally 
absent,  being  replaced  by  fibrous  tissue.  Ecchondroses  subsequently 
developing  into  bone  are  formed  at  the  margins  of  the  joint  surfaces, 
the  changes  thus  produced  being  somewhat  akin  to  those  of  osteo- 
arthritis. The  ligaments  and  synovial  membranes  may  remain  of  a 
normal  texture,  or  are  slightly  thickened,  and  usually  of  a  russet- 
brown  colour.  Adhesions  are  often  present,  causing  considerable 
impairment  of  mobility.  The  Treatment  consists  in  keeping  the  part 
at  rest,  and  applying  ice  in  the  early  stages ;  whilst,  later  on, 
friction,  massage,  and  pressure  may  be  employed.  The  surgeon 
must  never  attempt  to  aspirate  the  joint,  even  with  a  fine  needle. 

Loose  Bodies  in  Joints. 

Several  varieties  of  loose  body  are  met  with  in  joints,  which  may 
be  described  as  follows :  (i)  The  so-called  'melon-seed  bodies'  consist 
of  fibrin  derived  from  altered  blot-clot,  or  more  frequently  from  a 


DISEASES  OF  JOINTS 


673 


B 


IN   Joint, 

i'ORTION 


Fig.  312. — Foreign    Body 
probably  derived  from 
OF    Articular    Cartilage.     (From 
College  of  Surgeons'  Museum.) 

A,  Cartilage  ;  B,  bone. 


fibrinous  exudation  in  cases  of  very  chronic  tuberculous  disease.  At 
first  irregular  in  shape  and  laminated  in  texture,  they  are  generally 
transformed  into  round  or  flattened  pellets  or  elongated  masses  by 
the  movements  of  the  articulation.  Bursse  and  tendon  sheaths  are 
much  more  frequently  affected  than  joints.  The  number  present  i£ 
usually  considerable,  whilst  there  is  also  some  glairy  effusion,  causing 
distension  and  a  certain  amount  of  creaking.  In  one  case  the  knee- 
joint  was  occupied  by  a  number  of  rounded  yellowish-white  trans- 
lucent foreign  bodies,  several  of 

which  were  nearly  as   large   as  A 

walnuts ;  they  were  probably  of  ,?  "  _  I 

haemorrhagic  origin.  (2)  Portions 
of  articular  or  intra-articular  car- 
tilage may  be  broken  off  as  a 
result  of  mechanical  violence. 
They  usually  consist  of  a  smootli 
rounded  mass  of  articular  carti- 
lage enclosing  a  central  bony 
nucleus  (Fig.  312).  (3)  They 
are  sometimes  derived  from  the 
development  of  cartilaginous 
nodules  in  the  synovial  fringes  or 
villi,  which  either  may  remain  adherent  and  become  pedunculated,  then 
occasionally  wearing  a  bed  for  themselves  in  the  articular  surface,  or 
may  be  totally  detached.  Such  structures  are  usually  lobulated  and 
irregular  in  shape,  and  consist  of  calcified  cartilage  or  bone,  whilst  a 
certain  amount  of  normal  cartilage  is  also  present  (Fig.  313).  This  con- 
dition may  result  from  osteo-arthritis,  but  sometimes  the  cartilaginous 
cells  from  which  they  are  derived  have  persisted  as  a  '  foetal  residue.' 
(4)  Finally,  portions  of  bone  may  become  separated  from  their  sur- 
roundings, and  remain  loose  in  the  cavity.  Thus  ecchondroses  may 
be  broken  off  in  cases  of  osteo-arthritis,  or  portions  of  the  articular 
surface  detached  by  mechanical  means,  or  set  free  by  a  process  of 
rarefying  osteitis  without  suppuration,  constituting  what  Paget 
originally  described  as  '  quiet  necrosis.' 

Although  cut  off  from  all  vascular  supply,  the  growth  of  some  of 
these  loose  bodies  is  s.aid  to  continue,  owing  to  the  highly  nutritious 
fluid  which  bathes  their  surfaces. 

.The  Symptoms  caused  by  this  condition  are  produced  by  the  loose 
body  being  occasionally  caught  between  the  articular  surfaces,  leading 
to  a  temporary  locking  of  the  joint,  and  severe  pain,  owing  to  the 
stretching  of  the  ligaments.  The  fixation  is  but  momentary,  since 
the  foreign  body  is  readily  displaced,  but  an  attack  of  subacute 
synovitis  follows.  When  this  has  happened  several  times,  the  liga- 
ments are  likely  to  become  relaxed,  and  the  joint  somewhat  loose  and 
distended.  Under  such  circumstances  it  may  be  possible  to  feel  the 
foreign  body  and  to  shift  its  position,  but  frequently  the  surgeon 
is  unable  to  detect  the  intruder  as  it  slips  away  into  the  interior  of  the 
joint,  owing  to  its  ready  mobility.      From  this  point  of  view,  the 

43 


674  A  MANUAL  OF  SURGERY 

German  term  '  Gelenkmaus '  (joint  mouse),  as  applied  to  this  affec- 
tion, is  most  happy.  The  knee-joint  is  that  most  frequently  affected, 
but  the  same  condition  occurs  in  the  elbow  and  temporo-maxillary 
articulation. 

The  Diagnosis  between  a  loose  body  and  a  displaced  semilunar  carti- 
lage in  the  knee-joint  is  not  always  easy,  since  in  both  conditions 
painful  locking  of  the  joint  occurs.  The  fixation,  however,  is  but 
momentary  in  the  case  of  a  loose  body,  but  may  persist  until  reduced 
in  the  latter,  whilst  a  localized  spot  of  tenderness  may  be  detected 
corresponding  to  the  site  of  the  injury  to  the  inter-articular  cartilage. 
Moreover,  the  history  of  the  case  is  very  different,  since  the  disloca- 
tion of  a  semilunar  cartilage  is  always  primarily  referred  to  some 
twist  or  sprain  of  the  joint,  whereas  with  a  loose  body  no  such 
traumatic  influence  need  be  present.  It  is  sometimes  possible  to 
detect  a  loose  body  by  the  X  rays  if  there  is  any  osseous  tissue 
in  it. 


Fig.    313. ■ — Loose  Cartilage  in  Joint,  probably  developed  in  a  Fringe  of 
Synovial  Membrane.     (From  College  of  Surgeons'  Museum.) 

A,  Cartilage  ;  B,  bone. 

The  Treatment  consists  in  the  removal  of  the  foreign  body  by  an 
open  operation.  In  the  knee-joint  a  vertical  incision  should  be  made, 
about  2  inches  in  length,  extending  a  little  above  and  below  the  line 
of  the  articulation.  It  should  be  placed  about  i  inch  from  the  patella, 
on  whichever  side  the  loose  cartilage  presents  most  frequently,  but 
preferably  on  the  outer.  If  possible,  the  foreign  body  should  be  fixed 
by  the  finger  in  one  of  the  lateral  pouches  of  the  joint  before  making 
the  incision.  The  capsule  and  synovial  membrane  are  opened,  the 
loose  body  removed,  and  the  cavity  carefully  closed.  For  precautions, 
etc.,  see  p.  640. 

Neuralgic  Joints. 

In  neurotic  individuals,  especially  young  women,  a  neuralgic  con- 
dition of  the  joints  is  commonly  met  with,  simulating  disease  of  the 
articulation.  On  careful  examination  the  pain  is  found  to  be  super- 
ficial, not  increased  by  jarring  the  articular  surfaces  together,  and 


DISEASES  OF  yOINTS  675 

often  not  strictly  confined  to  the  joint.  The  movements  are  appar- 
ently limited,  but  if  the  attention  of  the  individual  is  diverted,  or 
anaesthesia  induced,  they  are  found  to  be  perfectly  free.  There  are 
no  signs  of  effusion  into  the  cavity,  and  no  starting  pains  at  night. 
Occasionally  a  similar  condition  is  met  with  in  men,  where  there  is 
no  suspicion  of  hysteria. 

The  treatment  is  constitutional  and  local.  The  former  is  directed 
towards  improving  the  general  health,  and  correcting  any  error  in 
the  uterine  functions.  The  latter  is  best  accomplished  by  the  use  of 
cold  douches  and  electricity,  although  counter-irritation  in  the  shape 
of  blisters,  or  even  the  actual  cautery,  applied  over  the  joint,  has  an 
excellent  moral  effect. 

Aixkylosis. 

By  ankylosis  is  meant  a  condition  of  immobility,  partial  or  com- 
plete, of  a  joint,  resulting  from  some  preceding  inflammation  of  the 
articular  structures. 

The  term  false  ankylosis  is  sometimes  applied  to  a  condition  re- 
sulting from  extra-articular  lesions.  Such  may  be  either  fibrous  or 
osseous,  and  is  due  to  cicatricial  contraction  of  the  skin,  shortening 
or  fibrosis  of  muscles,  or  even  to  the  development  of  bony  tissue 
within  them  (myositis  ossificans).  Tnie  ankylosis  always  involves  the 
articular  structures,  and  is  either  fibrous  or  bony. 

Fibrous  or  incomplete  ankylosis  results  {a)  from  thickening  and 
contraction  of  the  ligaments,  such  as  often  occurs  after  gonorrhoeal 
or  rheumatic  affections  ;  il)  from  the  formation  of  cord-  or  band- like 
adhesions  within  the  joint,  after  acute  synovitis  ;  {c)  from  erosion  of 
the  cartilage  and  exposure  of  the  bone  ;  granulations  sprout  up  on 
each  side,  and  by  their  union  lead  to  dense  fibroid  adhesions  between 
the  articular  surfaces.  Some  amount  of  movement  is  possible  in 
most  of  these  cases. 

Complete  or  osseous  ankylosis  (synostosis)  arises  from  the  union  of 
either  the  whole  or  part  of  the  opposing  surfaces  left  by  the  destruc- 
tion of  the  cartilage,  the  bond  of  union,  at  first  fibro-cicatricial,  being 
subsequently  ossified  (Fig.  314);  it  may  also  be  due  to  the  inter- 
locking and  fusion  of  osteophytes,  formed  at  the  margin  of  the  bone 
in  osteo-arthritis  or  Charcot's  disease. 

The  Causes  of  ankylosis  are  very  variable,  but  may  be  arranged  as 
follows : 

1.  Injury  to  the  articular  surfaces,  as  from  fractures  which  run  into 
a  joint. 

2.  Non-suppurative  inflammation  of  joints,  involving  the  formation 
of  fibrous  adhesions  or  the  contraction  of  ligaments,  as  in  synovitis, 
whether  traumatic,  rheumatic,  gouty,  gonorrhoeal,  etc.,  and  the  early 
stages  of  acute  or  tuberculous  arthritis. 

3.  Destruction  of  bones,  associated  or  not  with  articular  diseases, 
as  in  Pott's  disease  of  the  spine,  and  the  later  suppurating  stages  of 
acute  or  tuberculous  arthritis. 


676 


A  MANUAL  OF  SURGERY 


4.  Nervous  affections  may  be  the  cause  of  ankylosis,  by  leading  to 
a  chronic  form  of  arthritis.  The  lesions  may  be  central,  as  in  spina 
bifida,  tabes,  and  syringomyelia ;  or  peripheral,  as  in  neuritis,  Ray- 
naud's disease,  diabetes,  leprosy,  or  division  of  nerves. 

5.  Long-continued  abnormal  pressure  of  contiguous  bones  may 
result  in  ankylosis,  as  in  scoliosis  or  arthritis  deformans  of  the  spine. 
In  the  latter  affection  the  immobility  may  be  due  either  to  ossification 

of  ligaments  or  to  the  interlocking  of 
osteophytes. 

The  position  in  which  ankylosis 
occurs  and  the  effects  thus  produced 
differ  according  to  the  joint  affected. 

In  the  shoulder  there  is  but  little  dis- 
placement, and  the  existence  of  im- 
mobility is  of  less  importance  than 
elsewhere,  owing  to  the  free  move- 
ments of  the  scapula  and  clavicle. 
The  deltoid  muscle  is  usually  much 
atrophied.  The  elhow-joint  is  very  com- 
monly ankylosed  on  account  of  its  ex- 
posed position,  and  the  frequency  of 
fracture -dislocations  in  its  neighbour- 
hood. The  formation  of  callus  filling 
up  the  olecranon  and  coronoid  fossae, 
and  the  adhesions  likely  to  form  within 
the  joint  in  these  cases,  readily  explain 
its  frequency.  The  most  favourable 
position  for  ankylosis  is  when  the 
arm  is  flexed  to  a  little  more  than  a 
right  angle,  with  the  hand  midway 
between  pronation  and  supination. 
By  this  means  access  to  the  mouth  is 
possible,  and  the  patient  can  use  his  hand  for  feeding  purposes.  The 
wrist  is  most  commonly  fixed  as  a  result  of  gonorrhoeal  or  rheumatic 
synovitis.  In  the  hip-joint  (Fig.  314)  much  depends  upon  the  treat- 
ment as  to  whether  the  ankylosis  takes  place  in  a  good  or  bad 
position.  In  neglected  cases  the  thigh  may  be  in  a  position  of 
adduction  and  internal  rotation,  crossing  in  front  of  the  other  leg. 
Occasionally  a  scissor-like  defovuiity  has  resulted  from  inflammation  of 
both  hip-joints,  one  leg  lying  in  front  of  the  other ;  progression  is 
accomplished  with  difficulty,  the  body  twisting  at  each  step,  and 
crutches  are  often  needed.  In  the  knee-joint  ankylosis  in  an  absolutely 
straight  position  of  the  limb  should  be  aimed  at,  unless  complete 
synostosis  is  likely  to  occur,  when  a  slight  degree  of  flexion  may 
render  the  leg  more  serviceable.  In  the  ankle-joint  considerable 
trouble  may  arise  from  immobility,  unless  the  foot  is  at  right  angles 
to  the  leg. 

Treatment. — Fibrous  ankylosis,  due  to  massive  adhesions,  is  often 
best  left  alone,  since  even  if  the  adhesions  are  ruptured  by  manipula- 


FiG.  314. — Ankylosis  of  Hip- 
joint  IN  Good  Position  after 
Early  Hip  Disease.  (Howard 
Marsh.) 


DISEASES  OF  JOINTS  ,  677 

tion,  they  are  almost  certain  to  re-form.  Moreover,  in  an  old-standing 
case  marked  atrophy  of  bone  is  often  present,  and  a  fracture  can 
easily  be  produced.  The  existence  of  deformity,  however,  justifies 
the  employment  of  a  certain  amount  of  force  in  order  to  straighten 
the  limb.  If  due  to  tuberculous  disease,  the  possibility  of  lighting 
up  the  old  mischief  or  disseminating  the  virus  must  be  kept  in  mind, 
and  the  haphazard  methods  of  unscientific  bone-setters  in  such  cases 
have  often  been  followed  by  disastrous  results. 

For  osseous  ankylosis  various  operative  measures  may  be  employed, 
with  a  view  either  to  correct  the  deformity,  or  in  other  cases  to  restore 
movement  to  the  part.  At  the  shoulder,  wrist,  and  ankle  nothing  need 
be  undertaken  unless  obvious  and  troublesome  deformity  is  present. 
At  the  elbow  excision  may  be  beneficially  employed,  and  with  every 
prospect  of  gaining  a  moveable  joint.  If,  however,  ankylosis  is 
present  in  a  child,  the  operation  should  be  deferred  until  growth  has 
come  to  an  end.  Ankylosis  of  the  knee  in  a  false  position  needs 
cuneiform  osteotomy,  or  the  resection  of  a  wedge-shaped  portion  of 
bone,  in  order  to  secure  a  straight,  rigid  and  useful  limb. 

Ankylosis  of  the  hip-joint  in  a  bad  position  is  best  treated  by 
dividing  the  neck  or  the  upper  part  of  the  shaft  of  the  femur.  Several 
operations  have  been  devised  for  this  purpose.  i.  Adams'  subcu- 
taneous osteotomy  of  the  neck  of  the  bone  consists  in  passing  a 
sharp-pointed  bistoury  down  to  the  anterior  surface  of  the  cervix 
femoris,  from  a  point  midway  between  the  trochanter  and  the  anterior 
superior  spine  of.  the  ilium.  A  track  is  thus  made,  allowing  the 
introduction  of  an  Adams'  osteotomy  saw,  by  means  of  which  the 
neck  of  the  femur  is  divided  subcutaneously.  The  limb  is  put  up  in 
a  straight  position,  and  the  bone  allowed  to  re-unite.  2.  The  same 
result  may  be  obtained  by  an  open  method,  making  a  similar  incision 
as  in  the  anterior  operation  for  excising  the  joint  (p.  692).  3.  Gant 
suggested  division  below  the  lesser  trochanter.  This  may  be  accom- 
plished by  cutting  down  on  the  bone  from  the  outer  side  and  chiselling 
it  across. 

As  to  the  operation  to  select  in  any  particular  case,  the  surgeon's 
choice  must  be  guided  by  the  condition  of  affairs  present.  A 
skiagram  of  the  neck  of  the  femur  should  always  be  taken,  so  as  to 
ascertain  its  condition.  Sometimes  it  is  stunted,  and  has  practically 
disappeared ;  in  other  cases  it  is  much  thickened,  and  forms  a  large 
bony  mass  passing  from  the  trochanter  to  the  ilium,  and  probably 
containing  encapsuled  foci  of  tuberculous  material.  In  both  these 
conditions  subtrochanteric  osteotomy  must  be  employed,  but  prefer- 
ably in  an  oblique  and  not  a  transverse  axis  ;  it  is  not  unusual  to  find 
that  the  adductor  muscles  are  so  contracted  that  their  attachments 
to  the  pubes  require  section  before  the  limb  can  be  satisfactorily 
straightened.  Division  of  the  cervix  can  only  be  recommended  when 
that  structure  is  of  normal  length  and  size. 


678 


A  MANUAL  OF  SURGERY 


Hip-joint  Disease. 

Although  the  term  '  hip-joint  disease  '  is  usually  applied  to  a  tuber- 
culous arthritis,  it  is  not  the  only  affection  involving  this  articulation, 

as  rheumatic,  gonorrhoea!,  or 
pyaemic  affections  are  not  very 
uncommon.  Acute  arthritis  is 
also  met  with  secondary  to  an 
acute  infective  osteo-myelitis  of 
the  upper  end  of  the  femur,  and 
is  evidenced  by  all  the  ordinary 
signs  of  that  affection,  separa- 
tion and  necrosis  of  the  upper 
epiphysis  being  a  frequent 
result.  Osteo-arthritis  is  fre- 
quently seen  (p.  669),  whilst 
Charcot's  disease  may  also 
occur. 

Tuberculous  Disease  of  the 
Hip  {Syn. :  Morbus  Coxae,  Tuber- 
culous Coxitis,  Coxalgia)  differs 
in  no  respect  from  the  same 
disease  as  it  affects  other  joints, 
and  hence  no  detailed  notice  of 
the  pathological  anatomy  is  re- 
quired. Suffice  it  to  say  that 
it  may  originate  in  the  synovial 
membrane  or  bone,  more  fre- 
quently in  the  latter,  and  then 
commencing  either  beneath  the 
articular  cartilage  or  on  the  underside  of  the  neck  distal  to  the  epi- 
physeal cartilage  (Fig.  315).  Very  rarely  the  disease  becomes  cir- 
cumscribed in  the  neck  of  the  bone,  forming  a  chronic  abscess,  the 
diagnosis  of  which  is  exceedingly  difficult.  More  usually  the  disease 
spreads  from  the  under  side  of  the  neck,  and  involves  the  synovial 
membrane,  which  passes  into  a  state  of  pulpy  degeneration.  The 
substance  of  the  epiphysis  is  invaded,  and  caries  of  the  head  is 
thereby  produced,  together  with  necrosis  or  ulceration  of  the  cartilage 
(Fig.  302).  The  acetabulum  undergoes  similar  changes  ;  from  the 
contact  and  backward  pressure  of  the  diseased  head  the  posterior  aceta- 
bular margin  is  absorbed  and  the  cavity  extended,  whilst  at  the  same 
time  a  new  rim  of  bone  forms  beneath  the  adjacent  periosteum  at 
a  slightly  higher  level,  thus  giving  rise  to  what  is  known  as  a 
'  travelling  acetabulum '  (Fig.  316).  In  this  way  the  socket  is  in- 
creased both  in  size  and  depth,  travelling  backwards  and  upwards 
with  the  head  of  the  bone  towards  the  dorsum  ilii.  Other  factors 
assisting  in  the  displacement  of  the  head  of  the  bone  are :  the  tonic 
action  of  the  muscles,  keeping  the  limb  in  a  position  of  flexion, 
adduction  and  inversion,  thereby  causing  a  considerable  portion  of 


Fig.  315. — Tuberculous  Disease  of  the 
Head  and  Neck  of  the  Femur,  show- 
ing Sequestra  in  an  Abscess  Cavity, 
AND  Communication  on  the  Under 
Side  of  the  Neck  with  the  Joint. 
(Tillmanns.) 

The  epiphysis  of  the  head  has  been  in- 
vaded, and  the  articular  cartilage  entirely 
stripped  off  by  the  disease ;  the  con- 
tinuous black  line  indicates  the  amount 
of  bone  which  it  would  be  necessary  to 
remove,  if  excision  were  undertaken. 


DISEASES  OF  JOINTS 


679 


the  head  to  project  out  of  the  acetabulum ;  and  the  earlj'  softening 
and  destruction  of  the  posterior  ligaments,  which  are  much  thinner 
than  those  in  front  of  the  joint.  Occasionally  a  mass  of  protuberant 
granulations  sprouts  up  from  the  centre  of  the  cavity,  and  may  also 
assist  in  this  process.  Should  the  acetabulum  be  perforated,  a 
tuberculous  abscess  is  likely  to  form  within  the  pelvis.  .  The  adjacent 
pelvic  bones  may  either  become  thickened  by  the  deposit  of  osteo- 
phytes, or  carious ;  if  sepsis  is  present,  necrosis  may  also  supervene. 


Fa 


>. 


Fig.  316. — Femuk  and  Acetabulum 
IN  Hip  Disease.  (King's  College 
Hospital  Museum.) 

The  epiphysis  of  the  caput  femoris 
has  been  practically  destroyed, 
and  the  acetabulum  is  enlarged 
by  absorption  of  its  posterior 
margin  and  displaced  upwards 
{travelling  acetahihmi).  The  rami 
of  the  ischium  and  pubes  have 
been  removed. 


Fig.  317. —  Early  Stage  of  Hip 
Disease  (Left  Side)  in  a 
Child.     (From  a  Photograph.) 

The  black  line  is  drawn  from  one 
anterior  superior  spine  to  the 
other,  and  shows  not  only  the 
amount  of  abduction  present,  but 
also  the  tilting  down  of  the 
pelvis  on  the  affected  side. 


Clinical  History. — The  patient,  usually  a  child,  is  observed  to  limp, 
and  may  complain  of  pain  either  in  the  hip  or.  more  often  on  the  inner 
side  of  the  knee,  the  latter  being  due  to  the  fact  that  both  joints  are 
supplied  by  the  same  nerves— viz.,  the  anterior  crural,  sciatic,  and 
obturator  trunks.  There  may  be  some  history  of  injury,  but  not  neces- 
sarily. On  examining  the  limb  in  the  early  stage,  it  is  usually  found  to 
be  apparently  lengthened  {Fig.  317),  whilst  the  thigh  is  slightly  wasted. 
The  nates  are  flattened,  and  the  gluteal  fold  lost,  conditions  partly 


68o 


A  MANUAL  OF  SURGERY 


due  to  atrophy  of  the  muscles,  partly  to  the  flexion  of  the  limb.  The 
joint  is  more  or  less  rigid,  and  pain  is  produced  on  attempting  to  move 
it,  or  on  jarring  the  leg,  as  by  striking  the  heel  or  trochanter.     The 


Fig.  318.- 


-DiAGRAM  TO  Illustrate  the  Positions  Assumed  by  the  Limb  in 
THE  Early  and  Late  Stages  of  Hip  Disease. 


A  represents  the  position  of  abduction  taken  by  the  right  limb  in  the  early  stage 
of  hip  disease,  and  B,  Nature's  method  of  masking  this  by  tilting  the  pelvis 
down  on  the  affected  side,  while  the  other  leg  is  adducted  ;  the  effect  of  this 
on  the  spine,  in  causing  a  lateral  deflection,  is  also  indicated.  C  shows  the 
same  thing  in  the  later  stage,  when  adduction  is  present,  and  the  pelvis  is 
tilted  upwards  on  the  affected  side,  thus  producing  apparent  shortening  (D). 

position  assumed  in  this  early  stage  is  one  of  slight  and  increasing 
flexion,  abduction,  and  eversion  (Fig.  318,  A),  the  reason  for  this  being 
that  thereby  the  ligaments,  and  especially  the  ilio-femoral,  are  most 
relaxed,  and  the  capacity  of  the  joint  is  at  its  greatest.  The  latter 
fact  has  been  demonstrated  in  the  healthy  cadaver  by  inserting  the 
nozzle  of  a  syringe  into  the  joint  through  the  acetabulum,  and  forcibly 
mjecting  fluid,  when  this  position  is  at  once  assumed.  The  flexion 
and  abduction,  however,  are  not  always  evident,  since  the  flexion  is 
masked  by  lordosis  of  the  spine  (Figs.  319  and  320),  and  the  abduction 
by  the  pelvis  being  tilted  down  on  the  affected  side,  producing  thereby 
apparent  lengthening  of  the  diseased  limb  and  lateral  curvature  of  the 
spine,  with  its  lumbar  convexity  towards  the  affected  side  (Fig.  318, 
A  and  B).  The  sound  leg  being  brought  into  a  position  of  adduction, 
the  parallelism  of  the  limbs  is  maintained.  The  flexion  can  be 
demonstrated  by  any  method  which  obliterates  the  lumbar  curve  of 
the  spine,  as  by  fully  bending  up  the  sound  limb  on  the  abdomen,  the 
affected  thigh  rising  at  once  from  the  bed  and  forming  an  angle  which 
indicates  the  am.ount  of  flexion  (Fig.  319).  The  abduction  is  demon- 
strated by  laying  a  rod  across  the  two  anterior  superior  spines,  and 
placing  another  at  right  angles  to  its  centre.  This  will  not  correspond 
with  the  line  of  the  body  or  of  the  limb,  but  makes  an  angle  with  it. 
The  eversion  cannot  be  masked.  The  rigidity  is  easily  demon- 
strable in  that  all  movements  of  the  hip-joint  are  greatly  limited  ; 
thus  if  an   attempt   is   made   to   bend   the   affected   thigh   on   the 


DISEASES  OF  JOINTS 


681 


abdomen,  the  corresponding  side  of  the  pelvis  is  raised  with  it  from 
the  bed. 

As  the  disease  progresses,  and  the  bones  become  more  extensively 
affected,  the  pain  increases,  with  nocturnal  startings,  whilst  abscesses 
form,  and  a  certain  amount  of  fever  and  constitutional  disturbance  is 
f;aused  thereby.     The  position  of  ihe  limb  also  changes  ;  for  although 


Fig.  319. 


-Hip  Disease,  with  the  Back  Flat  on  the  Couch,  and  the  Leg 
Flexed  to  a  Considerable  Degree, 


Fig.  320. — On  Pressing  Down  the  Diseased  Limb,  the  Spine  becomes 
Arched  (Lordosis)  in  the  Lumbar  Region,  so  that  the  Hand  could 
be  readily  passed  below  it.  The  Eversion  of  the  Limb  is  very 
Evident. 

the  flexion  is  maintained  and  even  increased,  adduction  and  inversion 
are  now  associated  with  it.  The  pelvis  is  tilted  up  on  the  affected 
side  (Fig.  318,  C  and  D),  ca.usmg  apparent  shortening,  lateral  curvature 
with  a  lumbar  convexity  to  the  sound  side,  and  abduction  of  the 
healthy  limb.  No  satisfactory  cause  for  this  position  can  be  given, 
but  it  is  usually  attributed  to  the  yielding  of  the  posterior  and  outer 
part  of  the  capsule,  together  with  infiltration  and  weakening  of  the 
small  external  rotator  muscles,  allowing  the  adductors  and  internal 
rotators  unopposed  play. 

When  an  abscess  has  formed,  the  most  usual  situation  for  it  to 
point  is  a  little  in  front  of  and  internal  to  the  great  trochanter,  close 


A  MANUAL  OF  SURGERY 


to  the  insertion  of  the  tensor  fasciae  femoris.  It  may  reach  that  spot 
either  from  an  opening  in  the  anterior  part  of  the  capsule,  coming 
thus  to  the  surface  along  the  line  of  least  resistance,  or  it  may  burrow 
from  the  posterior  portion  of  the  capsule  along  the  rotator  muscles 
and  superior  gluteal  nerve.  Less  frequently  abscesses  pass  directly 
backwards  to  open  in  the  gluteal  region,  or  forwards  along  the  pubo^ 
femoral  ligament,  pointing  on  the  inner  side  of  the  femoral  vessels 


Fig. 


A  B 

321. — Position  of  the  Limb  in  the  Later  Stages  of  Hip  Disease. 


In  A  a  white  line  has  been  drawn  between  the  two  anterior  superior  spines  to 
indicate  the  tilting  of  the  pelvis  upwards  on  the  affected  side  necessitated  by 
the  adduction  of  the  limb.  Some  amount  of  flexion  was  present,  but  this 
was  not  marked.     In  B  the  secondary  curves  of  the  spine  are  well  seen. 

below  Poupart's  ligament.  As  a  rare  complication,  the  tuberculous  ^ 
process  may  extend  to  the  bursa  under  the  psoas  tendon,  which  some-^ 
times  communicates  wfth  the  joint,  leading  to  the  formation  of  an^ 
abscess  in  the  upper  part  of  Scarpa's  triangle,  and  occasionally  to  a. 
typical  psoas  abscess  from  extension  upwards.  An  intra-pelvici 
abscess  following  perforation  or  disease  of  the  acetabulum  may  either 
burrow  upwards,  and  come  to  the  surface  above  Poupart's  ligament, 
or  may  gravitate  downwards,  and  burst  in  the  ischio-rectal  fossa. 

The  final  stage  of  the  disease  is  one  of  real  shortening  (Fig.  321),  due 
to  erosion  of  the  head  of  the  bone  and  its  displacement  backwards 
upon  the  dorsum  ilii.     The  position   assumed  is  one  of  increased 


DISEASES  OF  JOINTS  6S3 

flexion,  adduction,  and  inversion;  whilst  if  suppurating  sinuses  persist, 
hectic  fever  and  amyloid  changes  in  the  viscera  are  likely  to 
follow. 

At  any  stage  cure  by  ankylosis  may  be  obtained ;  but  unless  the 
abnormal  position  has  been  corrected  by  extension,  deformity  is 
almost  certain  to  be  present,  whilst  interference  with  growth  may 
increase  the  shortening. 

The  Diagnosis  of  hip  disease  appears  to  be  a  matter  of  considerable 
difficulty  to  some,  if  we  may  argue  from  the  mistakes  which  com- 
monly occur.  The  pain  in  the  knee  present  in  the  early  stages  leads 
to  its  frequently  being  mistaken  for  disease  of  that  articulation  ;  all 
cases  of  pain  in  the  knee  without  apparent  cause  should  suggest  an 
examination  of  the  hip-joint,  as  well  as  of  the  knee  ;  a  very  slight 
amount  of  care  in  the  examination  should  prevent  such  an  error. 
From  disease  of  the  opposite  hip,  it  is  recognised  by  the  relative 
mobility  of  the  thigh  on  the  two  sides.  The  same  test,  viz.,  that  of 
the  mobility  of  the  joint,  should  prevent  congenital  dislocation  of  the 
hip  being  mistaken  for  tuberculous  disease,  as  is  not  unfrequent.  The 
diagnosis  from  sacro-iliac  disease  is  given  at  p.  688.  Spinal  mischief 
may  also  be  confounded  with  it,  if  a  psoas  abscess  points  at  any  of 
the  ordinary  situations  in  which  sinuses  form  in  connection  with  the 
hip-joint.  The  presence  of  spinal  deformity  and  the  ability  to 
perform  the  test  movement  for  hip  disease  should  readily  enable  the 
surgeon  to  make  a  correct  diagnosis,  but  it  must  not  be  forgotten 
that  the  two  conditions  may  co-exist.  If  the  limb  can  be  put  into 
what  is  known  as  the  tailor's  position — that  is,  flexion  to  a  right 
angle  with  marked  abduction  and  eversion — one  may  be  practically 
certain  that  hip  disease  is  not  present. 

An  encapsuled  abscess  in  the  neck  of  the  Jemur  is  a  condition  which  it  is 
very  difficult  to  distinguish  from  true  hip  disease.  A  constant  deep 
boring  pain  is  complained  of,  which  is  increased  by  pressure  over  the 
neck,  or  by  jarring  the  trochanter ;  but  if  the  limb  is  manipulated 
gently,  it  can  be  proved  that  the  movements  of  the  joint  are  not  really 
impaired.  Radiography  is  a  useful  aid  in  making  a  diagnosis  of  this 
condition. 

It  is  often  impossible  to  be  certain  as  to  the  nature  of  the  inflam- 
matory attack  following  a  slight  injury.  The  patient  is  treated  as  for 
the  graver  affection,  and  if  it  gets  well  in  a  week  or  two,  probably 
it  is  not  tuberculous.    Radiography  is  always  of  help  in  the  diagnosis 

(Fig-  323)- 

The  Prognosis  of  hip  disease  is  by  no  means  unfavourable  if  the 
condition  is  properly  treated.  Of  course,  the  patient  is  liable  to 
develop  acute  tuberculosis  or  tuberculous  disease  elsewhere  ;  or,  if 
abscesses  are  allowed  to  become  septic,  serious  complications — such 
as  pyaemia,  sapraemia,  hectic  and  amyloid  disease — may  ensue.  Apart 
from  these,  however,  no  serious  consequences  affecting  life  need  be 
feared,  although  the  usefulness  of  the  limb  may  be  seriously  crippled 
from  shortening  or  ankylosis,  especially  if  the  latter  occurs  in  a  faulty 
position. 


684 


A  MANUAL  OF  SURGERY 


Fig.  322.  —  Thomas's 
Hip-splint  applied. 


The  Treatment  of  hip  disease  must  be  conducted  along  the  same 
lines  as  for  tuberculous  lesions  generally.  In  the  early  stages  the 
limb  must  be  kept  at  rest  and  deformity  prevented.  This  is  perhaps 
best  accomplished  by  weight  extension  to  the 
affected  limb,  and  the  application  of  a  Liston's 
sphnt  to  the  sound  side ;  or  the  child  may  be 
fixed  down  by  sandbags,  or  a  Bryant's  splint 
employed.  For  weight  extension,  the  strap- 
ping must  be  carried  well  above  the  knee,  and 
only  enough  weight  used  to  keep  the  limb  from 
painful  starts.  If  the  amount  of  flexion  is 
slight,  the  limb  may  be  allowed  to  lie  on  the 
bed  in  the  horizontal  posture  ;  this  will  pos- 
sibly induce  some  compensatory  lordosis,  but 
as  the  muscular  spasm  relaxes,  the  curvature 
of  the  spine  disappears.  When,  however,  a 
considerable  degree  of  flexion  is  present,  ex- 
tension must  be  made  along  the  axis  of  the 
flexed  limb,  which  is  supported  on  pillows.  It 
will  be  found  that  after  a  few  days  the  flexion 
diminishes,  and  the  limb  will  then  gradually 
assume  the  horizontal  position.  Should  this 
precaution  not  be  adopted,  the  extension 
merely  produces  lordosis,  and  the  pain  from 
intraarticular  tension  is  increased  thereby.  The  general  health  of 
the  patient  must  at  the  same  time  be  attended  to,  and  cod-liver  oil 
and  syrup  of  the  iodide  of  iron  may  be  administered  with  benefit. 
When  the  more  urgent  symptoms  have  disappeared,  as  indicated  by 
the  absence  of  pain  on  the  reduction  or  removal  of  the  weight,  a 
Thomas's  hip-splint  is  applied,  so  as  to  enable  the  patient  to  get 
about  (Fig.  322).  This  consists  of  a  flat  bar  of  malleable  iron,  about 
an  inch  and  a  half  wide,  extending  from  the  lower  part  of  the  axilla 
nearly  to  the  ankle ;  it  is  shaped  so  as  to  fit  the  varying  curves  of  the 
body,  and  cross-pieces  embrace  the  trunk  at  the  level  of  the  nipples, 
as  also  the  thigh  and  the  calf ;  it  is  firmly  bandaged  to  the  body  and 
limb.  A  patten  is  placed  under  the  boot  of  the  sound  leg,  and  the 
patient  allowed  to  get  about  on  crutches.  This  apparatus  should  be 
worn  for  at  least  six  months  after  all  signs  of  active  disease  have 
disappeared.  It  may  also  be  employed  in  the  earlier  and  more 
painful  stages  if  it  is  at  first  bent  so  as  to  accommodate  itself  to  the 
flexed  position  of  the  limb  ;  as  the  effect  of  the  rest  becomes  evident 
in  a  diminution  of  muscular  spasm,  the  splint  can  gradually  be 
straightened  out,  so  that  at  length  the  limb  is  fully  extended. 

When  abscesses  form,  they  may  be  opened  antiseptically,  or 
preferably  tapped  and  injected  with  iodoform,  drainage  if  possible 
being  avoided  ;  of  course,  the  former  precautions  as  to  rest  and  con- 
stitutional treatment  are  still  maintained.  More  extensive  operative 
measures — such  as  excision  of  the  head  by  the  anterior  method  (p.  692) 
— are  sometimes  undertaken  in  the  early  stages  to  cut  short  the 


en      aJ  ,0) 


c3    ^ 


o    V: 


DISEASES  OF  JOINTS  687 

disease,  especially  when  prolonged  treatment  is  impracticable,  as 
amongst  the  poor,  or  when  the  general  health  and  constitutional 
powers  are  defective.  The  removal  of  the  whole  head  necessarily 
involves  the  upper  epiphysis,  and  hence  defective  growth  of  the 
femur  results,  as  well  as  immediate  shortening.  For  these  reasons, 
as  also  because  repair  is  possible  in  most  cases  without  operation 
(when  there  is  a  certain  amount  of  recuperative  power  and  pro- 
longed treatment  is  feasible),  this  proceeding,  at  one  time  so  com- 
mon, is  being  discarded  more  and  more  in  favour  of  conservative 
measures. 

It  is  sometimes  possible,  however,  to  save  some  portion  of  the 
head,  and  if  so,  this  should  always  be  attempted.  The  joint  may  be 
opened  from  the  front,  the  interior  freely  curetted  (perhaps  after  a 
temporary  dislocation  of  the  head),  the  bone  scraped,  and  even  a 
channel  gouged  along  its  anterior  wall  to  expose  and  remove  a  deep 
focus,  or  explore  the  epiphyseal  line.  By  this  plan,  shortening  and 
defective  growth  can  to  a  large  extent  be  avoided. 

In  the  later  stages,  and  especially  when  sinuses  have  formed  in  the 
gluteal  region  or  behind  the  trochanter,  excision  by  the  posterior  method 
(p.  692)  is  preferable ;  this  is  usually  an  easy  matter,  since  the  head 
is  probably  eroded  and  displaced.  The  sinuses  should,  if  possible,  be 
included  in  the  incision,  but  under  any  circumstances  must  be  opened 
up  and  scraped.  When  the  acetabulum  is  extensively  implicated, 
the  disease  can  only  be  satisfactorily  dealt  with  by  removing  the  head 
of  the  bone,  and  the  posterior  method  affords  the  best  means  of 
subsequent  drainage ;  of  course,  this  presumes  that  the  general  con- 
dition of  the  patient  has  not  been  seriously  undermined,  and  that  there 
is  a  good  prospect  of  gaining  a  useful  limb.  Otherwise  amputatioji 
through  the  hip-joint  is  required,  especially  when  the  mischief  has 
extended  into  the  pelvis,  or  when,  after  excision,  a  weak,  flail-like 
limb  results  or  osteo-myelitis  supervenes.  It  is  also  needed  when 
after  excision  sinuses  persist  and  lead  down  into  the  acetabular  cavity, 
from  which  there  is  a  plentiful  secretion  of  pus,  and  over  the  entrance 
to  which  the  upper  end  of  the  femur  is  drawn,  thereby  obstructing 
the  escape  of  the  discharge,  and  rendering  dressing  both  difficult  and 
painful.  The  operation  often  gives  most  excellent  results,  the  patient's 
condition  rapidly  improving.  Removal  by  the  anterior  racquet 
method  is  perhaps  the  most  convenient,  in  that  the  division  and 
ligature  of  the  vessels  can  sometimes  be  accomplished  through  a 
separate  incision,  or  at  any  rate  at  a  spot  where  drainage  is  most 
complete,  and  infection  least  likely  to  occur. 

Disease  of  the  Sacro-iliac  Joint. 

Tuberculous  disease  of  this  joint  is  most  commonly  met  with  in 
adults,  but  rarely  in  children.  It  may  commence  in  the  synovial 
membrane,  but  is  frequently  the  result  of  mischief  starting  in  the 
pelvic  bones,  especially  the  ilium.  The  Pathological  Anatomy  calls 
for  no  description,  inasmuch  as  it  follows  the  ordinary  course  of 
tuberculous  disease. 


688  A  MANUAL  OF  SURGERY 

The  Clinical  Signs  consist  of  pain  and  a  sense  of  weakness  in  the 
lower  part  of  the  back,  increased  by  standing,  walking,  or  any  move- 
ment— such  as  coughing,  sneezing,  and  the  like — which  calls  the  flat 
abdominal  muscles  into  sudden  action  and  drags  on  the  ilium.  It  is 
of  a  very  unpleasant  character,  a  sensation  as  if  the  pelvis  were  coming 
to  pieces  being  experienced  by  the  unfortunate  individual.  Owing  to 
the  fact  that  the  lumbo-sacral  cord  passes  in  front  of  the  articulation, 
pain  is  often  referred  to  the  gluteal  region  or  down  the  leg.  Move- 
ments of  the  limb  cause  pain  if  the  pelvis  is  not  supported,  but  can  be 
freely  performed  if  the  pelvis  is  steadied.  Compression  together  of 
the  innominate  bones,  or  their  forcible  separation,  is  the  means  of 
demonstrating  most  effectually  the  existence  and  situation  of  the 
pain.  The  patient  is  unable  to  stand  or  to  put  any  weight  on  the 
affected  limb,  and  hence  limps  during  walking,  allowing  his  body  to 
lean  forwards,  and  making  use  of  a  stick.  There  is  apparent  lengthen- 
ing on  the  affected  side,  but  on  measurement  from  the  anterior 
superior  spine  to  the  internal  malleolus  the  leg  is  found  to  be  of  the 
same  length  as  its  fellow.  This  appearance  is  due  to  the  fact  that 
the  whole  innominate  bone  is  tilted  downwards  and  forwards,  so  that 
the  anterior  superior  spine  is  at  a  lower  level  and  more  prominent 
than  that  on  the  opposite  side.  The  region  of  the  synchondrosis  is 
often  swollen,  puffy,  and  tender ;  whilst  after  a  time  abscesses  form, 
which  m.ay  either  point  immediately  over  the  articulation,  or  burrow 
upwards  into  the  lumbar  region,  or  forwards  into  the  iliac  fossa,  or 
downwards  into  the  pelvis,  opening  perhaps  in  the  ischio-rectal  fossa. 
The  last  is  a  most  serious  complication,  since  it  is  almost  certain  to 
introduce  the  septic  element. 

The  Diagnosis  needs  to  be  made  from  sciatica,  hip  disease, 
spinal  disease,  and  some  other  sources  of  pelvic  pain.  Sciatica  is 
known  by  the  character  of  the  pain,  which  shoots  down  the  back  of 
the  thigh  in  the  course  of  the  great  sciatic  nerve,  which  may  be 
distinctly  tender  on  pressure.  There  is  no  apparent  elongation  of  the 
limb,  and  compression  together  of  the  pelvic  crests  is  painless.  From 
affections  of  the  hip-joint,  sacro-iliac  disease  is  recognised  by  the  fact 
that,  if  the  pelvis  is  supported,  the  thigh  may  be  moved  in  all 
directions  without  great  discomfort ;  whilst  compression  of  the  pelvis 
in  hip  disease  causes  no  pain.  Moreover,  in  the  advanced  stages  of 
hip  disease,  there  is  apparent  or  real  shortening  and  deformity,  con- 
ditions never  noticed  in  the  sacro-iliac  affection.  From  spinal  disease, 
the  diagnosis  should  not  be  difficult  if  a  careful  examination  of  the 
spine  and  pelvis  is  made.  When  pain  is  the  most  marked  symptom, 
the  surgeon  must  exclude  other  possible  sources — e.g.,  rectal  or 
uterine  carcinoma ;  it  is  a  useful  rule  to  remember'  that  in  all  such 
cases  a  rectal  or  vaginal  examination  should  be  made.  It  is  quite 
possible  in  certain  cases  of  sacro-iliac  disease  to  detect  a  fulness 
on  the  anterior  wall  of  the  synchondrosis. 

The  Prognosis  of  sacro-iliac  disease  is  not  necessarily  un- 
favourable if  asepsis  is  maintained ;  the  admission  of  pyo- 
genic  bacterid   constitutes   the    main    danger.      In    young   women 


DISEASES  OF  JOINTS  689 

it  may  lead  to  subsequent  deformity  of  the  pelvis  and  trouble  in 
parturition. 

Treatment  in  the  early  stages  consists  in  absolute  rest  in  bed,  with 
the  application  of  a  pelvic  support,  and  attention  to  the  general  health. 
Abscesses  may  sometimes  be  dealt  with  in  the  usual  conservative 
fashion — viz.,  by  tapping  and  injection,  but  not  unfrequently  it 
is  necessary  to  lay  them  freely  open,  and  deal  with  the  diseased  bone 
by  scraping  or  gouging  it  away,  allowing  the  wound  to  heal  by 
granulation.  Occasionally  it  is  necessary  to  remove  the  posterior 
part  of  the  iliac  crest  in  the  neighbourhood  of  the  posterior  superior 
spine  in  order  to  gain  access  to  the  diseased  area  ;  this  may  be 
accomplished  by  the  chisel  or  trephine  through  a  vertical  incision, 
and  excellent  results  often  follow  this  proceeding. 

Excision  of  Joints. 

Excision  of  joints  is  an  operation  which  was  largely  placed  on 
a  scientific  footing  by  the  late  Sir  William  Fergusson,  and  to  his 
skill  and  insight  we  owe  much  of  what  has  thus  been  gained.  The 
chief  articular  lesions  for  which  excision,  partial  or  complete,  is 
now  recommended  are  as  follows :  (i)  For  compound  dislocations  or 
fracture-dislocations  ;  (2)  for  various  forms  of  simple  or  comminuted 
fracture  in  the  neighbourhood  of  joints  where  ankylosis  is  likely  to 
follow,  and  either  interfere  seriously  with  the  utility  of- the  joint  or  fix 
it  in  a  bad  position :  the  shoulder  and  elbow  are  the  joints  most 
frequently  dealt  with  in  this  way ;  (3)  for  some  forms  of  congenital 
or   old-standing   dislocation  which   cannot  be  otherwise   remedied ; 

(4)  in  the  later  stages  of  acute  arthritis,  where  the  ends  of  the  bones 
are  carious,  the  joint  disorganized,  and  chronic  suppuration  is  present; 

(5)  in  tuberculous  arthritis,  where  palliative  treatment  has  failed  to 
cut  short  the  disease,  or  where  disorganization  of  the  joint  has 
occurred  with  erosion  of  the  ends  of  the  bones ;  (6)  for  ankylosis  of 
certain  joints,  consecutive  to  arthritis,  either  acute,  tuberculous,  or 
syphilitic,  especially  if  in  a  bad  position  ;  (7)  for  osteo-arthritis  in 
special  regions. 

The  results  to  be  attained  necessarily  vary  in  the  different  joints, 
and  according  to  the  particular  causes.  Sometimes  ankylosis  in  a 
good  position  is  all  that  can  be  expected,  in  others  a  freely  moveable 
pseudarthrosis  ;  in  some  cases  the  removal  of  certain  diseased  tissues 
is  the  primary  object  of  the  operation,  whilst  in  others  no  disease  is 
present.  All  these  varying  conditions  must  be  taken  into  consideration 
in  determining  the  nature  and  extent  of  any  excision. 

In  a  small  text-book  like  this  we  must  perforce  limit  ourselves  to  a 
description  of  the  methods  most  commonly  adopted,  and  refer  students 
to  special  works  on  Operative  Surgery  for  further  details. 

Shoulder-joint. — Excision  of  the  shoulder -joint  may  be  needed  for  tuberculous 
disease,  for  the  later  stages  of  acute  arthritis,  occasionally  for  osteo-arthritis  if 
the  disease  is  limited  to  this  articulation,  for  compound  or  comminuted  fractures, 
and  possibly  for  simple  fractures  of  the  anatomical  neck  when  associated  with 
dislocation  of  the  small  detached  head  of  the  bone.     In  old  unreduced  disloca- 

44 


690  A  MANUAL  OF  SURGERY 

tions  where  passive  movement  is  impracticable,  and  there  is  little  hope  of  im- 
provement, excision  may  give  excellent  results. 

Operation. — The  patient  lies  on  the  back,  the  shoulder  projecting  somewhat 
over  the  edge  of  the  table,  and  with  a  sandbag  beneath  the  scapula  to  steady  it. 
The  arm  being  slightly  rotated  inwards,  an  incision  is  made  from  a  point  mid- 
way between  the  coracoid  process  and  the  acromion,  extending  downwards  and 
outwards  for  3  or  4  inches  through  the  fibres  of  the  deltoid  muscle  (Fig.  32^,  D). 
It  is  better  to  incise  the  deltoid  than  to  pass  between  it  and  the  pectoralis  major, 
the  cephalic  vein  and  accompanying  artery  being  thus  uninjured.  The  wound 
is  thoroughly  opened  up  by  means  of  retractors,  and  the  bicipital  groove  looked 
for  ;  an  incision  is  made  along  its  outer  border,  and  the  long  tendon  of  the 
biceps,  if  still  present,  turned  out,  and  held  to  the  inner  side  by  a  blunt  hook, 
A  twig  of  the  anterior  circumflex  artery  will  here  be  divided,  and  need  a  ligature. 
The  arm  is  now  thoroughly  everted,  and  the  tendon  of  the  subscapularis  and  the 
anterior  part  of  the  capsule,  with  which  it  is  incorporated,  freely  divided;  where 


Fig.  324.— Incision  for  Excision  of  Shoulder. 

A,  Coracoid  process  ;  B,  tip  of  acromion  ;  C,  intermuscular  line  between 

deltoid  and  pectoralis  major  ;   D,  incision. 

practicable,  the  attachments  of  the  muscle  to  the  bone  should  be  separated 
subperiosteally,  a  proceeding  presenting  no  difficulty  where  inflammation  has 
previously  existed.  The  arm  is  now  inverted  and  held  downwards  by  the  side 
of  the  table,  so  as  to  bring  the  great  tuberosity  into  view ;  the  muscles  attached 
to  this  process  are  dealt  with  in  a  similar  way,  and  the  upper  part  of  the  capsule 
freely  opened.  The  head  of  the  bone  is  then  protruded  into  the  wound,  and 
removed  by  the  saw.  It  will  often  suffice  to  apply  the  saw  obliquely  through 
the  substance  of  the  tuberosity ;  this  is  to  be  preferred  to  removal  of  the  whole 
tuberosity  by  a  horizontal  incision  at  a  lower  level.  The  synovial  membrane 
and  glenoid  cavity  are  dealt  with  as  circumstances  may  dictate,  and  it  is  often 
advisable  to  make  a  counter-opening  through  the  posterior  axillary  fold  for  the 
insertion  of  a  diainage-tube;  the  anterior  wound  can  then  be  entirely  closed.  In 
applying  the  dressing,  care  must  be  taken  to  put  a  good  pad  in  the  axilla,  so  as 
to  keep  the  arm  from  being  drawn  forcibly  inwards  by  the  muscles  attached 
to   the   bicipital  groove.     There  is  no    need  to  commence  passive    movements 


DISEASES  OF  JOINTS  691 

before  the  end  of  the  first  week.  Fibrous  union  usually  results,  and  the  move- 
ments  of  the  shoulder  are  generally  very  good,  with  the  possible  exception  ot 
abduction. 

Excision  of  the  Elbow  may  be  required  for  simple  or  compound  fracture-dis- 
location, or  for  subsequent  ankylosis,  especially  if  the  limb  is  in  a  bad  position,  for 
tuberculous  arthritis,  and  possibly  in  the  later  stages  of  acute  arthritis.  The  best 
plan  of  operating  is  as  follows:  A  single  longitudinal  incision,  5  inches  in  length, 
is  made  in  the  middle  line  of  the  posterior  aspect  of  the  joint,  extending  for  equal 
distances  above  and  below  the  tip  of  the  olecranon,  and  a  little  to  the  inner  side. 
The  limb  is  held  across  the  patient's  body,  the  surgeon  standing  on  the  affected 
side.  The  incision  extends  through  the  substance  of  the  triceps  down  to  the 
bone.  The  origin  of  the  flexor  carpi  ulnaris  and  the  inner  half  of  the  triceps 
tendon  are  detached,  and  the  hollow  between  the  olecranon  and  the  internal 
condyle  cleared,  the  knife  being  kept  close  to  the  bone,  and  the  soft  parts  effec- 
tively retracted.  By  this  means  the  ulnar  nerve  escapes  injury,  and,  indeed, 
,  is  often  not  seen  at  all.  The  internal  lateral  ligament  should  be  divided,  and 
the  common  origin  of  the  flexors  detached  from  the  front  of  the  inner  condyle. 
The  outer  half  of  the  joint  is  then  dealt  with  in  a  similar  way,  the  anconeus 
being  divided  close  to  its  insertion  to  the  ulna,  the  continuity  of  the  triceps 
with  the  deep  fascia  covering  it  being  also  maintained.  The  origin  of  the  ex- 
tensor muscles  is  separated  from  the  back  of  the  outer  condyle,  and  the  external 
lateral  ligament  severed.  The  joint  can  now  be  freely  opened  by  dividing  any 
of  the  fibres  of  the  posterior  ligament  which  remain  intact,  and  the  denuded 
ends  of  the  bones  protruded  from  the  wound.  The  lower  end  of  the  humerus  is 
thoroughly  cleared,  and  the  articular  surface  removed,  the  section  passing  through 
the  centre  of  the  olecranon  fossa.  The  olecranon,  together  with  the  upper  articular 
surface  of  the  coronoid  process  and  the  head  of  the  radius,  are  next  sawn  off,  care 
being  taken  to  draw  aside  and  protect  the  soft  parts  by  retractors,  especially  those 
covering  the  ulnar  nerve.  The  synovial  mem.brane  can  be  dealt  with  as  may  be 
necessary.  Even  if  the  head  of  the  radius  is  free  from  disease,  nothing  is  gained 
by  leaving  it  intact,  since  ankylosis  is  very  likely  to  follow  unless  plenty  of  bone 
is  removed.  As  a  general  rule,  a  gap  of  2^  inches  should  intervene  between  the 
divided  ends  of  the  bones.  The  wound  is  carefully  sutured,  and  a  drainage-tube 
inserted  for  a  few  hours.  The  limb  is  kept  on  a  hinged  angular  splint  for  a  week, 
by  which  time  union  of  the  external  wound  should  be  complete,  but  the  position 
is  altered  each  day.  After  a  week,  the  splint  may  be  dispensed  with,  and  the 
limb  kept  at  rest  on  a  pillow,  free  passive  movement,  both  angular  and  rotatory, 
being  daily  practised.  Considerable  attention  is  needed  in  order  to  obtain  a  good 
result,  but  in  a  successful  case  every  movement  of  the  joint  is  perfectly  restored. 
As  a  rule,  the  lower  end  of  the  humerus  develops  two  lateral  bony  processes,  like 
malleoli,  within  the  grasp  of  which  the  upper  rounded  ends  of  the  radius  and 
ulna  are  able  to  move. 

The  Wrist-Joint  is  only  excised  for  extensive  tuberculous  disease  when  abscesses 
and  sinuses  are  present.  Ankylosis  of  the  articulation,  though  a  troublesome 
condition,  is  not  sufficiently  so  to  require  such  treatment.  The  best  method 
to  employ  is  that  known  as  Lister's  operation,  a  somewhat  complicated  proceeding, 
but  which  in  suitable  cases  gives  excellent  results.  Prior  to  operating  the  fingers 
are  bent,  so  as  to  break  down  any  adhesions  present.  Two  incisions  are  made, 
one  on  the  radial  side  of  the  dorsum,  and  the  other  on  the  inner  or  ulnar  aspect 
of  the  wrist.  The  dorsal  incision  is  angular  (Fig.. 325,  L,  L),  commencing  at  a 
point  on  the  back  of  the  radius  between  the  tendons  of  the  extensor  secundi 
internodii  pollicis  (B)  and  the  extensor  communis  digitorum  (D)  ;  it  is  at  first 
parallel  to  the  former  tendon,  and  on  its  ulnar  side,  till  it  reaches  the  base  of  the 
second  metacarpal  bone,  when  its  direction  is  changed,  and  it  courses  downwards 
along  that  bone  for  an  inch  or  two.  It  should  extend  to  the  bone,  and  in  doing 
so  the  tendons  of  the  extensor  carpi  radialis  longior  and  brevior  (H  and  I)  are 
divided  as  close  to  their  attachments  as  possible.  The  tendinous  structures  are 
then  stripped  off  the  back  of  the  dorsum  on  either  side  of  the  incision  and  on  the 
Outer  side  a  pair  of  cutting-pliers  is  insinuated  so  as  to  detach  the  trapezium  from 
the  rest  of  the  carpus.  The  synovial  sheaths  of  these  tendons  should,  if  possible 
not  be  opened.     The  hand  is  then  rolled  over,  and  the  ulnar  incision  made  on 


692 


A  MANUAL  OF  SURGERY 


the  inner  side  of  the  limb,  extending  for  at  least  3  inches  between  the  extensor  and 
flexor  carpi  ulnaris  tendons.  The  separation  of  the  extensor  tendons  from  the 
back  of  the  carpus  is  now  completed,  and  the  attachment  of  the  extensor  carpi 
ulnaris  (K)  divided.  The  tissues  on  the  palmar  aspect  of  the  joint  are  detached, 
the  pisiform  being  severed  from  the  rest  of  the  carpus,  and  where  possible  left, 
and  the  hook  of  the  unciform  clipped  off  with  cutting-pliers.  The  carpus  ic  now 
free  front  and  back,  and  the  bones  are  either  removed  piecemeal  or  taken  away 
en  bloc  hy  inserting  a  pair  of  cutting- pliers  above -and  below,  and  dividing  their 
upper  and  lower  connections ;  more  usually  the  carpal  bones  are  picked  out  in 
fragments.  Attention  is  then  directed  to  the  lower  ends  of  the  radius  and  ulna, 
and  to  the  articular  ends  of  the  metacarpal  bones,  all  the  cartilage  and  the 
intervening  synovial  tissue  being  cleared  away.     Finally,  the  remaining  fragments 

of  the  carpus  are  dealt  with  as  the  case 
may   require.      The   radial   incision   may 
often  be  entirely  closed,  whilst  a  drainage- 
tube  is  inserted  through  the  ulnar  wound. 
The  hand  is  placed  on  a  special  splint, 
with  a  thick  convex  cork  support  for  the 
palm,  which  keeps  the  wrist  slightly  ex- 
tended, and  with  a  short  lateral  projec- 
tion   upon   which    the    thumb    can    rest. 
The  fingers  must  be  flexed  and  extended 
daily,  beginning  on  the  second  or  third 
7,  but  the  wrist  should  be  kept  at  rest 
is  quite  firm.      There  is  a  much 
tendency  to  a  flail-like  joint  than 
iue  fixity,  owing  to  the  amount  of  bone 
///> /     »"  11  III/!    \\V/i\       K'      \    \\*\     removed,  and  the  necessary  division  of  all 
g/j    /•  j  '/' ;    \W\      K        \     \\      the  extensors  of  the  carpus;  if  such  occurs, 

\i\     a  leather  support  must  be  worn,  either  as 
a  temporary  or  permanent  appliance. 

The  Hip-joint  is  rarely  excised  for  con- 
ditions other  than  tuberculous  disease,  and 
even  for  this  it  is  performed  much  less 
frequently  than  formerly.  There  are  two 
chief  methods  of  operating,  the  anterior 
and  the  posterior. 

I .  Excision  by  the  anterior  method  is ' 
carried  out  as  follows  :  The  incision 
(Fig.  108  ,  D  ;  p.  338)  extends  from  imme- 
diately below  the  anterior  superior  spine 
vertically  downwards  for  3  or  4  inches.  It 
passes  between  the  tensor  fasciae  femoris 
and  sartorius  muscles  superficially,  and 
between  the  glutei  and  rectus  deeply, 
a  small   arterial   twig  from  the  external 


Fig.  325. — Excision  of  the  Wrist. 
(Lister.) 

A,  Radial  artery ;  B,  extensor  secundi 
internodii  poUicis;  C,  ext.  indicis; 
D,  ext.  communis  digitorum  ;  E, 
ext.  minimi  digiti ;  F,  ext.  primi  in- 
ternodii pollicis ;  G,  ext.  ossis  meta- 
carpi  pollicis;  H,  ext.  carpi  radialis 
longior  ;  I,  ext.  carpi  radialis 
brevior ;  K,  ext.  carpi  ulnaris ; 
L,  L,  line  of  radial  incision. 


circumflex  being  divided  at  this  stage. 
The  neck  of  the  bone  and  capsule  of  the  joint  are  exposed,  and  the  latter  is 
freely  incised  along  its  attachment  to  the  anterior  inter-trochanteric  line,  so  as 
to  allow  of  the  admission  of  the  finger,  whereby  the  joint  can  be  explored.  The 
neck  of  the  bone  is  cut  through  in  situ  by  means  of  an  Adams'  osteotomy  saw,  the 
incision  through  the  bone  being  placed  obliquely  downwards  and  inwards.  The 
head  of  the  bone  is  now  either  prised  out  of  the  acetabulum  by  an  elevator,  or 
grasped  by  lion  forceps  and  twisted  out,  a  matter  easily  accomplished  where  the 
articular  structures  are  diseased,  but  a  proceeding  of  some  difficulty  in  the  normal 
joint  of  a  cadaver.  As  much  of  the  infected  synovial  membrane  as  possible  is 
clipped  away  with  scissors,  and  the  acetabulum  scraped,  if  necessary.  The 
external  wound  is  either  closed,  with  the  exception  of  an  opening  for  a  drainage- 
cube,  or  packed  with  gauze  soaked  in  iodoform  emulsion.  Weight  extension  is 
employed,  and  a  Liston's  splint  applied. 

2.  Excision  by  the  posterior  metliod,  as  we  have  already  said,  is  usually  under- 


DISEASES  OF  JOINTS 


693 


taken  in  the  later  stages  of  the  disease.  Any  sinuses  which  exist  posteriorly  may 
be  utilized,  but  if  the  skin  is  unbroken,  an  incision  known  as  Langenbeck's  may 
be  employed  (Fig.  326).  The  patient  lies  on  the  sound  limb,  whilst  the  affected 
thigh  is  ifexed.  The  incision  is  made  in  the  line  of  the  femur,  extending  2  inches 
above  the  top  of  the  great  trochanter,  and  about  3  inches  below  it.  It  is  carried 
at  once  down  to  the  bone,  and  the  muscles  attached  to  the  summit  and  posterior 
border  of  the  great  trochanter  freely  divided,  as  close  to  the  bone  as  possible. 
The  capsule  is  opened  to  a  sufficient  extent  to  allow  of  the  exploration  of  the 
joint  by  the  finger.  If  the  disease  is  very  extensive,  the  femur  is  now  chiselled 
across,  immediately  below  the  great  trochanter,  but  above  the  lesser.  The  upper 
end  of  the  bone  is  grasped  by  lion  forceps,  and  twisted  out  of  the  acetabulum, 
after  division  of  the  remaining  structures,  which  are  attached  chiefly  along  its 
anterior  border.  The  ligamentum  teres  has  almost  always  been  previously 
destroyed,  and  hence  this  stage  of  the  operation  is  not  especially  difficult.  The 
synovial  membrane  and  acetabulum  are  easily  reached,  and  the  diseased  portions 
removed.  In  favourable  cases  a  drainage-tube  may  be  inserted,  and  the  wound 
closed,  but  not  uncommonly  it  is  wiser  to  stuff  it  partially  with  gauze  infiltrated 
with  iodoform,  and  allow  it  to  heal  by  granulation.  Slight  extension  of  the  limb 
should  be  subsequently  made,  so  as  to  prevent  undue  shortening  from  the  traction 
of  the  long  thigh  muscles.  The  leg  is  placed  between  sandbags,  or  a  Liston's  long 
splint  applied.  Fibrous  ankylosis,  with  a  certain 
limited  amount  of  movement,  is  the  usual  result. 

It  is  not  always  necessary  to  include  the  tro- 
chanter in  this  operation.  If  the  disease  is  limited 
to  the  head  of  the  bone,  it  alone  should  be  removed, 
with  as  little  disturbance  as  possible  to  the  muscles 
passing  to  the  trochanter.  If  such  can  be  effected, 
the  subsequent  mobility  and  usefulness  of  the  limb 
are  increased. 

The  results,  however,  are  almost  always  bad, 
owing  to  the  shortening,  defective  growth,  and 
subsequent  limitation  of  movement.  However 
performed,  it  is  unusual  for  the  upper  end  of  the 
bone  to  remain  in  the  acetabulum  ;  as  a  rule  it 
slips  upwards  and  backwards  on  the  dorsum  ilii. 
So  bad  are  the  results  that  surgeons  rarely  under- 
take this  operation  at  the  present  day,  and  rely 
almost  entirely  on  constitutional  treatment  and 
conservative  measures,  and  if  need  be  a  limited 
scraping  away  of  diseased  tissues. 

The  Knee-joint  is  excised  for  tuberculous  disease, 
osteo-arthritis,  or  deformity  due  to  osseous  or 
fibrous  ankylosis  in  a  bad  position.  A  horse- 
shoe -  shaped  incision  is  made,  extending  from 
the  back  of  one  condyle  to  the  other,  reaching 
downwards  nearly  as  far  as  the  tubercle  of  the  tibia.  The  limb  is  flexed,  the 
ligamentum  patellae  divided,  and  the  joint  opened.  The  skin  and  subcutaneous 
tissues  are  then  separated  from  the  anterior  surface  of  the  patella,  which  may  be 
at  once  removed  by  a  curved  incision  above  it,  communicating  on  either  side  with 
that  already  made  below,  the  subcrureal  pouch  of  synovial  membrane  being  also 
removed  during  this  dissection.  The  flexion  is  now  increased,  and  the  lateral 
ligaments  divided  ;  by  this  means  the  interior  of  the  joint  is  exposed,  so  that  the 
attachments  of  the  crucial  ligaments  to  the  tibia  can  also  be  severed.  The  lower 
end  of  the  femur  is  then  cleared  of  diseased  synovial  membrane,  so  as  to  allow  of 
the  application  of  a  broad  excision  saw.  The  usual  rule  given  as  to  the  direction 
of  the  saw-cut  in  the  bone  is  that  the  exposed  bony  surface  left  after  removing  its 
articular  end  should  be  absolutely  horizontal,  supposing  the  patient  to  be  standing 
upright ;  some  surgeons  prefer  to  make  the  sections  so  that  the  limb  shall  be  left 
very  slightly  flexed  and  in-kneed,  a  position  which  greatly  adds  to  the  subsequent 
comfort  of  the  patient.  To  accomplish  this  the  saw  must  be  applied  parallel  to 
the  articular  surface — i.e. ,  at  right  angles  to  the  axis  of  the  body,  not  of  the  femur, 


Fig.  326. — Langenbeck's 
Incision  for  Excision  of 
THE    Hip    from    Behind. 

(TiLLMANNS.) 


694  A  MANUAL  OF  SURGERY 

and  with  a  slight  upward  slant  from  before  backwards.  The  bone  should  be 
partially  sawn  through  by  a  side-to-side  movement,  but  the  posterior  surface  of 
the  condyles  should  be  divided  by  raising  or  depressing  the  handle  of  the  instru- 
ment, so  that  the  structures  lying  behind  in  the  intercondyloid  notch  are  not 
encroached  upon.  Sufficient  bone  should  be  sawn  off  in  the  adult  to  include  the 
greater  part  of  the  articular  cartilage,  but  as  little  as  possible  consistent  with 
removing  all  the  disease,  otherwise  the  limb  is  shortened  to  such  an  extent  as  to 
interfere  with  its  subsequent  usefulness.  The  head  of  the  tibia  is  then  protruded, 
and  cleared  from  the  neighbouring  soft  parts  ;  it  is  held  absolutely  vertical,  and 
a  saw  applied  in  a  horizontal  position,  the  bone  being  divided  from  before  back- 
wards. All  diseased  synovial  membrane  is  dissected  away,  special  attention 
being  directed  to  the  posterior  aspect  of  the  joint.  Hsemostasis  having  been 
effected,  the  bones  are  fitted  together,  and,  if  considered  advisable,  secured  in 
position  by  thick  silver  wire,  nails,  or  screws  ;  if  wire  is  employed,  it  should  be 
introduced  horizontally  through  the  bones  from  side  to  side  rather  than  antero- 
posteriorly.  A  Gooch's  splint  is  applied  to  the  limb,  and  in  this  it  remains  until 
sound  healing  has  occurred,  after  which  an  immoveable  case  either  of  plaster  of 
Paris  or  water-glass  is  kept  on  for  eight  or  ten  weeks. 

The  Ankle-joint  is  excised  for  tuberculous  disease.  Two  incisions  are  made,  an 
inner  and  an  outer.  The  outer  incision  runs  along  the  anterior  border  of  the 
fibula  and  curves  round  the  outer  malleolus,  being  about  3  inches  in  length.  The 
lower  end  of  the  fibula  is  exposed,  and  by  preference  subperiosteally.  The 
external  lateral  ligament  is  split  vertically,  and  separated  from  its  attachments 
to  the  fibula,  its  continuity  with  the  periosteum  being,  however,  maintained.  The 
fibula  is  then  divided  about  i  inch  above  the  tip  of  the  malleolus,  and  the  latter 
process  of  bone  removed.  The  periosteum  and  ligaments  are  separated  as  far  as 
possible  from  the  front  and  back  of  the  bones.  The  inner  incision  is  T-shaped, 
and  is  made  along  the  inner  surface  of  the  tibia,  with  a  short  transverse  cut  at 
its  lower  end,  which  reaches  just  below  the  inner  malleolus.  The  periosteum 
and  internal  lateral  ligament  are  dealt  with  as  on  the  outer  side,  and  the  front 
and  back  of  the  tibia  are  easily  denuded.  The  inner  malleolus  is  projected  from 
the  wound,  and  the  lower  end  of  the  tibia  removed  by  a  keyhole  saw,  the  dorsal 
structures  being  held  aside  by  a  retractor.  The  articular  surface  of  the  astragalus 
is  sawn  off  from  the  outer  wound,  or,  if  advisable,  the  whole  of  the  bone  may  be 
removed. 

'  The  above  subperiosteal  method  of  excision  is  probably  the  best  that  has  been 
suggested.  The  greatest  care  should  be  taken  not  to  open  the  sheaths  of  the 
tendons,  and  in  dressing  the  wound  the  foot  must  be  kept  at  right  angles  to  the 
leg,  and  no  lateral  deviation  permitted.  As  soon  as  possible  it  is  encased  in 
plaster  of  Paris,  windows  being  left  for  dressing  the  wounds,  if  necessary. 

In  non-tuberculous  cases  a  transverse  incision  extending  from  one  malleolus  to 
the  other  may  be  employed.  Sutures  are  placed  through  the  tendons  above  and 
below,  and  they  are  then  divided ;  the  anterior  tibial  nerve  is  similarly  secured 
above  and  below  before  division,  and  the  vessels  are  divided  between  ligatures. 
By  opening  the  capsule  a  very  free  exposure  of  the  joint  surfaces  is  provided, 
permitting  a  very  thorough  excision.  The  divided  tendons  and  nerve  are  carefully 
sutured  together  before  closing  the  wound. 

Excision  of  the  Astragalus  is  sometimes  required  in  the  treatment  of  tuberculous 
disease  of  contiguous  joints,  as  also  in  some  cases  of  talipes  and  of  fractures  or 
dislocations  of  the  bone.  Many  methods  of  operating  have  been  described,  but 
it  may  be  accomplished  through  a  single  vertical  incision  over  the  front  of  the 
ankle,  running  parallel  to  the  vessels  and  tendons,  which  are  carefully  avoided 
and  stripped  back  from  the  dorsum  by  means  of  periosteal  detachers,  so  that  the 
upper  surface  of  the  astragalus  can  readily  be  reached.  The  astragalo-scaphoid 
joint  and  ankle  are  then  freely  opened,  and  the  ligamentous  and  fascial  connections 
on  either  side  severed.  The  neck  of  the  bone  may  with  advantage  be  divided  at 
this  stage,  and  its  head  removed,  so  as  to  give  access  to  the  under  surface  and 
allow  of  the  division  of  the  strong  interosseous  ligament  extending  between  the 
adjacent  surfaces  of  the  astragalus  and  os  calcis.  It  may  be  possible  to  remove 
the  rest  of  the  bone  in  one  fragment,  but  it  is  often  wiser  to  break  it  up  with 
thisel  or  gouge,  and  take  it  away  piecemeal. 


CHAPTER  XXIII. 

INJURIES  OF  THE  SPINE. 

The  spinal  cord  is  protected  from  injury  in  a  most  complete  and 
efficacious  manner,  (a)  Its  position  between  the  bodies  and  the 
laminae  with  the  spinous  processes  arising  therefrom  is  itself 
mechanically  advantageous,  since,  whether  the  spine  is  forcibly 
flexed  or  extended,  the  cord  remains  midway  between  the  points  of 
chief  compression  or  extension,  and  hence  in  a  position  of  rest. 
{b)  The  buffer-like  action  of  the  intervertebral  discs,  and  the  varying 
curves  of  the  column,  serve  to  distribute  some  part  of  any  force  that 
reaches  it.  (c)  There  is  ample  space  in  the  medullary  canal,  in 
which  the  cord  with  its  membranes  is  slung  by  prolongations  of  dura 
mater  around  the  issuing  nerves,  whilst  the  cord  itself  hangs  loosely 
within  the  dura  mater,  suspended  by  the  ligamenta  denticulata,  and 
surrounded  by  cerebro-spinal  fluid,  (d)  The  cord  terminates,  in  an 
adult,  at  the  lower  border  of  the  first  lumbar  vertebra,  a  spot  well 
above  the  junction  of  the  fixed  base  and  the  moveable  upper  part, 
a  point  where  the  effect  of  jars  and  wrenches  is  mainly  felt. 
(e)  Nature  has,  moreover,  introduced  a  whole  series  of  buffers  and 
other  means  of  preventing  shock  to  the  spine  when  a  person  falls  on 
his  feet — e.g.,  the  arches  and  elasticity  of  the  foot,  the  changes  in 
direction  of  the  bones  at  each  joint,  the  inter-articular  cartilages  of 
the  knee,  etc. 

The  parts  of  the  spine  most  exposed  to  injury  are  those  where  a 
fixed  and  moveable  portion  meet — e.g.,  the  dorsi-lumbar  and  the 
cervico-dorsal  regions.  Moreover,  the  upper  part  of  the  dorsal  curve, 
which  projects  backwards,  is  relatively  a  weak  spot,  and  fractures 
are  not  at  all  uncommon  about  the  fourth  dorsal  vertebra.  The  close 
proximity  of  the  head  explains  the  frequency  of  lesions  about  the 
upper  cervical  region. 

Strains. 

Sprains  and  strains  of  the  spine  are  very  common  accidents,  a  fact 
not  to  be  wondered  at,  when  its  complicated  muscular  and  ligament- 
ous arrangements  are  considered.  They  are  produced  by  any  sudden 
or  unexpected  movements,  such  as  falls,  especially  from  horseback, 
railway  accidents,  and  the  like.     The  injury  affects  most  frequently 

695 


696  A  MANUAL  OF  SURGERY 

mobile  parts  of  the  spine — e.g.,  the  cervical  and  lumbar  regions,  and 
may  be  limited  to  either  ligamentous  or  muscular  structures,  or  may 
involve  both.  The  resulting  Signs  are  simply  those  of  a  severe  but 
localized  trauma,  viz.,  pain,  tenderness,  and  perhaps  a  little  swelling 
or  bruising ;  the  subjective  phenomena  are  much  increased  by  move- 
ment, so  that  the  spine  is  kept  rigidly  quiet.  If  only  the  muscles  or 
interspinous  ligaments  are  involved,  no  further  consequences  are 
likely  to  arise ;  but  when  the  ligamenta  subflava  are  lacerated  and 
the  spinal  canal  is  thus  opened,  pressure  symptoms  may  arise  from 
blood  finding  its  way  into  the  canal  outside  the  dura  mater,  leading 
possibly  to  a  temporary  or  permanent  paraplegia.  Inflammation  of 
the  damaged  fibrous  tissues  may  extend  to  the  meninges  and  cord, 
and  cause  organic  disease.  Moreover,  in  patients  of  a  tuberculous 
temperament,  spinal  caries  may  follow  such  injuries ;  syphilitic  or 
malignant  disease  has  also  been  known  to  ensue. 

In  the  cervical  region,  sprains  may  occur  as  a  result  of  severe  blows 
on  the  head,  causing  rupture  of  the  inter-transverse  ligaments,  and 
the  displacement  may  be  so  great  as  to  simulate  dislocation.  The 
head  and  neck  are  held  immoveable  and  rigid,  and  there  is  often  con- 
siderable loss  of  power,  the  patient  being  sometimes  unable  to  lift 
the  head  spontaneously  from  the  pillow.  Sprains  in  the  lumbar 
region  are  very  common,  both  as  a  consequence  of  overlifting,  when 
the  quadratus  lumborum  is  most  likely  to  be  affected,  and  as  a  result 
of  railway  injuries,  when  they  are  often  associated  with  nervous 
symptoms  (p.  707).  The  back  is  kept  fixed  and  rigid,  the  patient 
being  unable  to  turn  or  stoop  without  pain.  Sometimes  haematuria 
results  from  injuries  in  the  lumbar  region,  arising  from  an  associated 
contusion  of  the  kidneys. 

Treatment. — The  patient  should  be  kept  at  rest,  and  fomentations 
applied  to  the  injured  part.  When  the  painful  or  inflammatory 
symptoms  have  disappeared,  massage  with  stimulating  liniments  is 
needed.  In  the  severer  cases  the  individual  should  be  kept  in  bed 
for  six  or  eight  weeks,  and  in  the  cervical  region  some  form  of 
mechanical  support  may  be  subsequently  necessary.  The  appear- 
ance of  inflammatory  symptoms  involving  the  meninges  calls  for  even 
greater  care ;  the  patient  should  then  be  kept  as  much  as  possible  in 
the  prone  position,  and  a  spinal  icebag  applied.  The  onset  of  para- 
plegia, due  either  to  haemorrhage  or  inflammatory  exudation,  would 
raise  the  question  of  laminectomy  (p.  711). 

Penetrating  Wounds  of  the  Spine. 

These  lesions  are,  fortunately,  uncommon  in  civil  practice,  being 
generally  due  to  stabs  with  pointed  instruments,  such  as  bayonets, 
or  to  gunshot  wounds.  They  occasionally  result  from  falls,  the 
unfortunate  individual  becoming  impaled  on  area  railings,  branches 
of  trees,  etc.  The  Symptoms  produced  are :  {a)  those  due  to  the 
wound  in  the  soft  parts,  which  may  also  involve  the  peritoneal  and 
pleural  cavities,  or  damage  some  of  the  viscera ;  in  the  neck,  the 


INJURIES  OF  THE  SPINE  697 

vertebral  artery  is  exposed  to  injury,  from  this  type  of  accident,  lead- 
ing to  serious  haemorrhage  ;  (b)  various  forms  of  fracture,  the  cord 
being  compressed  by  fragments  of  bone  which  have  been  driven 
inwards,  or  by  extravasated  blood ;  (c)  those  due  to  laying  open  the 
spinal  membranes — e.g.,  loss  of  cerebro-spinal  fluid,  which  in  itself 
might  prove  fatal  by  draining  the  cerebral  cavity,  and  so  causing 
pressure  on  the  base  of  the  brain,  or  at  a  later  date  may  determine 
the  patient's  death  by  setting  up  diffuse  septic  meningitis  (p.  705) ; 
and  (d)  those  due  to  wounds  of  the  spinal  cord.  The  effects  of  a 
total  transverse  lesion  at  different  levels  of  the  spine  are  given  at 
p.  708.  Of  course,  the  division  of  the  cord  may  be  only  partial, 
or  it  may  escape  entirely,  whilst  nerve  roots  or  trunks  may  be 
involved,  and  in  the  lumbar  or  sacral  regions  the  cauda  equina  may 
be  divided. 

Treatment  consists  in  exploring  thoroughly  the  wound  under  an 
anaesthetic,  removing  foreign  bodies  or  displaced  fragments  of  bone, 
and  attempting  to  render  it  aseptic.  Wounds  of  the  vertebral  artery 
or  other  structures  are  dealt  with  secundum  artem,  and  special  atten- 
tion is  naturally  given  to  the  cord  and  its  membranes.  Should  the 
dura  mater  have  been  opened,  and  the  cord  have  escaped  injury,  an 
attempt  may  be  made  to  close  the  wound  in  the  meninges,  and  the 
patient  should  subsequently  be  kept  in  the  prone  position  and  with 
the  head  low,  so  as  to  prevent,  as  far  as  possible,  the  escape  of 
cerebro-spinal  fluid.  If  the  cord  itself  is  divided  or  lacerated,  it  is 
useless  trying  to  unite  it,  since  its  function  in  conducting  impulses 
from  the  brain  downwards  is  inevitably  destroyed.  Where,  how- 
ever, the  Cauda  equina  has  been  injured,  it  is  perfectly  justifiable  to 
lay  open  the  spinal  canal  to  a  sufficient  extent  to  expose  the  divided 
nerve  trunks,  and  then  to  suture  them. 

Fractures  of  the  Spine. 

Causes. — The  spine  may  be  broken  as  the.  result  of  {a)  direct 
violence — e.g.,  a  fall  on  the  back  over  some  projecting  body,  such  as 
a  carpenter's  bench  or  a  railing,  or  a  blow  on  the  back  with  a  heavy 
stone  or  with  a  swinging  baulk  of  wood,  or  a  gunshot  wound.  This 
type  of  accident  may  involve  any  part  of  the  spine,  and,  excluding 
those  arising  from  gunshot,  is  less  frequent  than  the  class  next  to  be 
described.  Of  necessity,  the  spine  breaks  at  the  point  struck ;  the 
posterior  parts  of  the  vertebrae  are  most  likely  to  be  damaged  in  this 
form  of  injury,  {h)  Fractures  are  also  due  to  indirect  violence,  then 
usually  occurring  in  the  lower  cervical  or  upper  dorsal  regions. 
They  are  caused  by  forcible  flexion  of  the  spine,  as  by  a  fall  down- 
wards with  the  head  doubled  up,  or  by  taking  a  'header'  into  shallow 
water,  or  when  a  man,  being  driven  under  a  bridge,  omits  to  stoop, 
and  so  is  caught  between  the  arch  and  the  cart,  or  sometimes  by  the 
fall  of  a  heavy  weight  on  the  back  of  the  neck,  the  spine  bending 
and  breaking  at  the  weakest  spot. 

Fractures  of  the  spine  may  be   divided  into  two  main   classes, 


698 


A  MANUAL  OF  SURGERY 


according  to  whether  or  not  they  are  complete— that  is,  according  to 
whether  the  continuity  of  the  column  is  destroyed  or  not. 

(A)  Incomplete  Fractures  may  be  met  with  in  various  forms,  and 
are  most  frequently  due  to  direct  violence. 

(i.)  Fractures  of  the  Spinous  Processes  rarely  occur  except  in  the 
lower  cervical  or  dorsal  regions.  In  the  upper  cervical  region  the 
spines  are  short  and  retracted  to  allow  of  extension  of  the  head, 
whilst  in  the  lumbar  they  are  also  short,  but  very  strong.  The 
fracture  is  almost  always  due  to  direct  violence,  and  is  characterized 


Fig.  327. — Radiograph  of  Fracture  of  Fifth  Cervical  Vertebra 
(A.  D.  Reid). 

The  patient  whilst  walking  in  the  street  was  struck  to  the  ground  by  the  fall 
of  an  outside  shop-blind  ;  the  scalp  was  badly  cut,  and  complete  paraplegia 
from  the  sixth  cervical  nerve  downwards  was  immediately  evident.  He 
lived  for  about  thirty-six  hours,  and  died  in  a  condition  of  hyperpyrexia.  In 
the  skiagram  the  angle  of  the  lower  jaw  and  the  hyoid  bone  are  also  visible. 

by  the  signs  of  a  local  trauma,  together  with  great  mobility,  perhaps 
crepitus,  and  irregularity  in  the  line  of  the  spines.  The  broken 
fragment  is  occasionally  much  depressed,  and  may  even  cause 
paraplegia  by  being  driven  into  the  spinal  canal. 

(ii.)  Fracture  of  the  LaminiB  is  not  an  uncommon  accident,  always 
resulting  from  direct  violence.  If  only  one  lamina  is  broken,  the 
signs  are  not  very  distinct,  and  cord  symptoms  are  rare.  When 
both  laminae  yield,  the  posterior  part  of  the  neural  arch,  carrying 
with  it  the  spinous   process,  is  very  likely  to  be  depressed  to  a 


INJURIES  OF  THE  SPINE 


699 


sufficient  extent  to  compress  the  cord  and  give  rise  to  paraplegia. 
Crepitus  is  often  obtainable,  and  a  gap  in  the  line  of  the  spinous 
processes  can  usually  be  felt. 

(iii.)  Fracture  of  the  Transverse  Processes  is  but  rarely  met  with  apart 
from  other  lesions  of  the  spine. 

(iv.)  Partial  Fracture  through  the  bodies  may  occur  in  the  form  of 
fissures,  which  produce  but  little  effect,  except  pain  and  rigidity,  and 
cannot  be  diagnosed  with  certainty. 

Even  in  fractures  where  displacement  is  not  present,  paraplegic 
symptoms  may  arise,  either  immediately  from  concussion  of  the 
spinal  cord,  or  later  on  from  the  pressure  of  haemorrhage  or  inflam- 
matory effusions. 

The  Treatment  merely  consists  in  keeping  the  patient  at  rest  for 
a  time.  The  question  of  laminectomy  for  paraplegia,  due  either  to 
displacement  of  the  laminae  or  to  haemorrhage,  will  be  discussed 
later  (p.  711). 

(B)  Complete  Fractures  are  usually  associated  with  displacement, 
and  loss  of  continuity  of  the  spinal  column,  and  hence  are  often 
termed  Fracture-Dislocations.  They  result  either  from  direct  or 
indirect  violence,  and 
are  most  common  in  the 
lower  cervical  or  upper 
dorsal  region.  There  is 
always  a  tolerably  ex- 
tensive lesion  (Fig.  328); 
thus,  the  spinous  pro- 
cesses and  laminae  may 
or  may  not  be  fractured, 
the  ligamenta  inter- 
spinosa,  supraspinosa, 
and  subflava  torn,  the 
articular  processes  frac- 
tured in  the  lumbar  and 
dorsal  regions,  or  dis- 
placed without  fracture 
in  the  cervical,  and  either 
the  intervertebral  sub- 
stance torn  across,  or 
the  bodies  of  one  or 
two  adjacent  vertebrae 
broken,  thus  severing 
the  spine  into  two  halves. 
The  upper  or  moveable 

portion  is  usually  driven  forwards  over  the  lower  or  more  fixed 
fragment,  and  impaction  or  comminution  is  often  present.  The 
spinal  cord  is  compressed  between  the  upper  end  of  the  lower 
fragment  and  the  laminae  of  the  upper  fragment,  and  although 
the  displacement  may  be  naturally  remedied  by  the  falling  back 
of  the  bones  into  position  ('  recoil '),  yet  the  effects   of  the  crush 


Fig.  328. — Complete  Fracture-Dislocation 
OF  THE  Spine  in  the  Lower  Dorsal  Region, 
WITH  Displacement  and  Compression  of 
THE  Cord.     (After  Keen  and  White.) 


700  A  MANUAL  OF  SURGERY 

on  the  cord  are  usually  irremediable.  In  slighter  cases  the  spinal 
membranes  may  be  merely  punctured  by  a  splinter  of  bone,  or 
haemorrhage  may  occur  either  within  the  membranes,  or  outside 
them  in  the  fatty  theca  vertebralis.  Excessive  indirect  violence 
may  lead  to  an  associated  fracture  of  the  sternum. 

The  Signs  of  a  complete  fracture  are  usually  very  evident,  con- 
sisting of  local  pain,  swelling,  and  bruising,  and  a  certain  amount  of 
angular  deformity,  more  or  less  according  to  circumstances.  It  may 
be  possible  to  elicit  crepitus,  if  the  parts  are  not  impacted,  but  all 
unnecessary  movement  should  be  avoided  for  fear  of  adding  to  the 
injury  of  the  cord.  Paraplegia  below  the  part  injured  is  present  in 
most  cases,  and  with  it  some  amount  of  general  shock.  When  the 
cord  is  disintegrated  or  divided,  symptoms  of  spinal  myelitis  rapidly 
follow,  and  a  fatal  issue  often  occurs  at  an  early  date  from  toxaemia 
following  septic  cystitis  or  sloughing  of  the  nates.  The  special 
phenomena  of  paraplegia  are  dealt  with  at  p.  708.  It  may  be  stated 
here  that  lesions  of  the  cervico-dorsal  region  in  which  the  cord 
is  extensively  damaged  are  dangerous  to  life  in  that  they  cause 
paralysis  of  the  muscles  of  respiration,  with  the  exception  of  the 
diaphragm,  -and  hence  predispose  to  static  pneumonia.  Complete 
lesions  at  or  above  the  level  of  the  fourth  cervical  segment  are 
usually  fatal  at  once  from  paralysis  of  the  phrenic  nerve.  The 
general  mortality  of  fracture-dislocations  of  the  spine  is  about 
70  per  cent. 

The  Prognosis  of  these  cases  turns  largely  on  the  situation  of  the 
injury  and  the  amount  of  mischief  sustained  by  the  cord.  The 
higher  the  lesion,  the  greater  the  danger,  although  patients  with 
paraplegia  from  cervical  fracture  may  live  for  years,  and  even 
partially  recover,  if  the  cord  has  not  been  totally  disintegrated. 

The  Treatment  naturally  varies  with  the  character  of  the  case. 
The  patient  is  carefully  placed  on  a  prepared  bed,  the  greatest  gentle- 
ness being  used  in  handling  and  lifting  him,  for  fear  of  increasing  the 
damage  to  the  cord.  The  bed  must  be  firm,  though  not  hard  ;  perhaps 
the  best  type  to  employ  is  a  horsehair  mattress  placed  over  fracture- 
boards;  nothing  more  soft  or  yielding  is  permissible.  Spring  beds 
and  wire-wove  mattresses  are  most  undesirable.  A  water-bed  is 
required  in  the  later  stages,  but  should  not  be  used  at  first,  as  it  is 
scarcely  firm  enough.  The  shock  resulting  from  the  accident  is 
treated  in  the  usual  way  by  warmth  and,  if  need  be,  by  stimulants ; 
but  it  must  be  remembered  that  anaesthetic  regions  of  the  body  can 
be  easily  blistered  or  burnt  by  hot-water  bottles,  unless  carefully 
guarded  by  flannels.  When  reaction  has  occurred,  a  more  thorough 
examination  of  the  patient  can  be  made,  and  the  subsequent  course 
of  action  decided  on. 

(a)  In  a  small  minority  of  the  cases  operative  treatment  is  justi- 
fiable. The  indications  for  laminectomy  will  be  discussed  subse- 
quently (p.  711). 

ih)  When  the  displacement  persists  owing  to  impaction  of  the 
fragments,  reduction  under  an  anaesthetic  may  possibly  be  undertaken, 


W^URIES  6f  The  spine  7oi 

provided  that  the  lesion  is  not  in  the  cervical  region,  and  the  para- 
plegia not  complete.  Of  course,  if  other  internal  injuries  are  present 
which  render  the  case  hopeless,  nothing  should  be  done.  Great  care 
must  be  used  in  attempting  reduction,  since  any  undue  violence  may 
readily  increase  the  mischief;  in  the  lumbar  region,  however,  con- 
siderable force  may  be  employed  without  much  danger.  Whether 
reduction  is  accomplished  or  not,  the  further  treatment  must  be 
directed  in  accordance  with  the  indications  given  in  the  next  para- 
graph. Where  the  surgeon  fails  to  reduce  the  deformity,  it  may 
sometimes  be  advisable  to  make  gradual  weight  extension  from  the 
feet  or  neck. 

(c)  In  many  cases,  as  soon  as  the  patient  is  laid  flat  on  a  bed,  the 
displacement  remedies  itself,  especially  if  the  spine  has  been  com- 
minuted, and  then  the  treatment  must  be  symptomatic,  as  also  after 
reduction  or  operation,  where  the  paraplegia  persists  or  is  only  slowly 
recovered  from.  He  is  kept  in  bed,  absolutely  flat,  and  with  the 
head  low  ;  perhaps  some  form  of  mechanical  support — e.g.,  a  plaster 
of  Paris  or  leather  jacket — may  be  considered  advisable ;  but  its 
application  is  always  a  matter  of  difficulty,  and  in  the  early  stages  it 
does  but  little  good.  Food  is  regularly  administered,  and  at  first 
must  be  light  and  readily  assimilable. 

The  chief  care  of  the  attendants  must  be  directed  to  the  skin, 
bladder,  and  bowels.  Bedsores  are  extremely  liable  to  form  on  all 
points  of  pressure,  and  hence  the  nates  and  heels  must  be  carefully 
guarded  (p.  iii).  In  turning  the  patient  to  attend  to  the  nates,  the 
body  must  be  rolled  over  as  a  whole,  and  not  merely  the  pelvis  twisted. 
It  will  often  be  found  advisable  to  have  a  divided  mattress  placed 
beneath  the  pelvis,  so  that  one  lateral  segment  may  be  removed  at  a 
time,  and  thus  rotation  of  the  body  will  not  be  needed.  A  bedpan 
can  also  be  used  in  this  way  without  disturbing  the  spine.  When 
the  bladder  is  paralyzed,  the  urine  must  be  withdrawn  by  a  catheter. 
One  of  the  chief  dangers  that  the  patient  runs  is  from  the  super- 
vention of  septic  cystitis,  and  the  extension  of  the  inflammation  up- 
wards to  the  kidneys.  This  is  always  due  to  infection  from  without, 
and  the  greatest  care  must  be  taken  to  prevent  it.  The  penis  should 
be  thoroughly  purified,  and  the  urethra  well  flushed  out  before  passing 
an  instrument  in  these  cases ;  in  the  intervals  between  instrumenta- 
tion the  penis  is  wrapped  in  a  dry  sterile  dressing.  Only  soft  rubber 
catheters  are  employed,  and  these  must  be  boiled  before  use,  and 
lubricated  with  some  sterile  material.  Should  sepsis  occur,  the 
bladder  is  irrigated  twice  daily  with  some  mild  antiseptic,  such  as 
Condy's  fluid,  boric  acid,  boro-glyceride  (i  in  20),  or  sanitas  (i  in  20), 
whilst  urotropine,  salol  or  boric  ctcid  in  lo-grain  doses  may  be 
administered  by  the  mouth  thrice  daily.  Probably,  in  spite  of  all 
precautions,  the  condition  will  persist,  and  prove  fatal  from  extension 
to  the  kidneys.  Recognising  this  fact,  it  has  been  recommended  by 
some  authorities  to  allow  the  condition  of  distension  with  overflow  to 
occur  in  order  to  avoid  the  passage  of  catheters ;  the  urine  is  per- 
mitted  to  flow  away  into  sterile   flasks   frequently  changed.     The 


702  /I  MANUAL  OF  SURGERY 

bowels   are   always   obstinately   constipated,    and    must    be   opened 
either  by  purgatives  or  simple  enemata. 

Under  such  a  regime  the  patient  may  gradually  recover,  but  more 
often  succumbs  to  chronic  toxaemia  or  exhaustion.  Occasionally  he 
may  live  for  a  long  time,  although  paralyzed,  possibly  developing 
some  amount  of  reflex  micturition,  if  the  lumbar  centres  are  not 
involved.  Varying  degrees  of  restoration  of  power  in  the  lower 
limbs  are  observed. 

Dislocations  of  the  Spine. 

By  dislocation  of  the  spine  is  meant  a  displacement  forwards, 
either  partial  or  complete,  of  the  upper  part  of  the  spine,  with  separa- 
tion of  the  articular  processes,  and  tearing  of  the  intervertebral  sub- 
stance. A  pure  dislocation  can  only  occur  in  the  cervical  region,  and 
even  then  it  is  not  uncommonly  associated  with  a  fracture.  The 
reason  for  this  depends  partly  on  the  immobility  of  the  dorsal  and 
lumbar  vertebras,  and  partly  on  the  direction  of  their  articular  pro- 
cesses. In  the  cervical  region  these  look  mainly  upwards  and 
downwards,  with  a  slight  slope  forwards  and  backwards,  so  that  it 
is  not  difficult  for  one  to  slip  over  the  other ;  in  the  dorsal  region 
they  are  placed  nearly  vertical,  looking  forwards  and  backwards, 
whilst  in  the  lumbar  they  are  also  vertical,  but  look  [inwards  and 
outwards,  the  lower  enclosing  the  upper  as  in  a  sheath,  so  that  in 
the  last  two  regions  of  the  spine  dislocation  is  impossible  without 
concurrent  fracture  of  the  articular  processes  and  probably  of  the 
laminae. 

Any  part  of  the  cervical  region  may  be  the  seat  of  a  dislocation. 
The  occiput  has  been  displaced  from  the  atlas  in  a  few  cases,  resulting 
in  sudden  death  ;  but  if  incomplete,  life  has  been  prolonged  for  a  few 
hours  or  days.  Dislocation  of  the  atlas  from  the  axis  has  followed 
blows  on  the  neck,  or  has  been  the  cause  of  death  in  hanging,  whilst 
the  attempt  to  lift  a  struggling  child  by  the  head  has  sometimes  led 
to  this  calamity.  In  almost  all  cases  the  odontoid  process  has  been 
fractured  or  the  transverse  ligament  torn,  causing  instant  death  from 
compression  of  the  cord,  owing  to  the  head  and  atlas  slipping 
forwards.  Lateral  displacement  from  rotation  has  also  been  observed, 
the  cord  symptoms  then  being  of  a  milder  type. 

Dislocation  may  occur  between  any  two  of  the  lower  five  cervical 
vertehvcs,  but  perhaps  most  frequently  between  the  fifth  and  sixth.  It 
is  almost  invariably  the  result  of  forcible  flexion  of  the  head  and  neck, 
perhaps  combined  with  rotation,  and  as  a  rule  the  intervertebral 
articulations  are  torn  open,  whilst  the  supraspinous  and  interspinous 
ligaments,  the  ligamenta  subflava,  and  the  anterior  and  posterior 
common  ligaments,  are  lacerated,  and  the  intervertebral  substance 
torn  across,  or  a  scale  of  the  articular  surface  detached.  The  head 
and  upper  portion  of  the  spine  are  displaced  forwards,  so  that  the 
cartilaginous  surfaces  of  the  articular  processes  of  the  lower  vertebra 
project  behind  the  laminae  and  transverse  processes  of  the  upper, 
.,  nd  the  lower  articular  processes  of  the  upper  vertebra  lie  within 


INJURIES  OF  THE  SPINE 


703 


the  intervertebral  notch  of  the  lower  bone  (Fig.  329).     Two  forms 
of  dislocation  are  met  with — the  unilateral  and  bilateral. 

(a)  Unilateral  Dislocation  of  the  cervical  spine  is  due  to  force 
applied  from  the  back  and  side  of  the  neck.  The  head  is  turned 
towards  the  opposite  side,  and  more  or  less  fixed,  and  the  ear  is 
raised ;  there  is  no  evidence  of  compression  of  the  cord,  although  a 
tingling  and  neuralgic  pain  along  the  course  of  the  nerves  may  arise 
from  pressure  upon  and  stretching  of  the  nerve  roots  in  the  inter- 
vertebral notch.  The  spinous  processes  may  be  irregular  and 
displaced  laterally,  whilst  the 
line  of  the  transverse  processes 
is  similarly  altered ;  such  signs 
are,  however,  very  difficult  to 
make  out  in  thick  necks.  If  left 
unreduced,  the  vertebra  becomes 
fixed  in  its  new  position,  the  head 
and  neck  displaced,  and  perma- 
nent neuralgia  may  result.  In 
such  cases,  if  seen  early,  replace- 
ment may  be  accomplished.  The 
patient  is  anaesthetized,  the  body 
fixed,  and  traction  made  upon  the 
head  and  neck  away  from  the 
side  of  the  dislocation,  so  as  to 
unlock  the  edges  of  the  articular 
processes.  Reduction  may  be 
effected  with  a  definite  snap  or 
catch.  In  old-standing  cases  an 
operation  may  sometimes  be  at- 
tempted to  relieve  pressure  on 
the  nerves,  but  it  is  impossible  to 
replace  the  bones. 

{b)  Bilateral  Dislocation  (Fig. 
329),  if  complete,  is  always  ac- 
companied with  pressure  upon  the  cord  and  paraplegia ;  occasionally, 
however,  it  is  only  partial,  and  then  the  cord  may  escape  without 
immediate  injury,  owing  to  the  large  size  of  the  canal  in  this  region ; 
haemorrhage  and  inflammation  may  subsequently  cause  grave  symp- 
toms. Treatment  is  of  but  little  avail  in  most  of  the  cases  of  com- 
plete double  dislocation,  since  probably  the  cord  is  irretrievably 
damaged ;  but  when  paraplegia  is  incomplete,  it  is  possible  that 
benefit  may  arise  from  early  interference.  Replacement  by  traction 
on  the  head  with  the  neck  flexed  may  be  first  carefully  tried,  and 
failing  that  laminectomy  should  be  performed.  After  stripping  the 
muscles  from  the  bones,  the  surgeon  will  see  the  two  cartilage-covered 
surfaces  of  the  upper  articular  processes  of  the  lower  vertebra  standing 
out  clearly  behind  the  laminae  of  the  displaced  bone.  Upward  traction 
on  the  head  may  now  again  be  made,  and  reduction  thus  attempted ; 
but  if  this  does  not  succeed,  as  small  a  portion  as  possible  of  the  upper 


Fig.  329. — Dislocation  of  the  Cer- 
vical Spine.  (College  of  Sur- 
geons' Museum.) 

The  fifth  cervical  vertebra  is  dis- 
placed forwards,  projecting  in  front 
of  the  sixth ;  the  lower  articular 
process  of  the  fifth  vertebra  can  be 
seen  hitched  in  front  of  the  upper 
articular  process  of  the  sixth,  the 
body  of  which  is  slightly  fissured. 


^04  A  MANUAL  OF  SURGER^ 

margins  of  the  exposed  articular  processes  is  excised  in  order  to  allow 
of  the  unlocking  of  the  bones ;  if  the  whole  processes  are  removed, 
reduction  is  much  easier,  but  Nature's  barrier  to  prevent  a  recurrence 
of  the  trouble  has  been  taken  away,  and  fixation  of  the  spinal  column 
in  its  natural  position  becomes  impossible.  The  sudden  relief  of 
pressure  not  uncommonly  causes  such  an  interference  with  the  intra- 
vascular tension  in  the  cervical  cord  as  to  lead  to  a  temporary  cessa- 
tion of  the  breathing,  for  which  artificial  respiration  is  required.  It 
is  usually  advisable  not  only  to  replace  the  bones,  but  also  to  open 
the  spinal  canal  and  membranes,  so  as  to  remove  any  pressure  of 
blood  or  inflammatory  exudation  which  may  exist.  The  results  of 
such  operations  are  not  particularly  satisfactory. 

Affections  of  the  Cord  associated  with  Spinal  Injuries. 

Injuries  of  the  spinal  column  are  frequently  associated  with,  or  followed  by, 
conditions  affecting  the  cord  and  its  membranes  which  may  lead  to  the  gravest 
results,  even  when  the  local  lesion  to  the  spine  has  been  comparatively  slight. 
These  are  frequently  combined  with  one  another  in  the  most  puzzling  fashion, 
so  that  it  is  often  difficult  to  state  the  exact  nature  of  a  certain  group  of 
symptoms  ;  for  simplicity's  sake  we  shall  discuss  them  here  without  attempting 
to  describe  the  various  combinations  which  may  present  themselves. 

The  following  effects  may  be  met  with  in  connection  with  spinal  injuries : 
(a)  Direct  spinal  concussion  ;  (b)  spinal  haemorrhage ;  (c)  spinal  meningitis  ; 
(d)   spinal  myelitis ;  and  (e)  spinal  neurasthenia  (or  railway  spine). 

Direct  Concussion. — This  condition  may  be  due  to  severe  blows  on  the  back, 
which  do  but  little  damage  to  the  spinal  column,  or  may  be  caused  by  accidents 
which  lead  to  the  infliction  of  greater  mischief,  but  without  any  serious  dis- 
olacement  of  parts.  The  term  '  concussion  '  should  be  limited  to  those  cases 
where  energetic  traumatic  influences  {falls,  blows,  collisions,  etc.)  hdve  given  rise  to  a 
temporary  cessation  of  the  functions  of  the  cord  without  any  discoverable  anatomical 
changes.  In  fact,  the  term  is  really  only  applicable  to  those  cases  which  recover 
more  or  less  completely  ;  if  recovery  does  not  ensue,  minute  extravasations  or 
other  lesions  have  been  present,  constituting  a  condition  of  contusion  rather  than 
concussion. 

The  Symptoms  produced  are  those  of  a  more  or  less  complete  and  immediate 
loss  of  function  of  that  portion  of  the  cord  situated  below  the  point  struck. 
The  patient  is  usually  prostrate  from  general  shock  to  the  system,  and  the  reflexes 
are  often  totally  lost — at  any  rate,  for  a  time.  Death  may  be  caused  at  once  by 
a  blow  in  the  upper  cervical  region,  or  varying  degrees  of  loss  of  power  and 
sensation  may  be  produced  in  any  or  all  of  the  limbs.  In  the  lower  cervical 
region  the  arms  are  mainly  affected,  and  perhaps  some  particular  nerve  may  be 
picked  out  and  paralyzed.  In  the  lumbar  and  dorsal  regions  a  more  typical 
paraplegia  is  produced,  with  loss  of  power  over  the  sphincters,  and  loss  of 
reflexes.  Priapism  never  occurs  in  simple  concussion.  The  temperature  of  the 
body  is  depressed,  and  the  extremities  are  pallid  and  cold  ;  the  pulse  is  rapid  and 
weak,  and  the  respirations  are  shallow. 

The  Prognosis  is  always  uncertain,  as  in  cases  where  there  is  no  displacement  it 
is  impossible  to  gauge  the  extent  of  the  mischief.  If  merely  concussion  is  present, 
the  patient  is  likely  to  recover  in  a  short  time ;  if  the  cord  is  contused,  or 
haemorrhage  has  occurred  into  it,  a  perfect  recovery  can  scarcely  be  expected. 

In  the  Treatment,  absolute  rest  to  the  spine  is  of  the  greatest  importance,  and 
this  should  be  maintained  if  possible  in  the  prone  position,  so  as  not  only  to 
diminish  static  congestion,  but  also  to  remove  any  pressure  on  the  spine,  and  to 
allow  topical  applications  to  be  made.  A  spinal  icebag  may  be  applied,  or  the 
back  may  be  dry-cupped,  whilst  the  patient  is  kept  absolutely  still,  and  on  a  low 
diet.  The  bladder  and  bowels  need  attention,  but  no  special  drugs  are  necessary. 
Of  course,  local  injuries  require  suitable  treatment. 


myURIES  OF  THE  SPINE  '        705 

Spinal  Haemorrhage  can  here  only  be  discussed  as  resulting  from  injuries. 
A.part  from  traumatism,  it  is  interesting  to  note  that,  contrary  to  what  happens 
in  cerebral  haemorrhage,  it  occurs  more  frequently  in  young  persons  between  the 
ages  of  ten  and  twenty  than  in  old  people.  The  bleeding  may  take  place  either 
into  the  cord  itself,  or  outside  it,  and  hence  the  two  following  varieties  are 
described  : 

{a)  Intramedullary  Hsemorrhage,  or  spinal  apoplexy  [hcematomyelia) ,  is  met  with 
as  a  result  of  injury,  which  need  not  necessarily  involve  the  spinal  column  ;  the 
lower  cervical  region  is  the  part  usually  affected,  and  the  type  of  accident  some 
form  of  acute  flexion.  Extravasation  into  the  cord  is  rarely  extensive,  and  may 
occur  in  the  form  of  one  clot,  generally  not  larger  than  an  almond,  or  more 
commonly  in  many  spots,  the  grey  matter  being  more  or  less  ploughed  up.  The 
white  matter  is  compressed,  and  sometimes  the  blood  bursts  through  it  into  the 
subarachnoid  space.  Should  the  patient  survive  the  injury  for  any  length  of  time 
secondary  degenerations  are  established,  and  run  the  usual  course.  The  patient 
is  suddenly  struck  down  with  a  more  or  less  complete  paraplegia,  and  with 
perhaps  pain  in  the  back,  shooting  round  to  the  chest,  and  followed  by  a  rapid 
rise  in  temperature.  The  paraplegia  consists  of  a  flaccid  paralysis  of  the  arms 
due  to  destruction  of  these  centres  and  of  the  legs  from  interference  with  the 
descending  columns.  The  anaesthesia  usually  exhibits  dissociation  of  the  loss  of 
tactile  sensations  from  that  of  temperature  and  pain.  In  unilateral  lesions  the 
Brown-Sequard  syndrome  is  common.  Some  degree  of  recovery  follows, 
especially  in  the  legs,  but  the  parts  supplied  from  the  damaged  portion  of  grey 
matter — i.e.,  the  arms — are  likely  to  remain  paralyzed.  If  recovery  does  not 
occur  in  the  legs,  spastic  phenomena  with  increased  reflexes  develop.  In 
slighter  cases  only  involving  the  grey  matter,  the  arms  alone  may  show  signs  of 
paralysis  from  the  first.  The  Diagnosis  of  haemorrhage  turns  on  the  rapid  onset 
of  paraplegia,  which  may  be  incomplete,  and  without  spinal  irritation  ;  fever 
may  ensue  for  a  few  days,  and  if  the  cervical  region  is  affected,  extreme  contrac- 
tion of  the  pupil  (myosis)  may  result  from  destruction  of  the  cilio-spinal  centre. 
The  Prognosis  depends  on  the  size  and  situation  of  the  clot,  a  large  clot  producing 
more  injury  than  a  small  one  ;  haemorrhage  in  the  cervical  region  may  be  im- 
mediately fatal  by  interference  with  the  respiration,  whilst  in  the  lumbar  region 
it  is  unfavourable  on  account  of  the  effect  upon  the  sphincter  centres.  The  out- 
look is  best  when  the  dorsal  portion  of  the  cord  is  affected.  The  Treatment  is  the 
same  as  was  indicated  for  direct  concussion,  whilst  the  administration  of  a  few 
doses  of  ergot  may  be  beneficial. 

{b)  Extramedullary  Hsemorrhage  Qice^natorachis)  is  a  more  frequent  complication 
of  spinal  injuries,  such  as  sprains  or  limited  fractures,  than  the  former.  The 
blood  is  usually  extravasated  between  the  bones  and  the  dura  mater,  especially  in 
the  cervical  region,  but  may  occasionally  be  found  within  the  dura.  The 
symptoms  are  those  of  spinal  irritation — e.^.,  pain,  hyperaesthesia,  spasms,  cramps, 
etc. — rapidly  followed  by  loss  of  power  in  the  muscles  supplied  from  the  damaged 
area,  or  by  'gravitation  paraplegia'  (Thorburn),  which  gradually  extends  from 
below  upwards,  causing  death  by  asphyxia,  the  whole  series  of  phenomena  being 
afebrile.  In  intramedullary  haemorrhage  the  symptoms  of  paralysis  are  more 
evident,  and  those  of  spinal  irritation  less  marked.  If  a  diagnosis  can  be  made, 
ergotin  may  be  injected  in  the  hope  of  stopping  the  bleeding,  and  ice  applied  to 
the  spine,  or  even  laminectomy  performed  to  relieve  pressure  ;  later  on,  pro- 
longed rest  and  possibly  the  administration  of  some  absorbent,  such  as  iodolysin 
(p.  644),  may  cause  the  absorption  of  the  clot. 

Spinal  Meningitis. — Inflammatory  conditions  of  the  spinal  membranes  may 
spread  downwards  from  the  head,  or  commence  as  a  local  affection.  Two  forms 
are  met  with  resulting  from  injury  : 

{a)  In  Acute  Spinal  Meningitis  the  inflammation  mainly  affects  the  arachnoid 
and  pia  mater  (leptomeningitis).  It  is  usually  generalized  in  distribution,  and 
not  unfrequently  extends  to  the  cerebral  membranes.  It  occasionally  follows 
simple  injuries,  but  is  always  infective  in  origin.  Pathologically ,  it  is  evidenced 
by  hyperaemia  and  loss  of  polish  of  all  the  membranes,  with  an  abundant  exuda- 
tion ;  later  on,  lymph  or  even  pus  may  collect,  especially  about  the  posterior 
surface  of  the  cord ;  should  the  patient  live,  organization  of  the  effused  lymph 

45 


7o6  A  MANUAL  OF  SURGERY 

may  lead  to  extensive  adhesions.  Clinically,  the  disease  is  usually  ushered  in  by 
a  rigor,  especially  in  the  septic  cases,  and  then  runs  a  marked  pyrexial  course. 
The  symptoms  are  :  pain  in  the  back,  deep-seated,  boring,  and  severe,  increased 
on  all  movements,  and  often  extending  down  the  limbs  or  around  the  body  ; 
rigidity  of  the  spine  and  limbs,  accompanied  by  painful  cramps  and  muscular 
spasms,  almost  simulating  tetanic  convulsions  ;  extreme  hyperassthesia,  especially 
of  the  legs,  and  increased  reflex  excitability  ;  whilst  rapid  emaciation  from  pain 
and  sleeplessness  is  soon  produced.  If  the  condition  is  limited  to  the  spine,  it  is 
probably  followed  by  signs  of  myelitis,  viz.,  paraplegia,  together  with  bedsores 
and  vesical  troubles,  and  these  may  lead  to  a  fatal  issue ;  cases,  however,  are  met 
with  which  pass  into  a  chronic  state,  and  may  more  or  less  recover.  If  the 
process  also  involves  the  cerebral  membranes,  as  in  septic  cases,  the  symptoms 
of  diffuse  cerebral  meningitis  are  also  present,  and  the  patient  dies  of  coma. 
Treatment  in  the  cases  due  to  a  penetrating  injury  is  of  no  avail  if  prevention  of 
the  disease  by  asepsis  fails.  In  simple  cases  an  icebag  should  be  applied  to  the 
spine,  the  patient  remaining  in  the  prone  position.  Ergot  and  belladonna  may 
be  given  internally,  and  general  measures  to  allay  inflammation  adopted.  The 
bladder  and  rectum  must  be  attended  to,  and  bromides  and  chloral  administered 
to  gain  sleep. 

[b)  Chronic  Meningitis  is  usually  localized,  and  may  occur  either  as  an  inflamma- 
tion of  the  arachnoid  and  pia  mater  (leptomeningitis),  or  be  mainly  limited  to  the 
dura  mater  (pachymeningftis).  It  either  originates  as  a  chronic  affection,  or  is 
the  sequela  of  an  acute  attack,  and  is  more  likely  to  supervene  in  syphilitic 
individuals.  The  membranes  become  hyperaemic  and  thickened,  and  adhesions 
between  the  cord  and  its  membranes  may  occur.  The  extensions  of  the  pia 
mater  into  the  cord  explain  the  fact  that  a  chronic  sclerosing  myelitis  is 
frequently  associated  with  this  affection.  The  Symptoms  are  those  of  localized 
pain  and  rigidity  in  the  back,  increased  on  all  movements,  and  accompanied  by 
shooting  pains  and  hyperassthesia,  and  perhaps  muscular  pains  and  cramps.  The 
reflexes  are  usually  exaggerated ,  and  vesical  complications  may  follow.  Treatment 
consists  in  prolonged  rest,  with  counter-irritation  in  the  form  of  blisters  or  the 
button  cautery  applied  to  the  back,  whilst  mercuryand  iodides  are  administered 
internally. 

Spinal  Myelitis. — Inflammation  of  the  spinal  cord  may  follow  injuries  of  the 
spine,  either  as  a  direct  consequence  of  depressed  or  displaced  bone,  or  from 
simple  concussion  or  contusion  with  haemorrhage  ;  it  may  also  be  caused  at  a 
later  date  by  extension  of  inflammation  from  the  meninges,  or  result  from  com- 
pression by  lymph,  pus,  granulation  or  cicatricial  tissue,  or  callus.  It  may  be 
acute  or  chronic.  In  the  former  the  cord  becomes  red  and  softened ;  the  nerve 
elements  are  destroyed,  and  finally  replaced  by  cicatricial  tissue  if  the  patient  live 
long  enough.  In  chronic  cases  the  connective  tissue  becomes  thickened,  and  the 
nerve  structures  compressed  and  disintegrated,  whilst  the  meninges  are  always 
adherent  and  thickened. 

Symptoms. — Acute  Myelitis  is  evidenced  by  the  presence  of  pain  in  the  back  and 
along  the  course  of  the  nerves  arising  from  the  inflamed  area,  hyperaesthesia,  and 
muscular  cramps  in  the  earlier  stages,  soon  followed  by  paralytic  symptoms,  if 
these  are  not  already  present  as  the  result  of  the  injury.  The  irritative  symptoms 
are,  however,  much  less  marked  than  in  acute  meningitis.  The  reflexes  vary 
according  to  the  amount  of  destruction  of  the  cord  substance,  whilst  muscular 
atrophy  is  not  especially  rapid,  except  in  the  muscles  supplied  from  the  affected 
area.  The  sphincters  of  both  bladder  and  rectum  are  paralyzed,  causing 
retention  or  incontinence  of  urine,  and  incontinence  of  faeces ;  the  former  is 
almost  invariably  followed  by  severe  cystitis,  especially  when  the  trophic 
centres  in  the  lumbar  enlargement  are  involved.  Bedsores  are  very  liable  to 
be  produced,  and  may  become  very  extensive  and  serious.  Priapism  and 
hyperpyrexia  are  often  present  when  the  cervical  region  is  affected.  The  fatal 
issue  is  usually  due  to  septic  poisoning  from  the  urinary  tract,  or  perhaps  from 
the  bedsores. 

Chronic  Myelitis  gives  rise  to  a  great  variety  of  symptoms,  but  those  most 
marked  are  a  gradually  increasing  motor  weakness,  going  on  to  paralysis,  together 


INJURIES  OF  THE  SPINE  707 

with  various  sensory  phenomena  ending  in  anaesthesia,  whilst  there  is  trouble 
with  the  bladder  and  rectum. 

The  treatment  of  each  of  these  conditions  is  mainly  symptomatic. 

Spinal,  or  Traumatic,  Neurasthenia  {Syn. .-  Railway  Spine,  Indirect  Concussion 
of  the  Spine). — Cases  are  not  uncommonly  met  with  in  which,  although  there  has 
been  no  direct  injury  to  the  spinal  column  or  cord,  and  no  immediate  symptoms 
of  importance,  the  fact  is  manifestly  demonstrated  in  various  ways  that  consider- 
able commotion  and  disturbance  have  been  produced  in  the  nervous  system. 
Railway  accidents  are  the  most  common  cause  of  this  condition,  but  it  may 
arise  from  any  jar  to  the  spinal  column.  The  reason  why  railway  accidents  are 
so  often  responsible  for  this  state  is  that  the  forces  concerned  are  very  great,  and  the 
collision  unexpected,  so  that  the  muscles  and  ligaments  are  taken  at  a  disadvantage, 
being  off  their  guard,  whilst  the  shock,  terror,  and  mental  disturbance  are  also 
important  factors.  Ligamentous  and  muscular  lesions — i.e.,  sprains  and  strains 
— are  the  usual  local  phenomena  produced  by  such  accidents. 

In  the  majority  of  cases  the  symptoms  are  mainly  due  to  excessive  irritability 
and  weakness  of  the  spinal  and  cerebral  centres,  constituting  a  condition  of  nerve 
prostration,  or  Neurasthenia,  and  the  history  will  usually  be  somewhat  of  this 
type  :  The  individual  at  the  time  of  the  accident  is  thrown  from  side  to  side,  or 
severely  shaken,  but  does  not  lose  consciousness,  and,  although  feeling  somewhat 
dazed,  is  able  to  alight  without  help,  and  may  even  assist  others.  He  perhaps 
continues  his  journey,  and  goes  to  his  business,  but  finds  in  the  course  of  a  few 
hours  that  his  back  is  painful,  his  head  aching,  and  that  he  cannot  apply  himself 
to  his  work.  He  returns  home  and  goes  to  bed,  sends  for  his  doctor,  who  will 
probably  prescribe  rest  and  bromides.  His  condition  remains  for  a  time  un- 
altered ;  he  complains  of  pain  and  tenderness  over  certain  regions  of  the  spine, 
especially  the  lumbar,  and  is  unable  to  walk,  or  to  undertake  any  serious  mental 
or  physical  effort,  whilst  all  excessive  sensory  stimuli,  such  as  a  bright  lignt  or 
noise,  are  unusually  disturbing.  Neuralgia  is  often  present ;  the  pulse  is  weak  ; 
the  urine  may  be  retained  or  dribble  away,  and  the  temperature  may  be  for 
a  time  subnormal.  Accommodative  asth-enopia  (or  the  inability  to  accommodate 
for  near  objects),  resulting  in  a  temporary  condition  of  presbyopia,  is  also  a 
marked  feature  in  many  of  these  cases.  All  the  symptoms  are  aggravated  by 
mental  excitement  and  exertion,  such  as  are  produced  by  the  necessary  inter- 
views with  doctors  and  solicitors  pending  the  financial  compensation  by  the 
railway  company.  The  immediate  improvement  which  often  follows  the  satis- 
factory settlement  of  his  claim  for  damages  is  not  necessarily  due  to  imposture, 
but  may  result  from  the  removal  of  mental  tension  and  anxiety. 

This  condition  of  neurasthenia  may  develop  immediately  after  the  accident, 
as  an  acute  condition,  the  patient  lying  helpless  and  prostrate,  or  more  often 
chronically,  as  in  the  more  common  type  of  case  described  above.  To  it,  how- 
ever, is  frequently  added  a  considerable  element  of  Hysteria,  in  the  form  either 
of  an  acute  attack  of  hysterics,  or  of  a  chronic  unconscious  exaggeration  of  the 
sensory  symptoms.  If  the  patient  is  examined  in  the  supposed  hypersesthetic 
area  whilst  his  attention  is  distracted,  possibly  no  pain  will  be  complained  of. 

The  Prognosis  is  generally  favourable,  the  patient  recovering  in  time,  but  in  a 
few  instances  permanent  effects  may  be  produced. 

In  the  Treatmetit,  a  good  deal  of  care  is  needed  to  judge  rightly  when  the  period 
has  arrived  for  encouraging  movement  rather  than  rest,  and  thus  to  prevent  the 
patient  from  developing  a  condition  of  chronic  invalidism.  Rest  in  bed  is  to  be 
recommended  at  first,  bromides  given  in  moderation,  and  fomentations  applied 
locally.  Later  on,  friction  with  liniments  and  massage  should  be  employed,  and 
when  all  chance  of  secondary  inflammatory  disturbance  is  at  an  end,  movement 
should  be  encouraged,  and  change  of  air  advised,  whilst  a  course  of  strychnine 
and  iron  may  be  administered. 

In  a  few  cases,  however,  fortunately  much  rarer,  the  symptoms  run  on  into 
those  of  a  chronic  inflammatory  condition  of  the  spinal  cord  and  its  membranes, 
and  these,  to  which  Erichsen  formerly  applied  the  term  Indirect  Concussion,  are 
of  the  gravest  import.  In  others,  nothing  may  be  noticed  by  the  patient  for 
some  weeks  or  months  beyond  the  fact  that  he  feels  a  little  shaken,  and  not  so 
capable  of  doing  his  work  as  formerly  ;  but,  at  the  same  time,  he  loses  flesh,  and 


7o8  A  MANUAL  OF  SURGERY 

looks  ■worn  and  fagg'ed.  Gradually  other  phenomena  develop.  His  brain- 
power is  diminished,  and  any  mental  effort  causes  him  to  be  muddled  ;  memory 
fails,  the  temper  is  irritable,  and  his  sleep  disturbed  ;  the  head  is  often  hot.  The 
vision  is  usually  defective,  and  he  complains  of  noises  in  his  ears.  The  sense  of 
touch  is  impaired,  so  that  all  delicate  movements  are  hindered.  The  spino  is 
kept  rigidly  stiff,  the  head  fixed,  and  the  gait  is  somewhat  unsteady  and  shambling  ; 
the  walking  powers  are  much  diminished,  and  going  up  and  down  stairs  is 
especially  difficult.  Motor  power  in  all  regions  of  the  body  is  partly  lost ;  any 
or  every  modification  of  sensation  may  be  met  with,  whilst  the  reflexes  are 
increased.  The  bladder  may  lose  its  power  of  retaining  urine  for  a  time,  but 
this  is  not  always  a  marked  symptom  ;  there  is  great  impairment  of  both  sexual 
desire  and  power.  On  examining  the  back,  distinct  tenderness  is  felt  over  one 
or  more  spots,  especially  in  the  lower  cervical,  mid-dorsal,  and  lumbar  regions. 
In  such  cases,  where  the  symptoms  develop  slowly,  and  remain  unaltered  by 
treatment,  the  Prognosis  is  most  unfavourable,  since  they  are  probably  due  to 
inflammatory  changes  in  the  cord  and  brain,  and  although  the  patient  may  live 
for  years,  yet  he  is  permanently  crippled,  and  becomes  a  confirmed  invalid. 
Treatment  in  the  earlier  stages  consists  of  rest,  preferably  on  a  prone  couch,  with 
counter- irritation,  such  as  blisters,  or  even  the  actual  cautery,  over  the  spine, 
whilst  mercury  or  iodide  of  potash,  and  bark,  are  administered.  Careful  nursing, 
massage  of  the  limbs,  and  galvanism,  are  needed,  and  warm  sea-water  douches 
may  be  most  useful.  If,  however,  no  improvement  follows,  the  patient  must  be 
encouraged  to  get  about  as  best  he  can,  and  to  go  out  in  an  invalid  chair,  so  as 
to  maintain  the  general  health,  whilst  careful  attention  is  directed  to  the  personal 
hygiene. 

Paraplegia. 

Paraplegia  arises  in  the  course  of  spinal  injuries  from  a  variety  of 
causes,  which  may  be  classified  as  follows : 

1 .  Paraplegia  arising  immediately  after  the  accident,  from : 

(a)  Direct  concussion  without  evident  lesion  ; 
{b)  Disintegration  of   the  cord  from  intramedullary  haemor- 
rhage,  or  from  contusion  without  displacement  of  bone  ; 
{c)  Displacement  of  bones,  with  or  without  recoil,  crushing 

the  cord  ; 
{d)   Penetrating  wounds  dividing  the  cord. 
Ho\yever  produced,  the  same  symptoms  manifest  themselves  if  the 
lesion  is  complete  ;  recovery  is  alone  possible  in  the  first  and  perhaps 
in  the  second  group,  whilst  in  the  other  forms  the  paraplegia  is  main- 
tained by  a  subsequent  acute  transverse  myelitis. 

2.  Paraplegia  arising  after  an  interval,  from  : 

{a)  Extramedullary  spinal  haemorrhage,  if  the  symptoms  show 
themselves  without  pyrexia  in  twenty-four  or  forty-eight 
hours  ; 
{b)  The  pressure  of  inflammatory  exudations,  as  in   spinal 
meningitis,  when  the  symptoms  are  preceded  by  inflam- 
matory phenomena,  and  do  not  appear  before  seventy- 
two  hours  at  the  earliest ; 
{c)  The  pressure  of  callus  or  of  cicatricial  adhesions  around 
the  cord  and  membranes— «>.,  peri-pachymeningitis. 
It  is  unnecessary  to  discuss  further  the  special  signs  and  symptoms 
accompanying  each  form  ;  they  have  been  already  mentioned.     We 
merely  propose  to  indicate  briefly  the  effects  of  a  total  transverse 
lesion,  and  then  to  describe  the  results  of  paraplegia  as  they  vary  with 


INJURIES  OF  THE  SPINE  709 

the  situation  of  the  injury.  ■  It  must  be  remembered  that  the  nerves 
are  derived  from  spinal  segments  which  are  always  at  a  higher  level 
than  the  exit  of  the  nerves  from  the  canal;  i.e.,  the  nerves  travel 
downwards  within  the  spinal  canal  for  a  variable  distance,  less  in 
the  cervical  region,  more  in  the  lumbar,  before  escaping  through 
the  intervertebral  foramina. 

A  Total  Transverse  Lesion,  destroying  absolutely  one  segment  of 
the  cord,  will  result  in  the  following  symptoms  : 

1.  Paralysis  of  the  muscular  area  supplied  by  the  destroyed  seg- 
ment, followed  by  rapid  atrophy,  reaction  of  degeneration,  and  loss 
of  reflexes  in  this  particular  group  of  muscles. 

2.  Paralysis  of  all  the  muscles  supplied  by  the  segments  below  that 
which  has  been  destroyed.  The  trophic  condition  remains  normal, 
at  any  rate,  for  a  time,  but  when  secondary  descending  degeneration 
in  the  antero-lateral  columns  has  occurred,  the  muscles  become  con- 
tracted, tense,  and  rigid  (late  rigidity).  The  deep  reflexes  are  entirely 
and  permanently  lost,  but  the  superficial  reflexes,  though  absent  for 
a  time,  may  reappear.  If,  however,  a  portion  of  the  cord  remains 
intact,  both  superficial  and  deep  reflexes  may  persist  or  reappear,  and 
even  be  exaggerated. 

3.  Complete  anaesthesia  of  the  sensitive  area  supplied  by  the 
destroyed  segment,  and  of  all  the  sensitive  areas  below,  and  loss  of 
the  muscular  and  thermal  senses. 

4.  A  narrow  zone  of  hyperassthesia  is  found  at  the  upper  level  of 
the  anaesthetic  area,  due  to  the  irritation  of  the  nerve  roots  at  the 
site  of  injury. 

5.  Vasomotor  paralysis  combined  with  trophic  disturbances  in  the 
parts  which  are  paralyzed. 

6.  Visceral  changes,  especially  in  the  bladder  and  rectum. 
Phenomena  of  Paraplegia  at  Different  Levels,     i.  At  the  Upper 

End  of  the  Sacrum. — Total  transverse  lesions  at  this  spot  are 
exceedingly  rare  ;  they  only  involve  the  cauda  equina  and  cause 
paralysis  of  the  sacral  plexus.  The  effects  produced  are :  (i.) 
Paralysis  of  all  the  muscles  of  the  legs,  except  those  supplied  by 
the  anterior  crural,  the  obturator,  and  the  superior  gluteal  nerves, 
whilst  the  perineal  and  penile  muscles  are  also  affected,  (ii.)  Anaes- 
thesia of  the  penis,  scrotum,  perineum,  lower  half  of  the  gluteal  region, 
and  the  whole  of  the  legs,  except  the  front  and  outer  parts  of  the  thigh, 
which  are  supplied  by  the  cutaneous  branches  of  the  anterior  crural, 
and  the  region  supplied  by  the  long  saphenous  nerve,  (iii.)  The 
bladder  and  rectum  are  both  shut  off  from  their  spinal  centres,  and 
hence  there  will  be  temporary  retention  of  urine,  followed  by  disten- 
sion with  overflow,  and  incontinence  of  faeces.  The  bladder,  however, 
gradually  contracts,  its  walls  become  thickened,  and  its  capacity 
steadily  diminishes,  so  that  incontinence  becomes  more  and  more 
absolute. 

2.  If  the  lesion  is  situated  in  the  Dorsi-lumbar  region,  or  passes 
through  the  lumbar  enlargement,  which  corresponds  to  the  twelfth 
dorsal  and  first  lumbar  vertebrae,  there  is. complete  paralysis  of  the 


7IO  A  MANUAL  OF  SURGERY 

muscles  of  both  limbs,  including  those  passing  to  them  from  the 
trunk  ;  total  anaesthesia  of  the  legs,  gluteal  and  perineal  regions,  and 
possibly  the  lower  part  of  the  abdomen  ;  whilst,  if  the  vesical  centres 
are  destroyed,  there  is  total  paralysis  of  the  bladder,  with  relaxation 
of  the  sphincter,  dribbling  of  urine,  which  early  becomes  ammoniacal, 
and  cystitis,  due  to  trophic  changes  ;  if  the  centres  escape,  retention 
with  overflow  is  the  usual  result ;  the  rectum  and  sphincter  ani  are 
paralyzed,  causing  incontinence  of  faeces,  the  passage  of  which  is  un- 
recognised from  the  anaesthetic  condition  of  the  anus. 

3.  In  the  Mid-dorsal  region  the  same  phenomena  are  met  with,  but  to 
them  are  added  a  more  extensive  region  of  anaesthesia,  limited  above 
by  a  hyperaesthetic  zone,  which  feels  like  a  tight  painful  girdle  round 
the  waist ;  paralysis  of  the  flat  abdominal  muscles  ;  and  retention  of 
urine,  followed  by  distension  with  overflow.  Occasionally,  however, 
when  asepsis  is  maintained,  a  condition  of  reflex  micturition  develops, 
in  which  the  patient  passes  water  unconsciously  and  involuntarily, 
whenever  there  is  sufficient  intravesical  pressure  to  cause  sensory 
stimuli  to  ascend  to  the  undamaged  centres.  The  abdominal  paralysis 
is  a  most  important  addition  to  the  gravity  of  the  case,  for  all  straining 
movements  are  thereby  prevented,  and  thus  coughing  is  embarrassed 
and  defaecation  hindered.  The  gases  developing  from  the  stagnant 
faeces  accumulate  and  cause  distension  of  the  belly  (meteorism),  and 
thereby  respiration  may  be  seriously  impaired.  The  diaphragm, 
moreover,  is  hampered  in  its  action,  since  the  lower  ribs  cannot  be 
fixed  or  steadied,  and  hence  its  contractions  tend  to  pull  them  inwards, 
instead  of  increasing  the  dimensions  of  the  thoracic  cavity. 

4.  In  the  Cervico -dorsal  region  all  these  phenomena  are  present,  but 
the  anaesthesia  extends  over  nearly  the  whole  trunk,  and  the  hyper- 
aesthesia  may  involve  the  arms,  whilst  the  intercostal  and  spinal 
muscles  are  also  paralyzed.  Respiration  has  therefore  to  be  carried 
on  by  the  hampered  diaphragm,  with  the  assistance  of  a  few  of  the 
accessory  respiratory  muscles  in  the  neck,  and  hence  is  much  impeded ; 
if  bronchitis  is  present,  it  will  prove  fatal  by  asphyxia  in  a  few  days 
from  the  inability  to  expectorate.  Priapism  is  a  marked  feature  of 
cervical  paraplegia. 

5.  In  the  Lower  Cervical  region  the  arms  also  become  involved  in 
both  the  paralysis  and  anaesthesia,  and  the  patient  is  likely  to  die  in 
thirty-six  to  forty-eight  hours  in  a  condition  of  hyperpyrexia.  If  the 
lesion  is  situated  at  or  above  the  fourth  cervical  vertebra,  instant 
death  results  from  paralysis  of  the  phrenics  and  consequent  stoppage 
of  the  respiration. 

Death  from  Paraplegia,  therefore,  may  arise  from  a  variety  of 
causes  and  at  various  periods.  It  may  be  immediate,  from  respira- 
tory failure  in  lesions  above  the  fourth  cervical  vertebra  ;  or  it  may 
occur  from  accumulation  of  mucus  or  pus  in  the  air-passages,  when 
the  lesion  is  in  the  upper  dorsal  region ;  or  it  may  be  delayed  for 
weeks,  or  even  months,  and  then  be  due  to  sloughing  of  the  nates,  or 
septic  absorption  from  an  inflamed  or  ulcerated  bladder,  which  is 
often  associated  with  suppurative  pyelonephritis. 


INJURIES  OF  THE  SPINE  711 

The  Prognosis  and  Treatment  both  depend  on  the  position  and 
character  of  the  lesion  causing  the  paraplegia,  and  on  the  previous 
habits  and  condition  of  health  of  the  individual. 

Laminectomy. 

By  laminectomy  is  meant  an  operation  for  the  removal  of  the 
laminae  and  spinous  processes  of  one  or  more  vertebrae,  in  order  to 
relieve  pressure  on  the  cord,  whether  due  to  depressed  bone,  abscess, 
granulation  tissue,  excessive  callus,  cicatrices,  or  tumours.  The 
operation  consists  in  making  a  longitudinal  incision  in  the  middle 
line  of  the  back,  extending  to  the  spinous  processes ;  the  muscular 
and  tendinous  structures  are  then  cleared  from  the  posterior  aspect 
of  the  vertebrae  as  far  as  the  transverse  processes,  a  proceeding 
usually  attended  with  considerable  haemorrhage,  which  can  be 
checked,  perhaps,  better  by  hot  sponge  pressure  than  by  attempting 
to  secure  the  individual  vessels.  The  neural  arches  are  then 
examined  for  injury,  etc.,  and  those  which  seem  to  be  most  affected 
removed  by  cutting  pliers,  Hey's  saw,  or  laminectomy  forceps.  The 
posterior  aspect  of  the  membranes  of  the  spinal  cord  is  thus  exposed, 
and  the  various  conditions  which  may  be  present  are  dealt  with 
according  to  circumstances.  In  this  place  we  have  merely  to  con- 
sider the  use  of  this  operation  after  injury  to  the  spine.  For  its 
employment  in  other  conditions  see  Chapter  XXIV. 

It  must  be  remembered  as  a  fundamental  principle  that  repair  is 
impossible  after  the  spinal  cord  has  been  divided,  or  any  one  segment 
totally  disintegrated,  and  hence,  if  it  is  certain  that  a  total  transverse 
lesion  of  the  cord  has  been  caused  by  an  accident,  it  is  absolutely  use- 
less to  operate.  Early  and  complete  disappearance  of  all  the  reflexes 
is  a  suggestive  phenomenon,  but  cannot  be  looked  on  as  absolute 
evidence  of  a  total  transverse  lesion  ;  if,  however,  in  addition  to 
complete  sensory  and  motor  paralysis,  the  deep  reflexes  remain 
absent  for  any  length  of  time,  even  though  some  of  the  superficial 
ones  have  reappeared,  operation  is  useless.  The  presence  of  the 
deep  reflexes  is  always  an  evidence  that  at  any  rate  a  portion  of  the 
cord  remains  uninjured,  and  would  encourage  one  to  operate.  This 
question  cannot,  however,  be  absolutely  settled  in  the  early  stages  of 
the  case,  as  it  is  at  first  impossible  to  say  whether  the  symptoms  are 
due  to  concussion,  haemorrhage,  or  bony  pressure.  Fortunately, 
delay  does  not  appear  to  be  so  prejudicial  to  the  patient's  welfare  as 
one  might  at  first  expect,  and  many  cases  are  on  record  in  which  a 
good  result  was  obtained  even  after  months.  One  is  therefore  justi- 
fied in  waiting  a  while  in  doubtful  cases.  In  spite  of  this,  however, 
there  will  always  be  a  certain  number  of  cases  in  which  it  is  a  matter 
of  doubt  as  to  whether  or  not  any  benefit  will  accrue  from  operation. 
The  final  decision  under  such  circumstances  depends  on  the  special 
predilections  and  opinions  of  the  surgeon,  and  the  general  state  of  the 
patient. 

Apart  from  these  doubtful  cases,  the  following  are  generally 
admitted  as  being  suitable  for  operation:  (i)  Penetrating  wounds  or 


712 


A  MANUAL  OF  SURGERY 


fractures  with  displacement  which  involve  the  spine  below  the  first 
lumbar  vertebra  ;  the  cauda  equina  is  present  below  that  level,  and 
not  the  spinal  cord,  and  it  is  reasonable  to  treat  it  in  the  same  way  as 
one  would  treat  a  single  peripheral  nerve  ;  (2)  when  the  injury  is 
mainly  limited  to  the  neural  arch,  which  has  been  driven  in  by  diiect 
violence;  (3)  in  all  cases  of  bilateral  dislocation  of  the  cervical  spine 
where  the  patient  is  not  moribund ;  (4)  if  paraplegia  arises  with  or 
without  inflammatory  symptoms,  when  an  interval  has  elapsed  since 
the  accident ;  the  pressure  in  such  cases  may  be  produced  by  blood 
or  inflammatory  exudations,  and  benefit  may  possibly  arise  from  the 
operation  ;  if,  however,  it  is  due  to  a  total  transverse  myelitis,  no 
good  can  follow.  (5)  When  symptoms  of  irritation  or  paralysis 
supervene  at  a  later  date,  from  contraction  of  cicatrices  around  the 
cord  or  its  membranes  (peri-pachy meningitis),  or  from  excessive 
callus  formation,  laminectomy  may  be  performed  with  good  hopes  of 
a  successful  result. 


CHAPTER  XXIV. 
DISEASES  OF  THE  SPINE. 

Spina  Bifida. 

By  Spina  Bifida  is  meant  a  condition  of  imperfect  development  oi 
some  portion  of  the  posterior  aspect  of  the  spine,  with  or  without  a 
similar  affection  of  the  spinal  cord  and  membranes. 

It  must  be  remembered  that  the  spinal  cord  is  developed  as  a 
linear  involution  of  the  epiblast,  the  edges  of  this  medullary  groove 
growing  up  and  uniting,  so  as  to  include  a  passage  lined  with 
epithelium,  and  subsequently  known  as  the  central  canal.  The  cord 
is  gradually  separated  from  the  overlying  skin  by  an  intrusion  of 
mesoblastic  elements,  from  which  the  vertebrae,  together  with  the 
spinal  muscles  and  ligaments,  are  developed.  The  ossification  of 
each  vertebra  originates  in  three  main  centres — one  for  the  body,  and 
one  for  each  half  of  the  neural  arch,  whilst  epiphyses  are  developed 
as  plates  above  and  below  the  body,  as  also  for  the  transverse  and 
spinous  processes. 

The  following  are  the  chief  forms  of  spina  bifida  : 

1.  A  Myelocele  results  from  non-closure  of  the  primitive  medullary 
groove.  It  is  characterized  by  the  appearance  in  the  lumbo-sacral 
region  of  a  raw  surface,  which  consists  of  the  spread-out  structures 
of  the  cord,  at  the  upper  part  of  which  opens  the  central  canal.  The 
condition  is  incompatible  with  life,  and  the  child,  if  not  stillborn,  as 
is  usually  the  case,  does  not  live  beyond  a  day  or  two. 

2.  A  Syringo-Myelocele  (Fig.  330)  arises  from  a  distension  of  the 
central  canal  of  the  cord,  the  posterior  portion  of  which  usually 
remains  adherent  to  the  skin,  from  which  it  has  never  been  separated, 
owing  to  defective  development  of  the  mesoblastic  tissues.  The 
spinal  nerves  travel  round  the  walls  of  the  cyst  in  order  to  find  their 
way  to  the  intervertebral  foramina.  Trophic  phenomena  are  nearly 
always  a  prominent  feature  of  these  cases. 

3.  A  Meningo-Myelocele  (Fig.  331)  is  due  to  a  development  of  fluid 
within  the  membranes  which  remain  adherent  to  the  skin,  the  spinal 
cord  or  nerves  of  the  cauda  equina  passing  down  the  posterior  aspect 
of  the  cavity  as  a  strap,  and  the  nerves  traversing  and  perforating  the 
sac  to  reach  the  intervertebral  foramina. 

.4.  A  Meningocele  (Fig.  332)13  characterized  by  a  protrusion  of  the 
membranes,  containing  cerebro-spinal  fluid,  through  a  defect  in  the 

713 


714 


A  MANUAL  OF  SURGERY 


posterior  walls  of  the  vertebrae,  the  spinal  cord  and  nerves  being  in 
their  normal  position.     This  variety  is  uncommon. 

Of  these  forms,   the  meningo-myelocele  is  that  most  frequently 


C  SF- 


CSF 


Fig.  330, — Diagram  of 
Syringo-Myelocele. 


Fig.  331. — Diagram  of 
Meningo-Myelocele. 


Fig.  332. — Diagram 
OF  Meningocele. 


S  C,  Spinal  cord  ;  C  S  F,  cerebro-spinal  fluid  in  sac  ;  N,  nerves. 

seen  in  living  children,  although,  according  to  Bland-Sutton,  the 
first  is  really  the  most  common. 

Clinical  Characters. — A  spina  bifida  is  recognised  by  the  appear- 
ance of  a  tumour  in  the  middle  line  of  the  back  (Fig.  333),  most  com- 
monly involving  the  lower 
part  of  the  spine  ;  it  may  be 
covered  by  normal  skin,  but 
usually  that  over  the  con- 
vexity is  thin  and  translu- 
cent, and  not  unfrequently  a 
number  of  small  dilated  ves- 
sels are  seen  coursing  over 
it.  On  compressing  the 
tumour,  its  size  can  some- 
times be  diminished,  and  then 
in  infants  distension  of  the 
anterior  fontanelle  can  be 
felt,  showing  that  the  sac  is 
filled  with  cerebro  -  spinal 
fluid ;  there  is  usually  a  dis- 
tinct impulse  on  coughing 
or  crying.  The  defect  in  the 
posterior  portion  of  the  ver- 
tebrae is  often  evident,  the 
edges  of  the  bones  being 
felt  at  the  margins  of  the 
tumour.  Various  other  de- 
formities may  be  associated 
with  spina  bifida,  especially 
hydrocephalus  and  paralytic  talipes,  which  are  perhaps  most 
common  in  cases  of  syringo-myelocele  ;  perforating  ulcer,  anky- 
losis of  the  terminal  phalanges  of  the  toes,  and  other  trophic  pheno- 
mena, are  also  developed,  perhaps  at  a  much  later  date, 


Fig.  333. — LuMBO-SACRAL  Spina  Bifida  of 
the  Meningo-Myelocele  Type  in  a  Baby. 
(From  a  Photograph.) 


DISEASES  OF  THE  SPINE  715 

The  Diagnosis  is  usually  evident,  but  sometimes  in  the  cervical 
region  a  small  tense  meningocele  is  not  readily  recognised.  Radi- 
ography may  be  of  assistance  in  demonstrating  the  defects  in  the 
vertebrae. 

The  Prognosis  of  the  case  depends  mainly  on  the  thickness  and 
character  of  the  overlying  skin.  If  it  is  thin  and  atrophic,  as  in 
many  cases  of  meningo-myelocele,  the  sac  is  very  likely  to  give  way, 
causing  either  death  from  sudden  escape  of  cerebro-spinal  fluid,  or  a 
fatal  issue  in  a  few  days  from  infective  meningitis.  If  the  spina  bifida 
is  small,  and  covered  with  healthy  skin  and  subcutaneous  tissue,  the 
patient  may  reach  adult  life,  but  even  then  trophic  phenomena  may 
supervene,  possibly  as  the  result  of  the  presence  and  development  of 
foci  of  naevoid  tissue,  which  have  been  shown  to  occur  in  the  canal 
when  the  cord  is  absent.  Occasionally  a  meningocele,  with  only  a 
small  aperture  of  communication  with  the  spinal  canal,  is  cured 
spontaneously  by  the  gradual  development  of  the  bones  constricting 
the  neck  of  the  sac. 

Treatment. — A  large  number  of  these  cases  are  best  left  alone,  the 
tumour  being  merely  guarded  from  injury  by  the  application  of  a 
suitable  cap.  If  the  sac  is  gradually  increasing  in  size  and  threaten- 
ing to  give  way,  operative  interference  is  absolutely  necessary  if  life 
is  to  be  saved.  AcupuActure  through  the  thinned  integument,  the 
cerebro-spinal  fluid  being  allowed  to  drain  away  subsequently  into 
an  antiseptic  dressing,  or  tapping  through  the  healthier  integument 
around  the  base,  repeated  several  times,  and  followed  by  compression, 
may  lead  to  a  cure  in  favourable  cases.  Better  results,  however, 
are  obtained  by  tapping,  followed  by  the  injection  of  Morton's  fluid 
(B:.  lodi,  grs.  X. ;  pot.  iod.,  grs.  xxx. ;  glycerinum,  ad  gi.).  A  small 
quantity  of  the  cerebro-spinal  fluid  is  withdrawn,  and  then  from 
half  a  drachm  to  a  drachm  of  the  iodine  solution  is  introduced.  It 
diffuses  itself  slowly,  and  its  action  is  localized,  so  that  if  the  child  is 
kept  quiet,  and  only  semi-recumbent,  its  effect  will  be  limited  to  the 
sac  of  the  spina  bifida  and  its  neighbourhood.  In  some  cases  per- 
sistent leakage  may  follow  this  treatment,  and  will  need  the  applica- 
tion of  a  firm  antiseptic  compress  ;  in  many  the  injection  needs  to  be 
repeated  more  than  once. 

Of  late  years  treatment  by  an  open  operation  has  been  coming 
more  and  more  into  vogue.  Naturally,  it  is  chiefly  applicable  in  the 
meningocele  type,  and  infants  or  those  suffering  from  trophic  phe- 
nomena do  not  stand  it  well.  An  incision  is  made  over  the  sac, 
either  in  the  middle  line  if  the  cord  is  not  there,  or  to  one  side, 
if  it  is.  The  child  should  be  kept  with  the  head  low  when  the 
sac  is  opened,  so  as  to  limit,  as  far  as  possible,  the  loss  of  cerebro- 
spinal fluid.  In  a  meningocele,  the  protruding  membranes  are 
cut  away,  after  tying  or  suturing  carefully  the  pedicle,  and  the 
spinal  muscles  drawn  together  by  deep  stitches,  so  as  to  create  an 
extra  protective  barrier,  in  addition  to  the  skin  and  subcutaneous 
tissues.  When  the  cord  runs  down  the  back  of  the  sac,  it  is  freed  by 
incisions  on  either  side,  and  if  it  cannot  be  separated  from  the  skin, 


7i6  A  MANUAL  OF  SURGERY 

the  whole  strip  is  replaced  in  the  vertebral  canal,  the  membranes 
are  closed  over  it,  and  finally  the  muscles  and  skin  are  united  by 
rows  of  sutures.  The  results  obtained  by  this  means  have  been 
encouraging. 

Spina  Bifida  Occulta  is  the  term  applied  to  a  condition  in  which  the 
posterior  portion  of  the  vertebras  is  absent,  but  without  any  protrusion 
of  the  cord  or  its  membranes.  The  overlying  skin  may  be  cicatricial 
in  character,  or-a  large  growth  of  hair  may  arise  from  it ;  occasionally 
a  lipoma  develops  in  this  situation,  and  by  its  downward  growth 
compresses  the  spinal  cord,  causing  paraplegia.  Unless  such  a 
condition  is  present,  spina  bifida  occulta  calls  for  no  treatment,  but 
an  exploratory' operation  should  always  be  undertaken  when  nervous 
phenomena  supervene. 

Congenital  Sacral  Tumours. 

Other  congenital  conditions  of  the  lower  end  of  the  spine  are 
described  as  congenital  sacral  or  coccygeal  tumours.  The  majority 
of  these  arise  from  what  is  known  to  embryologists  as  the  neurenteric 
canal.  In  early  foetal  life  the  neural  and  alimentary  canals  are  con- 
tinuous, the  passage  of  communication  being  known  by  the  above 
name.  Ordinarily,  it  disappears  entirely  after  the  union  of  the  proc- 
todeum %vith  the  intestine,  but  evidences  of  its  existence  are  occa- 
sionally m.et  with,  either  in  the  form  of  a  cicatricial  dimple  adherent 
to  the  tip  of  the  coccyx  {post-anal  dimple),  or  as  one  of  the  following 
conditions : 

(i.)  A  dermoid  cyst,  contaming  the  usual  mixture  of  sebaceous 
material  and  epithelial  cells,  and  often  a  tuft  of  hair ;  it  develops  in 
the  space  between  the  rectum  and  coccyx,  and  may  either  project 
below  or  by  the  side  of  the  coccyx,  or  open  into  the  rectum ;  the  tuft  of 
hair  may  thus  find  its  way  out  of  the  anus.  In  a  cas.e  under  the  care 
of  Mr.  W.  Turner,  at  Westminster  Hospital,  it  was  actually  con- 
nected with  the  spinal  meninges,  removal  involving  the  loss  of 
cerebro-spinal  fluid. 

(ii.)  A  congenital  adenoma  of  the  post-anal  gut  is  occasionally  found 
in  the  same  region.  It  is  characterized  microscopically  by  the  exis- 
tence of  alveoli,  lined  by  cuboidal  epithelium,  held  together  by  con- 
nective tissue  ;  it  may  attain  a  large  size,  but  is  quite  innocent. 

Various  other  tumours  are  met  with  in  infants  in  this  region,  and 
the  same  title  of  congenital  sacral  or  coccygeal  tumour  has  sometimes 
been  applied  to  them  : 

{a)  A  spina  bifida  of  the  meningocele  type,  which  may  communicate 
with  the  subdural  space,  or  may  have  been  shut  off  by  a  natural 
process  of  cure. 

[b)  A  lipoma  may  also  form  here,  and  in  some  cases  has  simulated 
by  its  shape  a  caudal  appendage. 

{c)  A  partially-developed  foetus  may  be  met  with,  enclosed  within 
the  subcutaneous  tissues  of  the  sacral  region,  and  known  as  a  teratoma 

(p. -221). 

[d)  Sarcoma  and  cystic  hygroma  have  also  been  observed. 


DISEASES  OF  THE  SPINE  717 

Inflammatory  Affections  of  t^e  Spine. 

I.  Acute  Osteo-Myelitis  of  the  Spine  is  uncommon.  It  is  due  to  the 
same  causes  as  similar  disease  elsewhere,  viz.,  infection  with  pyogenic 
organisms  in  an  individual  of  low  germicidal  power.  It  is  charac- 
terized by  severe  pain  in  a  localized  portion  of  the  back,  and  fever ; 
deformity  is  not  a  marked  feature,  since  massive  necrosis  occurs, 
and  not  a  gradually  destructive  caries.  Abscesses  form  early,  and 
there  is  great  danger  of  an  extension  of  the  inflammation  to  the 
spinal  meninges,  leading  to  a  fatal  issue.  The  prognosis  is  extremely 
bad,  owing  to  this  latter  complication,  and  the  only  possible  treat- 
ment consists  in  early  incisions  to  give  exit  to  the  pus.  Sequestra 
can  easily  be  removed  from  the  back  of  vertebrae,  but  from  the  front 
only  in  the  lumbar  and  cervical  regions. 

II.  Tuberculous  Disease  of  the  Spine  or  Spinal  Caries  {Syn.  :  Pott's 
Disease,  Angular  Curvature). — The  above  names  are  applied  to  a 
tuberculous  disease  of  the  vertebrae,  originating  almost  invariably  in 
their  bodies,  which  are  more  or  less  destroyed,  leading  to  the  so- 
called  '  angular  curvature.'  The  term  '  Pott's  disease '  is  derived 
from  Percival  Pott,  who  first  described  it  accurately  in  1779. 

.ffitiology. — The  causes  are  much  the  same  as  those  of  tuberculous 
affections  elsewhere,  viz.  :  it  affects  an  individual  predisposed  to  its 
development  either  by  inherited  tendency,  or  by  impairment  of  the 
general  health,  as  from  some  preceding  illness,  or  exposure  to  defec- 
tive sanitary  conditions.  The  actual  deposit  of  tubercle  is  probably 
determined  by  some  injury,  such  as  a  strain  or  sprain  of  the  vertebral 
column,  or  of  the  soft  parts  attached  thereto,  which,  though  slight 
and  perhaps  not  noticed  at  the  time,  is  sufficient  to  cause  a  local 
diminution  of  vitality,  thereby  constituting  a  favourable  nidus  for 
the  B.  tuberculosis.  It  is  most  frequently  met  with  in  children,  but 
may  arise  at  any  age,  and  equally  in  either  sex.  Any  part  of  the 
spinal  column  may  be  involved,  but  the  lower  dorsal  is  by  far  the 
commonest.  The  cervical  region  is  rarely  attacked,  except  in 
children,  whilst  in  adults  the  dorsi-lumbar  vertebrae  are  the  favourite 
seat. 

Pathological  History. — The  actual  changes  in  the  bones  in  tuber- 
culous disease  are  exactly  similar  in  nature  to  those  already  described 
as  occurring  generally  in  cancellous  bone  (p.  578).  The  disease  starts 
most  frequently  in  the  interior  of  the  bodies,  and  in  children  attacks 
the  line  of  junction  of  the  upper  or  lower  plate-like  epiphyses ;  in 
adults  it  sometimes  commences  as  a  periostitis  of  the  anterior 
surface  of  the  vertebrae.  In  either  case  the  disease  quickly  spreads 
to  neighbouring  vertebrae,  either  along  the  under  surface  of  the 
anterior  common  ligament,  or  through  the  intervertebral  discs, 
which  are  disintegrated  by  the  process.  When  it  spreads  along 
the  anterior  common  ligament  (Fig.  334),  the  disease  may  become 
very  extensive,  body  after  body  being  eroded,  and  the  inter- 
vertebral discs  suffering  even  more  than  the  bones.  In  such  a 
case  the  deformity  produced  is  not  angular,  but  rather  of  a  general 


7i8 


A  MANUAL  OF  SURGERY 


kyphotic  nature.  Occasionally,  however,  the  disease  starts  simul- 
taneously in  many  foci,  so  that  the  bodies  of  several  vertebrae  become 
pitted  and  carious,  without  producing  general  destruction.  In  other 
cases  the  process  is  limited  to  the  bodies  and  intervertebral  discs  of 
two  adjacent  vertebrae,  the  periosteum  being  but  little  affected.  This 
variety  is,  perhaps,  most  common  in  the  lumbar  region,  where  the 

bodies  of  the  vertebrae  are  large 
and  permit  a  limiting  zone  of 
sclerosed  tissue  to  form ;  it  is  also 
not  uncommon  in  this  situation 
to  find  definite  sequestra  in  adults 

(Fig-  335)-      . 

Cure  is  effected  by  the  bodies 
of  the  vertebrae  falling  together 
and  becoming  ankylosed,  so  that 
a  deformed  and  immobile  con- 
dition of  the  diseased  portion  of 
the  spine  is  often  the  best  result 
that  can  be  anticipated.  The 
new  bone  thus  formed  becomes 
in  time  sclerosed  and  very  dense, 
and  the  synostosis  also  involves 
the  spines  and  laminae.  In  favour- 
able cases  this  occurs  without 
suppuration,  but  not  unfrequently 
abscesses  form  and  add  much 
to  the  gravity  of  the  condition. 
Occasionally,  the  tuberculous  pro- 
cess extends  backwards  through 
the  body  of  the  bone,  so  as  to 
implicate  the  posterior  common 
ligament,  and  paralytic  or  other 
symptoms  may  then  arise  from 
pressure  on  the  cord. 

Rare  cases  have  been  described 
in    which     the     disease    mainly 


Disease 


Fig.  334. — Tuberculous 

Spine,  showing  Destruction  of 
THE  Bodies  of  the  Vertebr/E  and 
Abscess  Formation  beneath  the 
Anterior  Common  Ligament. 
(Modified  from  Specimen  in  Col- 
lege OF  Surgeons'  Museum.) 


affected  the  sides  of  the  vertebrae, 
as  a  result  of  which  lateral 
deformity  occurred  ;  still  more  uncommon  are  those  in  which  the 
posterior  portion  of  the  neural  arches  is  primarily  involved. 

In  the  upper  cervical  region  the  disease  usually  starts  in  the  large 
joints,  either  between  the  occiput  and  atlas,  or  between  the  atlas  and 
axis.  For  a  time  it  may  be  limited  to  one  side,  but  the  body  of  the 
bone  is  attacked  at  an  early  stage,  and  the  trouble  then  spreads 
to  other  joints.  A  special  complication  of  this  variety  will  be 
mentioned  hereafter  (p.  725).    • 

The  Signs  and  Symptoms  produced  by  tuberculous  caries  of  the 
vertebrae  vary  considerably  in  different  situations,  but  for  practical 
purposes  may  be  described  under  the  following  five  headings  : 


DISEASES  OF  THE  SPIiJE 


7t9 


1.  Pain  is  a  constant  and  invariable  accompaniment  of  the  disease, 
although  in  the  early  stages  it  may  not  be  specially  prominent,  being 
only  elicited  by  careful  examination.     It  is  of  two  main  types,  the 
local  and  the  referred.     Local  pain  is  more  or  less  similar  in  character 
to  that  always  experienced  in  disease  of  bones,  although,  owing  to  the 
cancellous  nature  of  the  osseous  tissue  involved,  there  is  often  but 
little  tension,  and  hence  it  may  be  slight.    It  can  however,  be  elicited 
in  all  cases,  either  by  pressure  or  percussion  over  the  spines,  or 
perhaps  more  effectually  by  pressing  upon  the  transverse  processes, 
so   as   to   induce  rotation  of  the  vertebral  bodies  one  on  another. 
Movements  of  the  spine,  bending  or  twisting,  are  similarly  painful, 
whilst  the  same  result  can  be  brought  about  by  jarring  the  spine,  as 
by  a  blow  on  the  head  or  nates.    Referred  pain  is  produced  by  pressure 
upon,  or  irritation  of,  the  roots  of  the  nerves  as  they  emerge  from  the 
intervertebral       foramina  ; 
consequently    its    distribu- 
tion   is    governed    by    the 
arrangement  of  the  nerve- 
root    area    of   the   affected 
spinal     segment.       If     the 
lumbar  region  is   affected, 
the  pain  is  referred  down 
the  legs ;  in  the  dorsi-lumbar 
region    it   may   follow    the 
last   dorsal    nerve,  and  be 
noticed  in  the  lower  part  of 
the    abdomen,    or    in    tho 
gluteal  region  ;  in  the  lower 
dorsal    region    pain    is   re- 
ferred to  the   epigastrium, 
children    who    are    unable 
to  differentiate  its   precise 
nature  complainingof '  belly- 
ache ';  in  the  upper  dorsal 
and  lower  cervical  regions  the  pain  extends  into  the  arms,  whilst 
in  the  upper  cervical   region  neuralgia   follows  the  course  of   the 
cutaneous  branches  of  the  cervical  nerves.     Thus,  if  the  third  and 
fourth  cervical  nerves  are  involved,  pain  is  felt  along  the  course  of 
the    descending  sternal,   clavicular  and  acromial  branches  ;    if   the 
second  and  third  are  implicated,  pain  may  be  confined  to  the  great 
auricular  and  occipital  nerves  ;  if  the  atlas  and  axis  are  affected,  the 
neuralgic  pain,  if  any,  follows  the  occipital  branches. 

2.  Rigidity  of  the  spine  is  a  constant  accompaniment  of  Pott's 
disease.  In  the  early  stages  it  results  from  muscular  spasm,  the 
object  being  to  fix  and  immobilize  the  painful  part.  If  the  lower 
portion  of  the  spine  is  involved,  the  back  is  held  stiff  and  straight, 
the  patient  abstaining  from  all  movements  which  would  bend  or 
stretch  it.  Thus,  in  order  to  pick  up  an  object  from  the  floor,  the 
knees  and  hips  are  flexed,  and  the  patient  gradually  lets  himself  down 


Fig.  335. — Tuberculous  Disease  of  Two 
Lumbar  Vertebra,  showing  Sequestrum 
on  the  Anterior  Aspect,  and  Lateral 
Thickening  Preventing  Angular  De- 
formity. (College  of  Surgeons' 
Museum.) 


720  A  MANUAL  OF  SURGERY 

with  an  absolutely  rigid  back  into  a  sitting  or  squatting  posture ;  the 
body  is  raised  in  a  similar  manner  by  resting  the  hands  upon  the 
thighs,  the  patient,  as  it  were,  climbing  with  extended  arms  up  his 
own  legs.  In  a  child  rigidity  in  the  dorsi-lumbar  region  can  be 
demonstrated  by  laying  him  on  his  face,  grasping  the  ankles,  and 
ascertaining  the  amount  of  movement  of  the  spine  at  that  region  by 
lifting  the  legs  from  the  table,  and  also  by  moving  them  from  side  to 
side.  In  a  healthy  child  the  legs  can  be  elevated,  and  the  spine  bent 
back  in  the  dorsi-lumbar  region,  nearly  to  an  angle  of  sixty  degrees  ; 
whilst  lateral  mobility  to  the  extent  of  thirty  or  forty  degrees  on 
either  side  of  the  median  line  is  obtainable.  When  caries  is  present, 
neither  of  these  movements  can  be  made  without  including  the 
thorax  and  dorsal  spine.  In  cervical  caries  the  patient  steadies 
the  head,  and  at  the  same  time  raises  the  shoulders  by  the  help  of 
the  trapezius  and  sterno-mastoid  muscles,  whilst  the  chin  is  often 
supported  by  one  hand,  and  the  patient  twists  his  whole  body  in 
order  to  look  sideways. 

In  the  later  stages,  when  repair  is  taking  place,  or  has  occurred, 
rigidity  of  the  spine  is  due  to  osseous  ankylosis.  After  a  cure  has 
been  established,  compensatory  movements  of  other  portions  of  the 
spine  mask,  to  a  certain  degree,  the  localized  rigidity. 

3.  Deformity  is  necessarily  present  in  almost  all  instances  owing  to 
the  character  of  Nature's  method  of  repair,  although  in  a- few  cases, 
taken  in  hand  early,  it  is  possible  that  recovery  may  occur  without  it. 
The  amount  of  the  deformity  depends  on  a  variety  of  circumstances, 
and  perhaps  most  of  all  upon  the  number  of  vertebrae  affected. 
Where  only  two  bones  are  involved,  a  true  angular  deformity  may 
result,  the  body  of  the  upper  vertebra  being  welded  to  that  of  the 
lower,  so  as  to  produce  a  wedge-like  mass,  the  surfaces  of  which  are 
inclined  to  one  another  at  an  angle ;  compensatory  curves  of  the 
spine  elsewhere  enable  the  patient  to  assume  the  erect  posture.  In  the 
lumbar  region  (and  to  a  less  extent  in  the  cervical)  loss  of  the  normal 
forward  convexity  is  often  the  most  marked  feature,  the  vertebrae 
being  piled,  as  it  were,  one  above  the  other,  so  as  to  constitute  an 
absolutely  vertical  column  (Fig.  338).  When  the  affection  is  limited 
to  two  lumbar  vertebrae,  there  is  usually  little  or  no  displacement, 
the  disease  occupying  the  centres  of  the  bones,  so  that  the  sides  may 
escape  altogether,  and  preserve  the  integrity  of  the  spinal  column  ;  if 
a  distinct  projection  of  the  spine  is  present,  the  portion  of  bone 
which  appears  most  prominent  is  the  spinous  process  of  the  lower 
vertebra.  Owing  to  the  obliquity  and  length  of  the  spinous  processes 
of  the  dorsal  vertebrae,  the  projection,  even  when  only  two  bones  are 
involved,  is  very  considerable  ;  in  the  latter  case  the  spinous  process 
of  the  upper  vertebra,  by  becoming  horizontal,  is  the  more  prominent. 
When  a  large  number  of  dorsal  vertebrae  are  affected,  the  curvature 
is  never  angular,  but  the  whole  region  becomes  bent  forwards,  and 
that  sometimes  very  acutely  (Fig.  336).  In  the  cervical  region  there 
is  rarely  much  deformity,  owing  to  the  small  size  of  the  vertebral 
bodies,  but  if  several  bones  are  involved,  the  head  may  be  carried 


DISEASES  OF  THE  SPINE 


72i 


forwards  and  flexed,  necessitating  considerable  compensatory  changes 
in  the  dorsal,  or  even  lumbar,  regions.  Lateral  deviation  simulating 
torticollis  is  also  not  uncommon. 

Secondary  changes  in  the  shape  of  the  thorax  necessarily  accom- 
pany the  more  advanced  cases  of  caries  in  the  dorsal  region,  the 
sternum  becoming  convex  anteriorly  so  as  to  compensate  for  the 
diminished  vertical  measurement  of  the  thorax,  and  the  ribs  crowded 
together  to  such  an  extent  as  almost  to 
obliterate  the  intercostal  spaces.  The 
lower  floating  ribs  may,  however,  retain 
their  normal  position,  and  thus  a  horizontal 
groove  may  be  produced  corresponding  to 
the  line  of  the  tenth  rib.  In  such  cases 
the  patient  becomes  much  stunted  in  growth 
and  dwarfed,  constituting  the  typical 
'  hunch-back.' 

4.  Abscess  is  the  most  serious  result  of 
spinal  disease,  for,  owing  to  its  deep  origin, 
it  often  attains  considerable  dimensions 
before  it  is  recognised  or  treated,  whilst  it 
is  usually  impossible  to  deal  with  the 
causative  lesion  in  the  bones ;  if  once  the 
cavity  becomes  invaded  by  pyococci,  an 
exceedingly  grave  complication  is  intro- 
duced into  the  case,  which  may  even  deter- 
mine a  fatal  issue.  The  pus  collects 
primarily  on  the  anterior  aspect  of  the 
vertebrae  beneath  the  anterior  common 
ligament  (Fig.  334),  which  may  be  stripped 
from  the  bones  for  a  considerable  distance, 
owing  to  the  tension  within  the  abscess 
cavity.  It  thence  finds  its  way  to  the 
sides  of  the  bodies  after  perforating  the 
ligament,  and  burrows  in  various  directions, 
according  to  the  portion  of  the  spine 
involved. 

■  In  the  cervical  region  a  chronic  retro- 
pharyngeal abscess  is  first  formed ;  it  pushes  the  posterior  pharyngeal 
wall  forwards,  and  may  be  detected  from  the  mouth  as  an  elastic 
fluctuating  swelling,  which,  by  its  size,  often  leads  to  some  difficulty 
in  swallowing  and  breathing,  whilst  oedema  of  the  glottis  may  be 
induced.  Left  to  itself,  various  courses  are  open  to  it :  i.  The 
abscess  may  burst  and  discharge  into  the  pharynx,  the  cavity 
necessarily  becoming  septic,  and  the  osseous  lesion  thus  aggravated. 
2.  It  may  travel  downwards  behind  the  oesophagus  into  the  posterior 
mediastinum,  and  thence  extend  in  the  same  direction  as  abscesses 
in  the  dorsal  region.  3.  More  often  the  pus  finds  its  way  to  the  side 
of  the  neck,  behind  the  vessels  and  sterno-mastoid,  being  guided  to 
the  posterior  triangle  bv  the  prevertebral  fascia,  behind  which  it  is 

46 


Fig.  336. — Advanced  Tuber- 
culous Disease  of  Spine 
IN  Dorsal  Region. 


^±i 


A  MANUAL  OF  SURGERY 


situated ;  less  frequently  it  pierces  this  fascia,  and  presents  in  the 
anterior  triangle.  4.  In  the  lower  part  of  the  neck,  it  may  spread 
under  the  clavicle  into  the  axilla,  being  directed  by  the  same  fascia,, 
which  in  this  region  passes  downwards  behind  the  subclavian  trunks, 
and  forms  the  posterior  wall  of  the  sheath  of  the  axillary  vessels. 

In  the  dorsal  region,  the  abscess  starts  in  the  same  way  in  front  of 
the  vertebrae,  and  may  thence  extend  as  follows:  i.  Most  frequently 
it  passes  backwards  between  the  vertebral  ends  of  the  ribs  to  form  a 
dorsal  abscess,  which  points  3  or  4  inches  from  the  spinous  processes, 


Fig.  337. — Lumbar  Aeccess  arising 
FROM  Tuberculous  Disease  of  the 

DORSI-LUMBAR    SpINE. 

The  projection  of  the  spinous  processes 
is  evident ;  the  lateral  curve  is  prob- 
ably merely  an  associated  or  ante- 
cedent deformity. 


Fig.  338.  —  Lumbar  Abscess. 
Lateral  View  of  Same 
Patient. 


and  has  an  impulse  on  coughing.  2.  It  may  extend  between  the  ribs 
and  the  parietal  pleura  along  the  anterior  branches  of  the  intercostal 
vessels,  coming  to  the  surface  at  the  spot  where  the  lateral  cutaneous 
branches  are  given  off.  Tuberculous  disease  of  the  ribs,  leading  to 
caries  or  necrosis,  or  even  a  localized  empyema,  may  be  induced  in 
such  cases.  3.  Very  rarely  the  abscess  may  travel  up  to  the  neck, 
pointing  behind  the  sterho-mastoid  muscle.  4.  Not  uncommonly, 
however,  it  works  its  way  downwards,  passing  under  the  ligamentum 


DISEASES  OF  THE  SPINE 


72J 


arcuatum  internum  of  the  diaphragm,  thus  entering  the  psoas  sheath, 
and  giving  rise  to  a  psoas  abscess. 

In  disease  of  the  dorsi-lumbar  or  lumbar  regions,  either  a  lumbar 
or  a  psoas  abscess  may  result.  A  lumbar  abscess  (Fig.  337)  is  due  to 
the  passage  backwards  of  the  pus  along  the  posterior  branches  of  the 
lumbar  vessels  and  nerves  to  the  outer  border  of  the  erector  spinae, 
and  usually  presents  superficially  in  Petit's  triangle — i.e.,  between 
the  adjacent  borders  of  the  latissimus  dorsi  and  external  oblique 
muscles.  It  there  forms  a  tense  fluctuating  swelling,  with  an  impulse 
on  coughing.  A  psoas  abscess  lies  within  the  sheath  of  the  psoas 
muscle,  the  pus  being  usually 
superficial  to  the  muscular  fibres,  ' 

some   of   which  are  probably  de- 
stroyed.    It  is  often  preceded  by  a  ■      ' 
condition  of  spasmodic  contraction          * 
of  the  muscle  with  limited  exten- 
sion of  the  thigh,  which  may  dis-       /  ^  \ 
appear  after  a  period  of  rest.    If  it 
progresses,  a  resistant  mass  of  a                         * 
fusiform  shape  is  at  length  felt,    i 
placed  deeply  in  the  abdomen ;  as   ^1         • 
it  enlarges,  it  usually  burrows  out- 
wards  under   the   fascia  iliaca    tn 
form  a  tense  rounded  swelling  in 
the    iliac    fossa    (Fig.    339).      It 
thence     travels    under    Poupart's 
ligament,  behind  and  external  to 
the  common  femoral  vessels,  being 
constricted  at  this  spot   so  as  to 
form    a    narrow   neck.      The    sac 
then  expands  behind  the  common 
femoral  sheath,  the  vessels  being 
often  displaced  forwards,  and  the 
vein  flattened  out  and  compressed. 
Thence  passing  along  the  tendon 
of  the  ilio-psoas,  to  the  neighbour- 
hood of  the  lesser  trochanter,  the 
abscess   comes   into  relation  with 
the  internal  circumflex  artery,  and  usually  points  at  or  near  to  the 
saphenous  opening  to  the  inner  side  of  the  main  vessels.     It  may, 
however,  follow  the   different   branches  of   the   internal  circumflex 
amongst  the  adductor  muscles,  forming  a  large  swelling  on  the  inner 
side  of  the  thigh,  displacing  these  structures  ;  or  it  may  even  travel 
along  its  main  trunk   behind   the   neck  of  the   femur   to  reach  the 
surface  behind  the  great  trochanter.     In  other  rare  cases  the  abscess 
has  been  known  to  extend  down  the  leg,  and  has  even  been  evacuated 
by  the  side  of  the  tendo  Achillis.     Occasionally,  the  pus  finds  its 
way  down  into  the  pelvis  instead  of  passing  under  Poupart's  liga- 
ment, and  then  points  in  the  ischio-rectal  fossa,  or  possibly  burrows 
throusfh  the  sacro-sciatic  foramen. 


Y 


Fig.  339. — Psoas  Abscess  pointing 
IN  THE  Iliac  Fossa,  and  Burrow- 
ING  amongst  Adductor  Muscles. 


724  A  MANUAL  OF  SURGERY 

The  constitutional  disturbance  associated  with  the  formation  of 
these  abscesses  is  usually  but  slight,  and  there  is  no  leucocytosis  ; 
perhaps  there  is  a  small  rise  of  temperature  at  night,  but  if,  as 
occasionally  happens,  ordinary  pyogenic  organisms  find  their  way  into 
the  sac  from  within  the  body,  this  may  become  more  marked.  As 
they  come  to  the  surface,  considerable  pain  may  be  experienced  from 
the  tension  and  irritation  of  the  soft  parts,  and  fever  of  a  hectic  type 
is  induced. 

3.  raj.c..piegia  occurs  in  about  one  out  of  every  thirteen  cases 
of  tuberculous  caries  of  the  spine,  and  then  generally  in  bad  or 
neglected  cases.  It  is  scarcely  ever  due  to  the  acuteness  of  the 
curve.  It  has  been  known  to  resul'f"  from  a  fracture  of  fne  spine, 
the  integrity  of  which  has  been  weakened  by  the  inflammatory 
process,  but  it  is  usually  caused  by  an  extension  backwards  of  the 
disease,  so  that  a  nodule  or  button  of  tuberculous  material  forms 
beneath  the  posterior  commDn  ligament,  or  pushes  through  it,  com- 
pressing the  cord  against  the  laminae,  and  actually  invading  the 
dura  mater.  It  occasionally  originates  in  the  pressure  caused  by 
an  abscess,  which  extends  backwards  into  the  spinal  canal ;  in  these 
cases  the  symptoms  may  be  relieved  by  opening  the  abscess  even  at 
a  distance. 

The  effect  produced  on  the  cord  varies  with  the  rapidity  and 
acuteness  of  the  process.  When  the  pressure  is  rapidly  developed, 
a  subacute  myelitis  ensues ;  but  more  frequently  it  is  of  a  chronic  or 
sclerosing  type.  The  cord  is  then  found  to  be  constricted  or  indented 
by  the  tuberculous  mass,  and  perhaps  considerably  reduced  in  size  ; 
its  texture  is  firmer  than  normal,  and  the  colour  grayish.  The  onset 
of  symptoms  may  be  suddenly  induced  by  haemorrhage  or  displace- 
ment of  bone,  but  is  more  usually  gradual.  The  dorsal  region  (about 
the  eighth  vertebra)  is  that  most  often  involved,  since  there  is  plenty 
of  space  in  the  cervical  region,  and  in  the  lumbar  the  cord  has 
broken  up  into  the  cauda  equina. 

The  symptoms  arising  from  pressure  on  the  cord  must  be  distin- 
guished from  those  due  to  irritation  of,  or  pressure  on,  the  nerve 
roots.  The  latter  causes  neuralgic  pain  within  the  area  of  distribu- 
tion of  some  nerve-root,  possibly  in  the  later  stages  associated  with 
anaesthesia  {amsstJiesia  dolorosa),  or  a  limited  motor  weakness  if  the 
anterior  roots  are  involved.  In  compression  of  the  cord,  motor 
phenomena  are  more  evident  than  sensory,  since  the  sensory  track  lies 
towards  the  centre  of  the  cord,  and  so  is  more  protected  from  injury. 
At  first  there  is  some  dragging  of  the  toes  on  walking,  and  loss  of 
power  in  the  legs,  combined  usually  with  neuralgia,  weakness  of  the 
sphincters,  and  exaggeration  of  the  reflexes.  Later  on  the  paralysis 
becomes  complete,  and,  as  degeneration  of  the  cord  follows,  secondary 
contractions  and  rigidity  occur,  and  the  reflexes  diminish,  Absolute 
incontinence  sometimes  supervenes,  the  bladder  emptying  itself 
periodically  and  involuntarily,  or  the  urine  trickling  away  continually 
from  either  a  full  or  empty  viscus. 

Special  mention  must  be  made  here  of  a  grave  complication  only 


DISEASES  OF  THE  SPINE  725 

occurring  in  the  upper  cervical  region,  which  may  result  in  sudden 
death.  Tuberculous  disease  of  the  upper  two  vertebrae  usually 
originates  in  one  or  more  of  the  large  articulations  on  either  side  of 
the  atlas ;  if  these  joints  become  disorganized,  displacement  may 
occur  at  any  moment,  and  in  this  way  the  occiput  slips  forwards 
upon  the  atlas,  and  may  lead  to  gradual  or  sudden  compression  of 
the  cord  and  consequent  death.  The  disease  sometimes  spreads  to 
the  body  of  the  axis,  and  by  this  means  the  odontoid  process  becomes 
detached,  or  the  transverse  ligament  gives  way ;  in  either  case,  the 
weight  of  the  head  carries  the  arch  of  the  atlas  forwards,  and  death 
ensues  at  once  from  compression  of  the  medulla. 

Course  of  the  Case  and  Prognosis. — Left  to  itself,  the  disease  usually 
progresses  more  or  less  steadily,  the  bone  lesion  becoming  gradually 
more  marked,  and  abscesses  are  likely  to  develop.  If  treated  efficiently, 
and  taken  in  hand  early,  repair  by  ankylosis  may  be  confidently 
expected.  Even  when  an  abscess  forms,  prolonged  rest  may  lead  to 
its  disappearance,  the  fluid  part  of  the  pus  being  absorbed,  and  the 
solid  elements  becoming  inspissated  and  dry,  forming  a  putty  like 
mass  lying  on  the  front  of  the  vertebral  column  ;  this  may  subse- 
quently undergo  liquefaction,  probably  owing  to  infection  with  pyogenic 
cocci,  constituting  what  is  known  as  a  residual  abscess.  Should,  how- 
ever, the  abscess  burst  or  be  opened,  and  become  septic,  symptoms 
of  hectic  fever  and  amyloid  disease  are  almost  certain  to  develop,  and 
the  patient  is  sooner  or  later  exhausted  by  the  discharge,  and  dies 
from  asthenia.  If  dealt  with  judiciously,  and  sepsis  avoided,  the 
abscesses  may  be  cured,  and  if  at  the  same  time  the  spine  is  kept 
at  rest,  and  suitable  hygienic  measures  are  adopted,  the  lesion  in 
the  bones  is  able  to  consolidate.  The  onset  of  paraplegia  must  not 
be  looked  on  as  rendering  the  case  hopeless,  since  with  prolonged 
rest  the  paralytic  phenomena  often  disappear  entirely.  Septic 
cystitis  and  bedsores  may  arise  as  complications,  and,  if  allowed  to 
progress,  cause  death.  Occasionally,  as  a  result  of  the  implication 
of  the  spinal  canal,  diffuse  meningitis  follows,  leading  to  a  rapidly 
fatal  termination.  As  in  tuberculous  disease  elsewhere,  the  patient 
also  runs  the  risk  of  acute  miliary  tuberculosis,  whilst  other  organs — 
e.g.,  the  lungs,  brain,  or  kidney — may  become  affected.  In  spite 
of  these  possibilities,  however,  the  prognosis  is  good  as  regards  life 
in  cases  free  from  complications,  and  where  suitable  treatment  is 
practicable. 

The  Diagnosis  of  spinal  caries  is  rarely  a  matter  of  difficulty  when 
the  characteristic  deformity  exists,  but  in  the  early  stages,  when  the 
displacement  is  not  evident,  or  if  there  is  only  a  very  slight  promi- 
nence of  the  spinous  processes,  it  is  likely  to  be  mistaken  for  a  simple 
rachitic  or  statical  curve;  whilst  if  neuralgic  pain  is  a  prominent 
symptom,  it  may  possibly  be  looked  on  as  a  case  of  spinal  or  inter- 
costal neuralgia,  or  as  rheumatism,  or  even  be  ascribed  to  renal 
affections.  Tumours  of  the  spine,  such  as  cancer,  or  hydatid  cysts, 
syphilitic  disease,  and  aneurismal  erosion,  also  produce  symptoms 
somewhat  resembling  those  of  spinal  caries,  and  in  adults  it  may  be 


726.  A  MANUAL  OF  SURGERY 

impossible  from  the  local  phenomena  alone  to  determine  which  of 
these  conditions  is  present,  although  a  careful  consideration  of  the 
general  history  and  of  the  onset  of  the  symptoms,  and  a  radiographic 
examination,  may  throw  light  upon  the  case.  Frequently  the  course 
of  the  disease  and  the  reaction  to  treatment  must  be  mainly  relied  on 
in  forming  a  diagnosis.  The  spine  should  always  be  examined  from 
before  and  from  behind,  and  pain  on  pressure  over  the  transverse 
processes  and  rigidity  of  the  back  are  the  symptoms  on  which  most 
stress  should  be  laid. 

The  diagnosis  of  the  abscesses  connected  with  spinal  caries  is 
sometimes  not  devoid  of  difficulty,  especially  when  they  point  in  the 
groin  or  the  lumbar  region,  since  similar  collections  of  pus  may  arise 
from  a  variety  of  other  causes,  (a)  A  perinephritic  abscess  is  recognised 
by  the  association  or  pre-existence  of  symptoms  of  renal  disease, 
whilst  a  spinal  lesion  may  be  absent.  Of  course,  both  conditions 
may  be  present  in  the  same  individual,  and  the  diagnosis  can  then 
only  be  made  by  an  exploration  of  the  abscess  cavity,  (b)  An 
empyema  occasionally  points  in  the  loin  or  even  in  the  groin,  but 
should  be  recognised  by  an  examination  of  the  thorax.  [c)  A 
chronic  abscess,  due  to  appendicitis,  may  present  very  similar  signs 
to  those  of  a  deep-seated  abscess  in  the  ilio-psoas  region  on  the  right 
side,  if  it  has  not  extended  below  Poupart's  ligament.  Careful 
examination,  however,  will  demonstrate  the  upward  extension  of  the 
abscess  towards  the  spine  in  the  latter  case,  whilst  the  previous 
history  will  differ  considerably  in  the  two  conditions,  (d)  An  iliac 
abscess  may  arise  from  a  variety  of  conditions  other  than  spinal 
disease — e.g.,  necrosis  or  caries  of  the  ilium,  or  cellulitis  in  the 
tissues  under  the  fascia  iliaca.  It  is  recognised  by  being,  as  a  rule, 
more  distinctly  limited  in  extent  than  an  ilio-psoas  abscess,  and  by 
the  absence  of  symptoms  of  spinal  disease,  {e)  Abscesses  arising  in 
connection  with  hip  or  sacro -iliac  disease  occasionally  point  in  the  groin, 
but  are  easily  distinguished  from  a  psoas  abscess  by  not  extending 
upwards  along  the  course  of  the  psoas  muscle,  and  by  the  evident 
signs  of  hip  or  sacro-iliac  disease  which  are  always  present. 
(/)  Diffused  or  rtipiured  aneurism  of  the  iliac  artery  may  give  rise 
to  considerable  difficulty  in  diagnosis,  since  a  non-pulsating  tumour 
in  the  course  of  the  muscle  is  sometimes  produced.  The  preceding 
history,  the  absence  of  fluctuation,  the  oedema  and  congestion  of  the 
leg,  the  interference  with  the  pulse,  and  the  rapid  increase  of  the 
tumour,  should  indicate  the  nature  of  the  case,  (g)  The  diagnosis 
of  abscess  from  femoral  hernia  is  given  elsewhere. 

Local  Treatment. — In  order  to  promote  the  development  of  a 
suitable  and  sufficient  synostosis,  the  great  essential  is  absolute 
immobilization  and  freedom  from  weight-bearing.  At  the  same 
time  it  is  desirable  that  means  should  be  taken  to  limit  the  degree  of 
deformity.     These  objects  may  be  effected  in  the  following  ways  : 

(a)  By  the  Adoption  of  the  Recumbent  Posture. — The  patient  is  kept  in 
bed  lying  on  his  back  without  a  pillow,  and  with  sheets  passing  over 
the  trunk  and  thighs,  secured  by  sandbags  on  either  side  and  between 


DISEASES  OF  THE  SPINE 


727 


the  legs.  If  thought  necessary,  extension  by  weight  and  pulley 
attached  to  the  legs,  as  described  at  p.  537,  may  also  be  employed, 
together  with  extension  of  the  head  by  a  weight  attached  to  a  chin 
strap  and  occipital  band,  which  are  united  just  above  the  ears.  For 
children  a  weight  of  three  pounds  attached  to  each  of  these  usually 
suffices  to  tire  the  muscles  and  prevent  serious  deformity.  The  child 
is  kept  lying  down  in  this  way  for  some  months  (probably  six  as 
a  minimum),  and  certainly  until  the  pain  has  ceased.  It  may  then 
be  possible  to  arrange  for  the  application  of  a  suitable  jacket  or  brace, 
and  in  this  the  child  may  be  allowed  to  walk  about  until  the  disease 
is  absolutely  cured. 

(b)  The   use   of  Phelps'  Box    is    specially  valuable  when   treating 


Fig.  340. — Phelps'   Box  without 
THE  Pads. 


Fig.  341. — The  Same  with  the 
Child  in  Position. 


children.  The  child  is  placed  in  a  wooden  box  6  inches  deep 
(Fig.  340),  the  lower  end  of  which  is  divided  into  two  portions,  one 
for  each  leg,  a  suitable  aperture  being  left  at  the  junction  of  the 
divided  parts  for  the  passage  of  the  excreta.  Careful  padding  is 
applied  to  the  whole  of  the  interior,  and  the  child  is  strapped  and 
bandaged  into  this  apparatus  (Fig.  341),  and  kept  there  for  a  period 
varying  from  six  to  twelve  months.  The  whole  trunk  is  thus 
immobilized,  and  the  child  can  be  carried  about  in  his  box,  and 
taken  into  the  open  air.  Extension  can  also  be  made,  if  neces- 
sary, by  elastic  accumulators  attached  to  the  head  and  neck,  or  legs. 


73Se 


A  ULASPD^L.  OF  SUSG^ST 


I 


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DISJiAS/iS  01'  TIIR  SI'IUE 


729 


but  above  this  the  patient  must  be  vertical,  so  as  to  extend  the 
spine.  This  is  best  secured  by  suspendinj^  him  by  means  of  a  bridle 
attached  to  the  head  in  a  tripod  or  ji^allows,  and  the  toes  may  be 
allowed  to  touch  the  j:(round.  The  jacket  may  be  reinforced  to  meet 
particular  strains,  and  may  subsequently  be  lightened  by  cutting  out 
unnecessary  portions.  It  must  be  worn  until  all  fjain  and  evidence 
of  active  disease  have  finally  disappeared,  and  after  that  the  patient 
should  be  fitted  with  a  poroplastic  support  for  a  time. 

[e)  Some  surgeons  prefer  to  use  braces  rather  than  a  plaster 
jacket  in  the  treatment  of  Pott's  disease.  Many  such  appliances 
have  been  devised,  but  perhaps  the  most  satisfactory  is  that  known 


Img. 


343. 


-Taylor'",  Bpack  (Postrpior 

VU:.vV). 


Fro,    344. — Taylor's    Brack    (AN'r/ikioh 
View),  with  Leather  Apron  applied. 


as  Taylor's  brace.  For  a  full  description,  larger  textbooks  should  be 
consulted.  It  must  suffice  here  to  point  out  that  it  consists  of  two 
upright  steel  bars  (Fig.  343),  placed  one  on  either  side  of  the 
spines  of  the  vertebra;,  and  carefully  moulded  to  the  back. 
They  are  connected  below  to  a  U-shaped  piece  of  steel  which 
runs  down  on  either  side  to  about  the  level  of  the  middle  of 
the  sacrum,  and  is  secured  below  by  straps  passing  round  the 
thighs  and  groins;  and  above  they  are  attached  to  a  shallower 
U-shaped  steel  frame  wliich  passes  over  the  root  of  the  neck 
and  the  clavicles.  In  front  a  leather  apron  (iMg.  344)  covers  the 
front  of  the  chest  anrl   upfjer  part  of  the  abdomen,  and  is  secured 


730  A  MANUAL  OF  SURGERY 

by  straps  and  buckles  to  the  brace  about  its  centre,  and  to  the 
ends  of  the  upper  U-shaped  cross-piece.  Carefully-fitted  pads  are 
placed  on  either  side  of  the  spine  opposite  the  point  of  greatest 
projection  and  secured  to  the  steel  bars.  They  serve  as  points  of 
pressure  against  the  spine  so  as  to  prevent  or  limit  deformity,  whilst 
at  the  same  time  the  upper  part  of  the  spine  and  the  thorax  is  pre- 
vented from  falling  forwards  and  thus  increasing  the  deformity. 
Should  the  cervical  or  cervico-dorsal  region  be  involved,  a  ring  or 
collar  to  support  and  carry  the  chin  in  a  suitable  position  of  extension, 
and  fixed  by  a  vertical  rod  to  the  brace,  must  be  added  to  the 
apparatus. 

During  the  whole  course  of  treatment,  the  general  condition  of  the 
individual  must  be  carefully  attended  to,  and  suitable  food  and  tonics 
administered.  The  child  should  spend  as  much  time  as  possible  in 
the  open  air,  and  preferably  at  the  seaside.  When  all  symptoms  of 
pain  and  irritation  have  disappeared,  the  patient  may  be  allowed 
gradually  to  get  about  again  with  a  mechanical  support,  and,  indeed, 
this  should  not  be  dispensed  with  for  twelve  months  after  apparently 
complete  recovery. 

The  Treatment  of  the  Chronic  Abscesses  is  always  a  matter  of 
anxiety,  since,  when  once  opened,  they  usually  take  a  considerable 
time  to  heal,  and  if  allowed  to  become  septic  the  prognosis  of  the 
case  is  seriously  affected.  A  general  description  of  the  methods 
employed  has  already  been  given  at  p.  176. 

A  Retropharyngeal  Abscess  should  always  be  dealt  with  from  the 
neck,  as  described  in  Chapter  XXIX. 

A  Dorsal,  Lumbar,  or  Psoas  Abscess  should  be  tapped  with  a  large 
aseptic  trocar  and  cannula,  and  then  irrigated,  injected  with  sterilized 
iodoform  emulsion,  and  afterwards  closed  without  drainage.  Occa- 
sionally a  cure  can  be  obtained  in  this  way  by  one  tapping,  but  only 
when  no  active  disease  is  present,  and  when  the  patient's  general 
health  is  good  ;  more  commonly  the  fluid  will  re-collect,  and  the 
same  process  may  need  to  be  repeated  two  or  three  times.  Sometimes 
the  fluid  finds  its  way  along  the  track  of  the  cannula,  and  a  sinus 
results  ;  such  must  be  dressed  antiseptically  until  cicatrization  has 
occurred.  The  best  position  in  which  to  tap  a  psoas  abscess  is  at  a 
spot  just  internal  to  the  anterior  superior  spine  ;  a  small  incision  is 
made  in  the  skin,  sufficient  to  allow  of  the  insertion  of  the  trocar  . 
through  the  abdominal  muscles  into  the  cavity  of  the  abscess,  but  the 
surgeon  must  make  certain  that  the  intestines  have  been  previously 
displaced  to  one  side.  In  a  large  abscess  no  fear  need  be  entertained 
on  this  score,  since  the  parietal  peritoneum  is  always  pushed  inwards  ; 
but  if  there  is  any  doubt,  the  abdominal  muscles  must  be  cleanly 
divided  through  an  incision  about  i^  inches  long,  so  as  to  expose  the 
abscess  sac  ;  a  sinus  is,  however,  more  likely  to  form  if  this  is  done. 
Should  the  abscess  point  below  Poupart's  ligament,  close  to  the 
saphenous  opening,  it  may  be  necessary  to  deal  with  it  there,  perhaps 
in  addition  to  tapping  it  in  the  usual  place.  It  must  be  remembered 
that  the  femoral  vessels  are  displaced  somewhat  and  stretched  over 


DISEASES  OF  THE  SPINE  731 

the  sac,  and  precautions  should  be  taken  to  prevent  puncture  of  the 
vein,  an  accident  which  has  occurred. 

Some  prefer  to  open  the  abscess  freely,  and  curette  its  interior 
gently  with  a  Barker's  flushing  gouge.  Certainly  by  this  means 
the  tuberculous  membrane  and  debris,  and  spicules  of  bone,  etc.,  can 
be  thoroughly  removed,  but  there  is  also  more  likelihood  of  a 
sinus  remaining.  Personally  we  are  not  in  favour  of  its  use  for  this 
purpose,  and  maintain  that  the  method  which  we  have  advocated 
above  is  better,  since  there  is  less  probability  of  the  wound  becoming 
infected  with  the  tuberculous  material,  and  hence  of  the  formation 
of  a  sinus. 

Occasionally  it  may  seem  advisable  to  open  freely  the  sac  of  a 
psoas  abscess,  and  where  the  disease  originates  in  the  lumbar  verte- 
brae, it  has  been  recommended  by  Sir  F.  Treves  and  others  to  cut 
down  along  the  outer  border  of  the  erector  spinae,  and  deal  with  it 
from  behind.  A  vertical  incision  is  made  in  this  situation,  down  to 
the  transverse  processes,  and  the  lumbar  fascia  and  quadratus  lum- 
borum  are  divided  by  a  transverse  cut  opposite  the  tip  of  one  of  these; 
the  abscess  sac  is  then  easily  reached  and  opened.  The  advantage 
of  this  plan  is  that  the  bodies  of  the  vertebrae  can  be  examined,  and 
even  scraped,  or  sequestra  removed. 

The  Treatment  of  Paraplegia  arising  in  the  course  of  Pott's 
disease  consists  in  maintaining  the  immobilization  of  the  spine  by 
recumbency,  combined  with  weight  extension  applied  to  both  legs. 
At  the  same  time,  extra  precautions  should  be  adopted  in  order  to 
prevent  bedsores  over  points  of  pressure.  Should  any  difficulty  in 
micturition  arise,  regular  catheterism  must  be  adopted,  and  the 
greatest  care  directed  to  the  sterilization  of  the  catheters,  septic 
cystitis  being  always  due  to  external  contamination.  In  such  cases 
the  penis  and  urethra  must  be  purified,  and  the  former  wrapped  in  a 
dry  aseptic  dressing  in  the  intervals  between  catheterism.  Laminec- 
tomy (p.  711)  is  required  in  order  to  relieve  pressure  upon  the  cord 
in  the  following  cases :  (a)  When  septic  cystitis  or  the  existence  of 
deep  bedsores  is  threatening  life ;  (b)  when,  in  spite  of  complete  rest, 
the  symptoms  persist  or  increase,  and  particularly  when  the  paralytic 
phenomena  come  on  rapidly,  suggesting  the  rupture  of  an  abscess  or 
displacement  of  a  fragment  of  bone  ;  (c)  when  paraplegic  symptoms 
manifest  themselves  late  in  the  case,  and  are  possibly  due  to  a 
development  of  fibro-cicatricial  tissue  outside  the  membranes  (peri- 
pachymeningitis), (d)  Finally,  whenever  the  tuberculous  process 
mainly  affects  the  neural  arches,  there  is  no  reason  for  not  treating  it 
by  operation,  if  necessary. 

III.  Syphilitic  Disease  of  the  spine  develops  in  the  shape  of  gum- 
mata,  commencing  beneath  the  periosteum  which  covers  the  bodies  ; 
it  is  of  unfrequent  occurrence,  and  gives  rise  to  symptoms  somewhat 
similar  to  those  of  tuberculous  caries,  from  which  the  diagnosis  is  not 
always  easy,  apart  from  the  history  and  its  reaction  to  treatment.  It 
usually  occurs  in  adults,  and  is  said  to  affect  mainly  the  cervical 
vertebrse  (Tubby) ;    cases  have  been  recorded  in  which  a  gumma 


732  A  MANUAL  OF  SURGERY 

opened  into  the  pharynx,  and  portions  of  bone  were  discharged  there- 
from and  expectorated.  The  co-existence  of  a  syphiHtic  history  and 
of  specific  lesions  elsewhere  may  help  one  in  coming  to  a  decision  as 
to  the  nature  of  the  affection. 

Treatment  consists  in  the  administration  of  suitable  anti-syphilitic 
drugs,  and  in  the  use  of  a  spinal  support. 

IV.  Rheuinatic  Spondylitis  is  a  condition  occasionally  met  with 
arising  from  the  same  causes,  and  associated  with  much  the  same 
phenomena  as  rheumatism  elsewhere.  It  may  involve  either  the 
ligamentous  or  muscular  tissues,  or  may  attack  the  intervertebral 
joints.  Any  part  of  the  spine  is  involved,  but  perhaps  the  most 
marked  features  are  presented  in  the  cervical  region.  Considerable 
impairment  in  the  movements  of  the  head  is  then  produced,  and  the 
neck  may  be  laterally  deflected,  somewhat  simulating  torticollis.  If 
untreated,  adhesions  form  between  the  bones,  and  the  loss  of  move- 
ment may  be  permanent.  Considerable  pain  of  a  neuralgic  type, 
due  to  implication  of  or  pressure  upon  the  nerve-roots,  is  usually 
experienced.  The  treatment  is  of  an  ordinary  anti-rheumatic  nature, 
combined,  perhaps,  with  the  use  of  a  support. 

The  so-called  Gonorrhceal  Rlieumatism  also  affects  the  spine 
occasionally,  and  brings  about  much  the  same  results. 

V.  Spondylitis  Deformans  is  the  term  applied  to  a  condition  of 
the  spine,  which  results  in  rigidity  and  kyphosis.  It  is  seen  most 
frequently  in  old  people,  who  become  bent  and  shorter  than  for- 
merly ;  but  it  also  develops  in  those  who  have  had  to  follow  laborious 
occupations,  especially  if  in  the  bending  position,  and  hence  is  not 
uncommon  in  country  workhouses  and  infirmaries  amongst  those 
who  have  had  to  live  and  work  in  the  fields.  It  is  more  or  less 
akin  to  osteo-arthritis,  and  characterized  by  very  similar  anatomical 
changes.  The  spine  is  stiff  and  rigid  (hence  the  name  '  poker-back ' 
sometimes  applied  to  it),  and  this  results  from  absorption  of  the 
intervertebral  discs,  from  synostosis  of  the  vertebral  bodies,  some- 
times with  the  formation  and  interlocking  of  osteophytes,  and  especi- 
ally from  ossification  of  the  spinal  ligaments.  Pain  is  sometimes, 
but  not  invariably,  a  marked  feature  of  the  case,  and  is  then  due  to 
irritation  of  nerve-roots.  A  large  portion  of  the  spine  is  usually 
involved,  and  marked  kyphosis  is  the  result.  Two  chief  varieties 
have  been  described,  but  it  is  likely  that  they  are  merely  modifica- 
tions of  the  same  process  ;  (a)  Von  Bechterew's  variety  is  one  in 
which  the  upper  cervical  and  dorsal  regions  are  mainly  involved, 
producing  a  limited  kyphosis,  with  flattening  of  the  chest  and  fixation 
of  the  ribs.  In  many  of  these  cases  evidences  are  present  of  de- 
generative changes  in  the  posterior  columns  of  the  cord  and  of 
irritation  of  the  nerve-roots,  (b)  The  Striimpell- Marie  type,  some- 
times known  as  spondylose  rhizomelique,  is  characterized  by  the  affec- 
tion first  attacking  the  lower  portion  of  the  spine,  but  it  also  involves 
the  hip  and  shoulder-joints.  In  both  forms  there  is  a  gradual  ex- 
tension of  the  process  through  the  whole  length  of  the  column,  and 
finally  it  attacks  the  articulations  between  the  ribs  and  the  verte- 


DISEASES  OF  THE  SPINE  733 

brse ;  when  these  become  fixed,  the  respiratory  movements  are 
considerably  impaired,  and  hence  death  is  hkely  to  ensue  from 
pulmonary  mischief.  Treatment  must  follow  along  the  lines  laid 
down  for  osteo-arthritis. 

Tumours  of  the  Spine  are  usually  malignant  in  character,  and  most  commonly 
secondary  to  cancer  or  sarcoma  elsewhere.  Simple  tumours,  such  as  chon- 
droma, osteoma  and  hydatid  cysts,  do  occur,  as  also  primary  sarcoma.  The 
chief  symptoms  are  severe  and  localized  pain,  which  is  constant,  and  unrelieved 
by  rest  in  the  recumbent  posture,  together  with  early  excurvation  and  paraplegia. 
Deformity  is,  however,  by  no  means  constant.  Neuralgic  pain  and  motor 
spasms,  due  to  involvement  of  the  nerve  roots,  may  considerably  aggravate  the 
patient's  sufferings.  These  phenomena  manifesting  themselves  in  an  adult  should 
always  suggest  the  presence  of  a  morbid  growth,  and  the  more  rapid  the  onset, 
the  more  likely  is  a  diagnosis  of  malignant  disease.  Treatment  necessarily  is 
but  rarely  feasible,  although  an  exploratory  operation  is  quite  justifiable  if  the 
disease  is  primary  and  the  patient  not  profoundly  cachectic. 

Tumours  of  the  Spinal  Cord  and  Membranes  develop  in  several  situations,  and 
tbe  symptoms  are  thereby  somewhat  modified.  (a)  Outside  the  spinal  dura. 
Lipoma  and  sarcoma  are  here  most  often  seen,  and  the  symptoms  of  cord 
pressure,  such  as  loss  of  power  and  sensation,  are  preceded  by  those  of  spinal 
irritation,  e.g.,  neuralgic  pain,  increased  on  movement,  and  are  often  limited  for 
some  time  to  one  side.  Multiple  neuro-fibromata  of  the  nerve  roots  are  by  no 
means  uncommon,  (b)  They  may  grow  from  the  inner  aspect  of  the  dura  mater,  and 
thus  produce  symptoms  of  cord  pressure  and  meningeal  irritation  concurrently. 
Sarcoma,  endothelioma,  fibroma  and  gumma,  are  the  commonest  forms  of 
neoplasm  in  this  situation,  (c)  From  the  spinal  cord  itself,  myxoma,  psammoma, 
and  sarcoma  may  originate.  The  symptoms  are  those  of  paraplegia  combined 
with  some  localized  and  referred  pain  or  tenderness,  and  either  bilateral  from 
the  start,  or  sometimes  of  the  crossed  type,  anaesthesia  being  marked  on  one  side 
of  the  body,  and  paralysis  and  hypersesthesia  on  the  other — i.e.,  on  the  side  of 
the  tumour.  Left  to  themselves,  patients  suffering  from  any  of  these  growths 
are  certain  to  die,  and  hence  an  exploratory  laminectomy,  with  a  view  to  removal 
of  the  growth,  if  practicable,  is  always  indicated  when  a  diagnosis  has  been 
effected.  The  possibility  of  the  disease  being  syphilitic  in  origin  must  not  be 
overlooked,  and  hence  a  preliminary  thorough  course  of  iodide  of  potassium  and 
mercury  should  always  be  instituted  before  operating.  The  results  hitherto 
obtained  have  been  distinctly  encouraging,  although  many  of  the  cases  are  left 
till  too  late,  and  the  mortality  is  certain  to  be  high. 

The  only  inflammatory  disease  of  the  cord  which  need  be  alluded  to  here  is 
one,  the  results  of  which  have  already  been  mentioned  constantly  in  the  chapter 
dealing  with  the  deformities  of  the  body  (Chapter  XVIII.),  viz.,  Infantile 
Paralysis.  This  condition  is  due  to  an  inflammation  (certainly  infective,  although 
the  nature  of  the  organism  is  somewhat  doubtful)  of  the  anterior  cornua  of  the 
gray  substance  of  the  cord  (anterior  polio-myelitis) ,  as  a  result  of  which  the  multi- 
polar ganglion  cells  situated  therein  are  destroyed.  Several  members  of  a  family 
may  be  affected  at  the  same  time.  The  symptoms  come  on  abruptly,  and  are 
often  introduced  by  a  short  febrile  attack  ;  paralysis  shows  itself  at  once,  and 
quickly  attains  its  maximal  proportions,  being  usually  followed  by  a  certain 
amount  of  recovery.  The  portions  that  remain  paralyzed  early  lose  their 
nutrition,  owing  to  the  destruction  of  their  trophic  ganglionic  centres,  and 
become  cold  and  bluish  in  colour ;  finally,  deformities  due  to  the  unbalanced 
action  of  opposing  groups  of  healthy  muscles  may  appear,  whilst  the  development 
and  growth  of  the  affected  limbs  are  impaired.  The  distribution  of  this  affection 
is  very  variable,  but  speaking  generally,  the  legs  are  most  commonly  affected, 
the  lower  halves,  and  not  the  upper,  being  mainly  involved  ;  various  forms  of 
talipes  may  result  therefrom,  as  also  weak  and  flail-like  conditions  of  the  knee 
and  ankle.  When  the  thigh  is  included,  the  quadriceps  extensor  and  adductors 
are  usually  picked  out.     In  the  arm  the  deltoid  is  most  often  paralyzed,  and  after 


734  A  MANUAL  OF  SURGERY 

this  the  muscles  on  the  extensor  side  of  the  fore-arm,  excluding  the  supinator 
longus.  The  face  and  neck  are  rarely  involved,  but  the  abdominal  and  back 
muscles  may  be  attacked.  The  Treatment  in  the  early  stages  is  directed  towards 
improving  the  general  health,  and  maintaining  the  nutrition  of  the  affected 
muscles  as  far  as  possible  by  electricity  and  massage.  In  the  later  stages,  when 
deformed,  or  weak  and  flail-like,  limbs  have  resulted,  various  means  may  be 
adopted  in  order  to  improve  the  functions  of  the  part,  (a)  Mechanical  support  is 
often  needed,  and  this  must  be  carefully  regulated,  in  order  to  assist,  and  not  to 
hamper,  the  movements  of  the  individual  by  its  unnecessary  weight.  In  para- 
lytic talipes,  irons  fixed  to  the  boots,  and  rising  above  the  knee,  or  even  some- 
times running  up  to  the  pelvis,  are  frequently  required,  (b)  Tenotomy,  or  division 
of  muscles  or  fasciae,  may  also  be  needed  in  certain  deformities,  {c)  Tenoplasty, 
or  the  grafting  of  a  healthy  tendon  into  a  paralyzed  one,  has  been  occasionally 
utilized,  as  also  the  transplantation  of  the  bony  attachments  so  as  to  put  the 
relaxed  and  weak  muscles  on  the  stretch  (p.  421).  {d)  Arthrodesis,  or  the  fixation 
of  joints,  is  a  useful  proceeding  under  circumstances  where  the  unnatural  mobility 
is  difficult  to  control,  or  would  necessitate  considerable  increase  in  the  weight  of 
the  apparatus  required,  or  where,  from  the  poverty  of  the  patient,  the  apparatus 
cannot  be  obtained.  It  is  especially  serviceable  in  cases  where  two  joints  in  a 
limb  are  flail-like,  one  of  which  may  then  be  ankylosed  with  advantage.  The 
operation  consists  in  a  modified  excision,  the  cartilage  alone  being  sawn  or 
scraped  from  the  ends  of  the  bones,  but  it  must  always  be  remembered  that  the 
reparative  activity  in  paralyzed  limbs  is  small,  {e)  Where  the  whole  limb  is 
hopelessly  paralyzed  and  a  great  inconvenience  to  the  patient,  amputation  is  often 
the  best  practice.  In  the  lower  extremity,  when  the  knee  and  ankle  are  both 
powerless  and  flail-like,  arthrodesis  of  the  knee  and  removal  of  the  foot  by  a 
Syme's  amputation  will  often  provide  the  patient  with  a  serviceable  limb. 


CHAPTER  XXV. 
AFFECTIONS  OF  THE  SCALP  AND  CRANIUM. 

Injuries  of  the  Scalp. 

Wounds  of  the  scalp  are  produced  either  by  sharp  or  blunt  instru- 
ments, by  falls  on  the  head,  or  by  gunshot  injuries.  From  the 
tenseness  of  the  scalp  over  the  cranium,  it  often  happens  that  a  blunt 
weapon,  such  as  a  policeman's  truncheon,  will  cause  a  wound  nearly 
as  cleanly  cut  as  if  it  had  been  made  with  a  sharp  instrument.  The 
depth  to  which  the  injury  extends  is  a  most  important  element  in 
these  cases,  and  so  long  as  it  is  superficial  to  the  occipito-frontalis 
aponeurosis,  but  little  harm  is  done  ;  if,  however,  the  layer  of  loose 
cellular  tissue  between  the  aponeurosis  and  the  pericranium  (the 
'  dangerous  area ')  is  opened  up  and  infected,  cellulitis  (p.  79)  is 
likely  to  ensue.  The  superficial  extent  of  the  wound  is  a  matter  of 
little  moment,  since  the  vascular  supply  is  so  good  that  sloughing  is 
uncommon  ;  a  large  portion  of  the  scalp  may  be  torn  and  bruised, 
and  yet,  if  it  is  carefully  Avashed  and  rendered  aseptic,  there  is  every 
probability  that  it  will  retain  its  vitality. 

Treatment. — Effective  purification  is  of  the  first  importance  in 
these  cases.  The  hair  should  of  course  be  cut  away  from  the  neigh- 
bourhood of  the  wound,  which  is  well  bathed  with  Lister's  strong 
mixture.  The  edges  should  be  excised  if  badly  bruised,  or  if  dirt  is 
ground  into  them.  The  iodine  method  of  gaining  asepsis  (p.  272)  is 
particularly  useful  in  injuries  of  this  nature,  and  may  limit  the  extent 
of  skin  requiring  to  be  shaved.  Stitches  are  introduced  to  draw 
the  parts  together,  and  for  choice  are  of  a  non-absorbent  variety, 
e.g.,  horsehair.  A  drainage-tube  may  be  employed  if  necessary. 
Haemorrhage  from  the  scalp  is  often  severe,  owing  to  the  density  of 
the  tissues,  which  prevents  contraction  and  retraction  of  the  divided 
vessels.  For  a  similar  reason  it  is  sometimes  difficult  to  secure  them 
by  ligature,  and  a  suture  must  then  be  passed  under  the  vessel  in 
such  a  way  as  to  control  it. 

Contusions  of  the  scalp  may  occur  without  solution  of  continuity  of 
the  surface,  and  result  in  the  formation  of  bruises  or  haematomata. 
A  similar  condition  is  found  in  new-born  infants  ;  it  is  due  either  to 
pressure  or  injury  to  the  head  during  its  passage  through  the  mother's 
.  pelvis,  or  to  the  compression  of  obstetric  instruments.  Three  varieties 
of  the  so-called  cephal-h^matoma  have  been  described,  viz. :  (a)  the 
Superficial,  which,  confined  to  the  dense  subcutaneous  tissue,  is 
necessarily  small  and  limited,     (b)  The  Subaponeurotic  occupies  the 

735 


736  A  MANUAL  OF  SURGERY 

loose  tissue  under  the  aponeurosis,  and  is  only  limited  by  the  attach- 
ments of  this  structure.  It  forms  a  large,  soft,  fluctuating  swelling, 
upon  which  the  scalp  appears  to  float,  bagging  down  over  the  eyes 
or  occiput.  It  is  often  due  to  fracture  of  the  underlying  bone,  (c)  The 
Subpericranial  is  limited  by  the  pericranium  dipping  down  into  the 
sutures  around  the  bone  with  which  it  is  connected.  Most  com- 
monly it  forms  over  one  of  the  parietal  bones  in  infants,  presenting 
a  soft,  fluctuating  swelling,  which  soon  gains  an  indurated  margin 
owing  to  a  deposit  of  fibrin,  and  in  this  condition  may  simulate  a 
depressed  fracture  of  the  skull,  inasmuch  as  the  cup-like  fluid  centre 
allows  the  finger  to  sink  in  and  touch  bone  below.  It  is  not  difficult 
to  recognise,  however,  since  the  indurated  margin  can  be  readily 
indented  by  the  finger,  whilst  the  edge  is  definitely  raised  above  the 
surface  of  the  cranium,  and  hence  the  sensation  of  depression  of 
bone  felt  through  the  fluid  is  only  apparent.  In  old-standing  cases 
ossification  of  the  walls  of  this  cavity  has  even  been  known  to  occur. 
Treatment. — All  that  is  required  is  the  application  of  evaporating 
lotions.  There  is  hardly  ever  any  need  to  lay  open  or  drain  these 
swellings  unless  underlying  mischief  is  present. 

Diseases  of  the  Scalp. 

It  would  involve  a  needless  amount  of  repetition  to  mention  and 
describe  in  detail  all  the  many  conditions  which  may  be  met  with  in 
the  hairy  scalp,  and  therefore  it  is  only  necessary  to  deal  with  those 
which  are  of  the  greatest  importance. 

Suppuration  is  of  common  occurrence,  arising  mainly  from  external 
infection,  but  being  occasionally  due  to  disease  of  the  subjacent  bones. 
The  extent  of  the  abscesses  is  limited  by  the  same  anatomical  features 
as  obtain  in  connection  with  haemorrhage.  Thus,  a  suhctitaneons 
abscess  is  necessarily  small  in  size,  owing  to  the  density  of  the  tissues 
in  which  it  is  located  ;  it  arises  most  frequently  as  a  result  of  eczema 
or  impetigo,  and  is  often  due  to  the  presence  of  pediculi,  or  to  the 
action  of  irritants  used  in  the  cure  of  ringworm.  A  subaponeurotic 
abscess  usually  results  from  a  septic  penetrating  wound,  and  is 
associated  with  cellulitis.  A  subpericraniat  abscess  is  rarely  seen 
except  in  connection  with  injury  or  disease  of  the  bony  calvarium ; 
the  pus  is  limited  to  the  affected  portion  of  bone. 

Erysipelas  and  Cellulitis  have  been  described  elsewhere  (pp.  79 
and  122). 

Tumours  occurring  in  and  under  the  scalp  may  be  considered 
according  to  whether  or  not  they  pulsate. 

I.  Pulsating  Tumours  of  the  Scalp  arise  from  three  distinct  sources: 

I.  They  may  be  of  Extracranial  origin,  and  then  are  mainly  asso- 
ciated with  the  superficial  bloodvessels,  (a)  Ordinary  aneurisms  of 
traumatic  origin  are  not  uncommonly  seen  ;  they  rarely  attain  any 
considerable  size,  and  are  readily  dealt  with  by  excision,  {b)  Arterio- 
venous wounds  give  rise  either  to  an  aneurismal  varix  or  to  a  varicose 
aneurism.  They  usually  involve  the  temporal  trunk,  and  their 
symptoms  and  treatment  require  no  special  notice,     (c)  A  curious 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  737 

dilated  and  tortuous  condition  of  one  of  the  scalp  arteries,  most  often 
the  temporal,  is  occasionally  seen,  and  is  known  as  an  arterial  varix ; 
it  may  be  treated  by  complete  excision,  {d)  A  ncBVUs  situated  over 
the  anterior  fontanelle  may  derive  a  communicated  impulse  from  the 
subjacent  dura.  It  has  no  special  features  apart  from  this,  and  is  to 
be  treated  in  the  same  way  as  other  naevi  of  the  scalp,  viz.,  by  excision 
or  electrolysis,  {e)  A  much  more  serious  and  interesting  phenomenon 
than  any  of  the  others  is  that  known  as  a  cirsoid  aneurism. 

Cirsoid  Aneurism  is  more  frequently  met  with  in  the  scalp  than 
elsewhere,  and  mainly  involves  the  auriculo-temporal  region,  but  may 
also  spread  in  all  directions,  even  downwards  into  the  neck.  The 
origin  is  very  uncertain ;  in  a  few  cases  it  has  been  preceded  by  a 
nsevus,  and  sometimes  there  is  a  history  of  injury.  A  tumour 
of  greater  or  less  size  is  seen  under  the  skin,  consisting  of  distended, 
tortuous,  pulsating,  bluish-looking  vessels,  the  arteries  opening 
directly  into  cavernous  spaces  without  the  intervention  of  capillaries ; 
it  is  easily  emptied  by  pressure,  but  quickly  refills,  owing  to  the 
abundant  arterial  supply.  The  rate  of  growth  is  variable,  and  the 
patient  often  complains  of  headache  and  giddiness  ;  the  skin  becomes 
thin  and  atrophic,  the  hair  falls  out,  and  finally  ulceration  may  occur, 
the  patient  probably  dying  from  haemorrhage.  The  Treatment  is 
eminently  unsatisfactory,  complete  excision  being  the  ideal  cure, 
but  this  in  the  worst  cases  is  impracticable.  If  it  be  attempted,  the 
incisions  should  be  made  wide  of  the  disease,  and  the  supplying 
vessels  secured,  if  possible,  between  double  ligatures  before  dividing 
them ;  if  this  precaution  is  not  adopted,  frightful  haemorrhage  may 
result.  It  is  necessary  in  some  cases  to  deal  with  the  tumour  in 
separate  segments,  allowing  time  between  the  operations  for  the 
patient  to  recover  from  the  loss  of  blood.  Probably  electrolysis,  com- 
bined with  ligature  of  the  main  nutrient  vessels,  holds  out  the  best 
chance  of  success.     (For  methods  of  electrolysis,  see  p.  355.) 

2.  The  chief  pulsating  tumours  of  Cranial  origin  are  as  follows : 
{a)  Sarcomata  arising  from  beneath  the  pericranium  or  from  the 
diploe  (p.  743).  {b)  Secondary  nodules  of  cancer  may  develop  in 
the  diploic  tissue  ;  those  due  to  the  form  known  as  thyroid  cancer 
are  specially  noted  for  their  pulsation,  (c)  Aneurism  by  anastomosis 
occasionally  develops  in  the  cancellous  tissue  of  the  diploe,  and  gives 
rise  to  pulsation,  which  can  be  felt  when  the  bones  are  sufficiently 
expanded  and  atrophied  (p.  608). 

3.  Pulsating  swellings  of  Intracranial  origin  include  the  following 
conditions:  Encephalocele  (p.  738);  traumatic  cephal- hydrocele 
(p.  744) ;  hernia  cerebri  (p.  792) ;  and  sarcoma  of  the  dura  mater 

(P-  743)- 

II.  Non-Pulsating  Tumours  of  the  Scalp. — Almost  any  of  the 
ordinary  connective-tissue  or  epithelial  growths  may  occur,  but  the 
following  are  the  more  important. 

Papillomata  are  not  uncommon  in  the  form  of  small  hard  warty 
outgrowths,  giving  rise  to  but  little  inconvenience,  unless  situated  on 
some  spot  where  the  hat  rests.     They  are  easily  removed. 

47 


738  A  MANUAL  OF  SURGERY 

Epithelioma  also  occurs,  arising  either  from  an  irritated  papilloma, 
or  possibly  in  connection  with  a  sebaceous  cyst.  As  soon  as  a 
diagnosis  is  made,  the  growth  should,  if  possible,  be  extirpated,  and 
the  resulting  raw  surface  may  be  either  left  to  granulate,  or  dealt 
with  by  Thiersch's  method  of  skin-grafting. 

Fibroma  may  occur  in  the  shape  of  a  localized  development  of 
hard  fibrous  tissue,  and  often  grows  on  the  forehead  where  the  hat 
crosses  it ;  or  it  may  attain  much  larger  dimensions,  involving 
perhaps  half  the  scalp,  and  giving  rise  to  an  irregular  nodulated 
outgrowth  of  soft  fibro-cellular  tissue,  which  has  sometimes  been 
termed  a  pachydermatocele  (p.  205),  and  is  then  of  neuro-fibromatous 
origin.     Either  form  may  be  dealt  with  by  excision. 

Sarcomata  of  various  types  involve  the  scalp,  presenting  as  large 
fleshy  tumours  which  may  pulsate  or  fungate.  They  usually  develop 
rapidly,  but  are  limited  for  some  time  by  the  aponeurosis  of  the 
occipito-frontalis;  glandular  infection  is  uncommon.  In  their  removal 
it  is  useless  to  attempt  to  save  the  aponeurosis  ;  the  whole  thickness 
of  the  scalp  must  be  sacrificed,  and  the  incisions  should  be  wide  of 
the  growth.  The  wound  is  allowed  to  granulate,  or  covered  in  with 
Thiersch  grafts. 

Dermoid  Cysts  are  by  no  means  uncommon  in  this  region,  their 
favourite  situation  being  near  the  outer  canthus,  the  temple,  or  the 
root  of  the  nose.  For  a  general  description,  see  p.  222.  They  do 
not  attain  any  great  size,  and  may  not  become  evident  till  after 
puberty.  The  underlying  bone  is  often  hollowed  out  from  a  defective 
development  of  the  mesoblastic  tissues  around  them  ;  and  a  congenital 
opening  may  even  exist  through  which  a  narrow  neck  passes,  bringing 
the  cyst  into  direct  connection  with  the  dura  mater.  The  treatment 
consists  in  removal ;  but  it  is  advisable  to  delay  this  till  after  puberty 
if  the  tumour  seems  at  all  fixed  to  the  skull,  or  if  the  bone  is  felt  to 
be  defective  beneath  it,  as  in  such  cases  the  communication  with  the 
interior  of  the  cranium  is  often  shut  off  by  that  time. 

Sebaceous  Cysts  (p.  407)  find  their  most  usual  situation  in  the 
scalp,  where  they  not  only  are  frequently  multiple,  but  also  may 
reach  a  considerable  size.  Their  removal  is  best  accomphshed  by 
transfixion,  squeezing  out  the  contents,  and  picking  out  the  cyst 
wall  by  a  pair  of  forceps  without  dissection.  The  wound  is  closed 
by  one  or  two  stitches. 

Sebaceous  Adenoma  is  most  frequently  seen  on  the  scalp  (p.  408). 

Affections  of  tbe  Cranium. 

I.  Congenital  Affections. 

I.  Meningocele,  Encepbalocele,  and  Hydrencepbalocele  consist  of  a 
protrusion  of  the  dura  mater,  with  or  without  part  of  the  brain, 
through  an  opening  in  the  cranial  wall.  They  are  due  to  defective 
intrusion  of  the  mesoblastic  tissues  outside  the  primitive  cerebral 
vesicle,  so  that  part  of  the  brain  or  its  membranes  remains  superficial 
and  extracranial.  They  occur  most  frequently  at  the  root  of  the 
nose,  and  in   the   occipital    region  (Fig.    345),   occasionally  at  the 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM 


739 


Fig.  345. — Congenital  Encephalocele  of  the 
Occipital  Region.     (Tillmanns.) 


anterior  or  lateral  fontanelle,  or  at  the  base  of  the  skull.  A  Menin- 
gocele is  simply  a  protrusion  of  the  brain  membranes  containing 
cerebro-spinal  fluid.  It  forms  a  soft,  rounded,  fluctuating  swelling, 
attached  to  the  skull  by  a  base  of  greater  or  less  size,  and  covered  by 
skin,  which  may  be  thick  and  healthy,  or  thinned,  bluish,  and  trans- 
lucent when  the  tumour 
is  large.  The  vessels 
present  in  the  skin  are 
often  dilated  and  naevoid. 
It  increases  in  size  and 
tension  on  any  expira- 
tory effort,  such  as  cough- 
ing or  crying,  and  it  may 
be  partially  reducible, 
thus  allowing  the  mar- 
gins of  the  opening  m 
the  cranium  to  be  de- 
fined. Symptoms  of 
cerebral  compression, 
convulsions,  etc.,  are 
likely  to  be  produced  by 
such  manipulation.  An 
Encephalocele  is  a  similar 

type  of  tumour,  but  contains  brain  substance,  and  pulsates  almost 
synchronously  with  the  heart ;  it  is  most  commonly  situated  at  the 
back  of  the  skull.  A  Hydrencephalocele,  or  Meningo-encephalocele,  is 
a  condition  in  which  the  tumour  contains  both  brain  substance  and 
fluid.  Two  varieties  have  been  described — one  in  which  there  is  a 
small  protrusion  of  the  brain  associated  with  an  ordinary  meningo- 
cele, and  the  other  in  which  the  fluid  is  contained  in  a  cavity  com- 
municating with  one  of  the  ventricles,  and  covered  by  a  thin  layer 
of  brain  substance.  They  are  usually  of  considerable  size,  con- 
stituting a  type  of  hydrocephalus,  and  are  situated  in  the  occipital 
region,  either  above  the  tentorium,  and  then  possibly  associated  with 
distension  of  the  posterior  cornu  of  one  of  the  lateral  ventricles,  or 
below  that  structure,  the  osseous  defect  extending  in  some  cases  as 
far  as  the  foramen  magnum,  and  a  portion  of  the  cerebellum  being 
within  the  sac. 

The  Prognosis  of  these  conditions  is  exceedingly  grave.  Fortu- 
nately, many  of  the  subjects  are  born  dead,  or  die  soon  after  birth. 
In  the  more  severe  cases,  idiocy  and  microcephaly  are  not  uncommonly 
associated,  whilst  sometimes  true  internal  hydrocephalus  is  present. 
The  protrusion  may  increase  steadily  in  size  and  finally  burst,  causing 
death  by  purulent  meningitis,  or  in  more  favourable  cases  it  may 
remain  stationaxy.  In  a  meningocele,  the  subsequent  growth  of  the 
cranial  bones  may  suffice  to  close  the  communication  between  the 
interior  and  the  tumour,  which  thus  becomes  shut  off,  and  remains 
as  a  cyst-like  swelling,  with  the  base  fixed,  and  without  pulsation  or 
respiratory  impulse. 


740  A  MANUAL  OF  SURGERY 

Treatment.— Most  cases  should  be  left  alone ;  but  if  the  tumour 
is  steadily  increasing  in  size,  aseptic  puncture  and  subsequent  com- 
pression may  hinder  the  process ;  a  pure  meningocele  may  possibly 
be  cured  in  this  way.  Where  the  communication  with  the  skull  is 
small,  it  may  be  feasible  to  excise  the  tumour,  taking  special  care  to 
suture  the  base  securely,  and  attempting  when  practicable  to  make 
good  the  cranial  deficiency  by  osteoplasty. 

2.  In  babies  the  ossification  of  the  bones  may  be  incomplete,  con- 
stituting what  is  known  as  aplasia  cranii  congenita,  and  is  due  to  a 
cachectic  condition  of  the  mother.  Occasionally  a  similar  atrophic 
condition  of  the  bones  may  persist  through  life,  exposing  the  patient 
to  increased  risk  from  injuries  which  otherwise  would  do  but  little 
harm. 

3.  Localized  congenital  atrophy  of  the  bones  is  also  sometimes 
met  with  in  connection  with  dermoid  cysts,  as  mentioned  above. 

II.  Acquired  Aflfections  of  the   skull  are  atrophic,  hypertrophic, 

inflammatory,  or  neoplastic  in  nature. 

Acquired  Atrophy  of  the  skull  occurs  in  many  forms  : 

{a)  Cmniotabes  is  a  condition  met  with  during  the  first  year  of  life, 

usually  as  a  result  of  inherited  syphilis  (p.  589)- 

(b)  Senile  atrophy  may  affect  the  whole  cranium,  which  becomes 
thinned  and  rarefied,  or  it  may  be  localized,  as  pointed  out  by  the 
late  Sir  G.  M.  Humphry,*  to  the  parietal  bones,  constituting  hollow 
depressions  which  extend  antero-posteriorly.  No  symptoms  are 
caused  thereby,  but  the  patient  runs  a  certain  increased  risk  from 
injuries  to  the  head. 

(c)  Localized  loss  of  substance  may  result  from  the  pressure  of 
tumours,  such  as  Pacchionian  bodies  and  aneurisms,  or  from  necrosis, 
or  traumatic  and  operative  lesions.  If  these  are  at  all  extensive,  the 
cerebral  pulsations  can  be  felt  distinctly  through  the  skin.  It  is 
then  advisable  to  provide  the  patient  with  some  guard  to  protect  him 
from  injury.  This  may  be  accomplished  by  means  of  a  metal  plate 
worn  over  the  scalp  ;  but  of  late  years  operative  measures  have  been 
introduced  to  obviate  this.  Autoplasty  is  the  term  applied  to  a  pro- 
ceeding whereby  the  defect  is  closed  by  a  plate  of  bone  removed  from 
the  patient's  own  skull.  A  suitable  scalp  flap  is  turned  down,  and 
then  a  portion  of  the  outer  table  is  chiselled  up  sufficient  in  size  to 
close  the  aperture.  The  pericranium  is  utilized  on  one  side  as  a 
pedicle,  and  by  means  of  this  it  is  stitched  down  into  the  gap,  the 
margins  of  which  have  been  previously  freshened.  By  heteroplasty  is 
meant  a  similar  proceeding  when  the  hole  is  closed  by  a  plate  of  gold, 
platinum,  or  vulcanite,  fixed  by  wires  or  nails  to  the  surrounding 
bone.  The  results  of  these  procedures  have  been  on  the  whole 
satisfactory. 

(d)  Chronic  Internal  Hydrocephalus  is  always  associated  with  atrophy 
and  thinning  of  the  cranium  ;  it  may  be  congenital,  or  may  commence 
early  in  life.     It  is  produced  in  almost  all  cases  by  a  distension  of 

*  Med.-Chir.  Trans.,  1890,  p.  37. 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM 


741 


the  lateral  ventricles  with  fluid,  the  result  of  congenital  malformation 
or  of  inflammatory  affections,  causing  exudation  from  the  choroid 
plexuses,  pressure  upon  the  veins  of  Galen  or  inferior  longitudinal 
sinus,  and  possibly  closure  of  the  foramen  of  Magendie.  The  head 
becomes  more  and  more  distended  (Fig.  346),  the  bones  expanded 
and  thinned,  and  the  sutural  areas  increased,  whilst  the  brain  is  sub- 
jected to  such  pressure  as  may  be  incompatible  with  life.  Fluctuation 
is  distinctly  felt,  and  the  bones  may  crackle  under  the  fingers ;  the 
face  looks  abnormally  small,  and  the  eyes  protrude,  owing  to  the 
depression  of  the  orbital  plates.  Treatment. ^-Tapping  of  the  ventricles 
is  useless,  as  even  if  a 
considerable  amount  of 
the  fluid  is  withdrawn, 
and  elastic  pressure  sub- 
sequently maintained, 
recurrence  is  almost  in- 
evitable. The  only  hope 
is  to  establish  a  free 
communication  between 
the  ventricular  and  sub- 
dural spaces,  so  that  the 
excess  of  fluid  in  the 
ventricles  may  escape  ; 
it  will  be  absorbed  from 
the  subdural  space  as 
soon  as  the  tension  rises 
above  the  intravenous 
pressure.  A  silver  tube 
should  be  inserted  be- 
tween the  two  spaces, 
or  a  tube  of  decalcified 
bone  carrying  a  catgut 
drain  ;  to  be  of  any 
value,  the  operation 
must  be  undertaken  before  the  cerebral  cortex  has  been  so  thinned 
as  to  interfere  with  its  functional  activity. 

(e)  By  Microcephaly  is  meant  a  condition  of  diminished  size  of  the 
cranial  cavity  due  to  premature  ossification  of  the  sutures,  and 
resulting  from  non-development  of  the  brain.  It  is  usually  associated 
with  idiocy,  and  possibly  with  cretinism.  Attempts  have  been  made 
to  relieve  this  by  the  operation  of  linear  craniectomy  or  removal  of 
portions  of  the  cranium,  so  as  to  allow  of  the  expansion  of  the  brain. 
Temporary  improvement  has  followed  in  a  few  cases,  probably  from 
the  individual  attention  given  to  the  patient;  the  final  result  is 
extremely  uncertain,  most  of  the  patients  relapsing  owing  to  the 
contraction  of  the  dense  cicatricial  material  which  replaces  the  bone, 
and  to  the  atrophic  condition  of  the  brain. 

Hypertropliic  Changes  of  the  Skull  result  from  simple  chronic  in- 
flammatory affections,  or  from  injury,  etc.     Special  types  of  enlarge- 


FiG.  34G. — Hydrocephalus. 

(From  photograph,  by  permission  of  Mr.  F.  F. 
Burghard.) 


742  A  MANUAL  OF  SURGERY 

ment  are  seen  in  inherited  syphilis  (p.  589),  rickets  (p.  590),  osteitis 
deformans  (p.  595),  and  acromegaly  (p.  596).  In  leontiasis  ossea 
(p.  814)  the  cranium  becomes  thickened  and  enlarged;  but  the 
cranial  cavity  is  also  encroached  on,  constituting  what  is  known  as 
concentric  hypertrophy,  in  contrast  to  most  of  the  other  forms,  which 
are  eccentric  in  type.- 

Infla,mmatory  Affections  of  the  Cranial  Bones. — The  cranium  is 
liable  to  any  of  the  diseases  which  generally  occur  in  bone. 

1.  Acute  Periostitis,  or  Pericranitis,  is  usually  infective  in  origin, 
following  cellulitis  of  the  scalp ;  it  is  likely  to  result  in  necrosis  of 
the  outer  table. 

2.  Acute  Infective  Osteo-myelitis,  or  acute  necrosis,  consists  of  an 
acute  inflammation  of  the  diploe,  due  to  pyogenic  organisms,  and  either 
following  an  infected  scalp  wound  or  compound  fracture,  infective 
inflammation  of  one  of  the  air-sinuses  or  the  operation  necessary  for 
its  treatment,  or  a  simple  contusion  of  the  bone  in  a  person  of  low 
germicidal  powers.  The  symptoms  and  signs  are  those  generally 
characteristic  of  the  disease,  being  ushered  in  by  a  rigor,  followed  by 
headache,  fever,  and  the  development  of  a  localized  oedematous 
swelling,  known  as '  Pott's  puffy  tumour'  (Fig.  355).  The  pericranium 
is  stripped  up  by  diffuse  suppuration  beneath  it,  and  an  abscess  often 
forms  between  the  bone  and  the  dura  mater.  Necrosis  of  the  whole 
thickness  of  the  skull  is  likely  to  follow,  but  is  usually  limited  by 
the  sutures  to  the  particular  bone  affected.  Pyaemia  and  extension 
of  the  inflammation  to  the  membranes,  venous  sinuses  or  brain,  are 
the  chief  dangers  arising  from  it.  The  prognosis  is  always  grave, 
even  when  early  operative  treatment  is  undertaken ;  apart  from 
operation,  it  is  almost  hopeless.  The  Treatment  consists  in  free 
external  drainage,  together  with  the  removal  of  the  outer  table  to 
enable  the  infected  diploe  to  be  scraped  away,  and  the  parts 
thoroughly  disinfected  with  pure  carbolic  acid.  If  signs  of  subcranial 
suppuration  ensue  (p.  777),  the  inner  table  must  also  be  removed. 

3.  Clironic  Periostitis  of  the  cranium  is  occasionally  met  with  in 
the  form  of  a  node.  It  is  usually  the  result  of  some  long-continu6d 
irritation,  such  as  carrying  baskets  or  weights  on  the  head.  Treh- 
ment  consists  in  the  removal  of  the  irritation,  and  there  is  no  objection 
to  chiselling  away  the  node,  if  necessary. 

4.  Tuberculous  Disease  of  the  cranial  bones  is  not  common  ;  it 
occurs  as  a  primary  phenomenon,  or  is  secondary  either  to  a  cuta- 
neous lesion,  such  as  lupus,  or  perhaps  more  commonly  to  a  menin- 
geal focus.  It  may  start  in  the  periosteum  or  diploe,  leading  to  the 
formation  of  a  node,  or  perhaps  to  expansion  of  the  bone,  and 
followed  by  suppuration  and  caries.  When  of  meningeal  origin, 
there  is  a  considerable  amount  of  erosion  of  the  inner  table,  and 
possibly  some  necrosis  ;  sooner  or  later  the  outer  table  is  perforated 
and  a  subpericranial  abscess  forms.  The  amount  of  mischief  in  the 
outer  table  is  no  criterion  of  the  extent  of  the  disease  within,  and 
hence  very  thorough  exploration  is  necessary.  The  prognosis  in  this 
variety  is  not  good.     The  mastoid  process  and  the  orbital  margin 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  743 

in  the  neighbourhood  of  the  external  angular  process  of  the  frontal 
bone  are  rather  favourite  situations  for  the  disease,  which  is  then 
often  accompanied  by  other  manifestations. 

5.  Syphilitic  Disease  of  the  cranium,  on  the  other  hand,  is  exceed- 
ingly common,  occurring  usually  in  the  tertiary  stage,  and  affecting 
most  frequently  the  frontal  and  parietal  bones.  It  has  been  already 
described  (p.  587). 

Tumours  of  the  Cranial  Bones. — The  chief  Tumours  affecting  the 
calvarium  are  osteomata  and  sarcomata. 

Osteoma  of  the  cranium  occurs  as  a  localized  overgrowth  of 
compact  bone  from  the  outer  surface  of  the  calvarium,  from  the 
inner,  or  from  both.  The  frontal  bone  and  external  auditory  meatus 
are  the  sites  of  election.  If  arising  externally,  a  smooth,  rounded, 
globular  swelling  is  produced,  hard  to  the  touch,  quite  painless,  and 
fixed  to  the  subjacent  bone  by  a  broad  base ;  more  than  one  m.ay 
be  present.  If  the  main  growth  is  internal,  symptoms  of  cerebral 
irritation  or  pressure  may  be  produced.  Osteomata  are  to  be 
distinguished  from  inflammatory  hyperostoses  (usually  of  syphilitic 
origin)  by  their  sharp  limitation,  absence  of  pain,  and  slower 
progress ;  whilst  osteo-sarcomata  are  commonly  rapid  in  growth, 
painful,  and  of  unequal  consistency  in  different  parts.  Treatment  is 
rarel}^  necessary.  Small  growths  may  be  encircled  in  the  crown  of  a 
trephine  and  thus  removed.  Large  ones  must  be  dealt  with  by  a  burr 
driven  by  an  electric  dental  engine,  the  bone  being  divided  just 
outside  the  dense  compact  tissue,  and  thus  the  tumour  is  set  free. 
No  attempt  should  be  made  to  chisel  away  these  growths,  as  serious 
cerebral  concussion  may  follow  the  prolonged  use  of  the  chisel  and 
mallet  against  the  skull. 

Sarcoma  of  the  cranium  originates  either  from  the  pericranium, 
the  diploe,  or  from  the  dura  mater. 

The  extra-  or  peri-cranial  variety  consists  of  a  round  or  spindle- 
celled  tumour  growing  from  the  pericranium,  and  possibly  attain- 
ing a  considerable  size.  It  may  contain  a  certain  amount  of  ossific 
deposit,  or  the  tumour  remains  of  a  soft  consistency,  and  then  often 
pulsates.  The  subjacent  bone  is  sometimes  absorbed,  and  the  dura 
mater  affected  secondarily.     General  infection  of  the  system  follows. 

Central  sarcoma  of  the  cranium  starts  from  the  diploe  as  a  myeloid 
tumour.  It  does  not  grow  so  rapidly  as  the  other  forms  ;  it  is  single, 
and  generally  covered  with  a  layer  of  expanded  bone,  which  gives 
a  sensation  of  eggshell  crackling  to  the  finger.  Later  on  it  involves 
the  dura  mater  and  skin,  and  may  fungate. 

Sarcoma  of  the  dura  mater  may  be  attributed  to  some  injury  to  the 
head,  and  is  characterized  by  the  occurrence  of  severe  cerebral  symp- 
toms— e.g.,  intolerable  localized  headache,  epileptic  fits,  double  vision, 
optic  neuritis,  etc. — prior  to  any  evident  appearance  of  a  tumour. 
Gradually  the  bones  become  expanded  and  perforated,  and  a  soft 
and  exceedingly  vascular  pulsating  growth  is  felt  beneath  the  scalp. 
This  fungates  sooner  or  later,  and  possibly  the  meningeal  cavity  is 
laid  open  by  ulceration,  death  from  septic  meningitis,  cerebral 
compression,  or  exhaustion,  ending  the  chapter. 


744  -  .  ^  MANUAL  OF  SURGERY 

TnatmenL — These  cases  have  usually  gone  too  far  before  being 
recognised.  If  an  early  diagnosis  can  be  arrived  at,  free  removal 
may  be  undertaken  by  trephining  and  the  use  of  the  chisel,  sharp 
spoon,  or  gouge. 

Secondary  Carcinoma  of  the  cranial  bones  is  by  no  means  un- 
common, and  may  follow  cancers  of  the  mamma,  thyroid  body, 
etc.  The  growths  are  usually  small  and  multiple,  and  may  show 
pulsation.     Neuralgia  and  persistent  headache  may  result  from  them. 

III.  Traumatic  Affections  of  the  Cranium. 

Contusions  of  the  Cranial  Bones  apart  from  fracture  may  lead  to 
serious  results,  i.  Many  of  the  inflammatory  conditions  of  bone 
just  described  may  be  originated ;  e.g.,  if  the  patient  is  in  a  condition 
of  low  germicidal  power,  acute  osteo-myelitis  may  follow ;  or  chronic 
sclerosis  and  overgrowth  of  the  bone,  local  or  diffuse,  may  supervene. 
Syphilitic  or  tuberculous  manifestations  may  be  similarly  lighted  up 
if  the  patient  is  the  subject  of  either  of  these  diseases.  2.  In  addition 
to  such  osseous  conditions,  pus  may  form  within  the  cranium  outside 
the  dura  mater  {subcranial  abscess,  p.  777),  and  necessitate  trephining. 
3.  The  dura  mater  may  be  detached  by  a  simple  contusion,  leading 
to  meningeal  haemorrhage  (p.  773).  4.  Any  of  the  cerebral  lesions 
detailed  hereafter  may  be  produced.  Contusions  of  the  cranium 
must  obviously  never  be  treated  lightly,  even  when  they  are  asso- 
ciated with  unbroken  skin  ;  much  more  are  they  serious  when  com- 
pound, owing  to  the  risks  of  mfection. 

Fractures  of  the  Skull  may  be  described  for  convenience  under 
the  following  headings :  Fissured  Fractures  of  the  Vault ;  Fractures  of 
the  Base  (usually  fissured)  ;  and  Depressed  or  Punctured  Fractures. 

I.  Fissured  Fractures  of  the  Vault  are  always  due  to  external 
violence,  direct  or  indirect.  In  the  former  case  the  skull  first  yields 
at  the  injured  spot,  but  the  fissure  may  extend  from  it  for  some 
distance;  in  the  latter  the  fracture  results  from  the  yielding  of  the 
skull  when  compressed  beyond  its  natural  limits  of  elasticity. 

A  simple  fissure  gives  rise  to  no  symptoms  indicating  its  presence 
with  certainty.  There  may  be  some  amount  of  superficial  ecchy- 
mosis,  but  nothing  more  definite.  When  compound,  the  line  of 
fracture  may  be  seen  as  a  red  streak,  or  even  felt  with  the  finger  as 
an  irregular  ridge.  It  consists  of  a  mere  longitudinal  fissure,  or  may 
be  starred ;  if  uncomplicated,  it  is  of  but  little  importance,  and  needs 
nothing  beyond  general  treatment — of  course,  the  greatest  care  being 
taken  to  insure  asepsis.  Occasionally,  however,  an  osseous  growth 
forms  from  protuberant  callus  on  the  inner  aspect  of  the  cranium  at 
the  site  of  fracture,  and  gives  rise  to  traumatic  epilepsy  or  insanity 
(p.  790). 

Traumatic  Cephal-hydrocele  is  the  name  given  to  a  rare  condition 
following  simple  fractures  of  the  vault,  especially  in  children.  It  is 
characterized  by  the  formation  of  a  fluid  swelling  under  the  scalp, 
which  pulsates  synchronously  with  the  heart-beat,  and  has  a  definite 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  745 

impulse  on  any  expiratory  effort ;  it  varies  in  size  from  time  to  time 
and  is  sometimes  partially  reducible.  It  contains  cerebro-spinal  fluid, 
and  communicates  with  either  one  of  the  lateral  ventricles  or  the 
subarachnoid  cavity.  In  one  case  it  was  proved  on  operation  to  be 
connected  with  an  arachnoid  cyst,  due  to  a  localized  subarachnoid 
haemorrhage.  Probably  it  is  wise  to  leave  this  condition  alone, 
although,  if  one  could  be  tolerably  certain  that  the  ventricle  was  not 
affected,  it  might  be  laid  open  and  drained. 

2.  Fractures  of  the  Base  of  tlie  Skull  are  almost  always  fissured, 
only  occasionally  punctured  or  depressed. 

Causes. — (a)  Violence  may  he  directed  to  the  vertex  or  to  some  part  of  the 
cranial  convexity,  as  from  a  blow  or  fall  upon  a  hard  substance.  There 
has  been  a  good  deal  of  discussion  as  to  how  a  fall  on  the  vertex 
causes  fracture  of  the  base.  Two  main  theories  hold  the  field,  each 
being  probably  responsible  for  a  certain  number  of  cases,  (i.)  Aran's 
theory  of  irradiation  maintains  that  a  fracture  of  the  base  is  always 
due  to  direct  extension  of  the  fissure  from  the  injured  vertex,  a  pro- 
position probably  quite  true  in  many  cases,  but  insufficient  to  explain 
all.  (ii.)  A  more  recent  idea,  known  as  the  bursting  or  compression 
theory,  is  based  on  the  fact  that  the  cranium  is  not  a  solid  and  totally 
unimpressionable  body,  but  is  highly  elastic,  as  has  been  proved  by 
the  observation  that  hair  and  even  pieces  of  skin  have  been  found 
nipped  in  a  fissured  fracture  of  the  vault,  which  had  evidently  gaped 
open  and  closed  again.  Severe  compression  necessarily  diminishes 
the  diameter  of  the  skull  along  the  axis  of  greatest  pressure,  making 
it  bulge  in  other  diameters ;  if  this  exceeds  the  limits  of  elasticity  of 
the  bone,  a  fracture  must  result.  The  direction  of  fractures  pro- 
duced in  this  manner  varies.  Most  commonly  the  lines  of  fracture 
are  parallel  to  the  direction  of  the  compressing  force,  the  bone  thus 
bursting  open  along  its  convexity  (fracture  by  bursting) ;  less  fre- 
quently it  gives  way  at  right  angles  to  the  direction  of  the  force 
where  the  bulging  is  greatest  (fracture  by  compression).  Inasmuch, 
however,  as  the  force  is  transmitted  equally  in  ail  directions,  the 
weakest  and  least  elastic  part  is  most  likely  to  give  way,  viz.,  the 
base.  Whether  these  ideas  are  justified  is  a  question  ;  certainly  the 
figures  quoted  by  Phelps*  indicate  that  irradiation  is  responsible  for 
a  very  large  proportion  of  fractures  of  the  base,  {h)  Direct  or  in- 
direct injury  to  the  base  of  the  skull  is  undoubtedly  the  cause  of  a 
certain  number  of  fractures,  and  some  of  these  are  depressed,  and 
not  fissured,  in  character.  Thus,  the  point  of  an  umbrella  or  stick 
may  be  thrust  through  the  upper  wall  of  the  orbit,  or  up  the  nose 
though  the  cribriform  plate  of  the  ethmoid  ;  the  condyle  of  the  jaw 
may  be  driven  through  the  glenoid  cavity  into  the  middle  fossa  by  a 
blow  on  the  chin ;  direct  injury  from  a  fall  or  a  stab  may  penetrate 
the  occipital  bone,  whilst  a  gunshot  wound  in  the  mouth  is  another 
illustration  of  this  kind  of  injury,  {c)  The  impact  or  resistance  of  the 
vertebral  column  against  the  occipital  condyles  produces  fractures  in  the 
posterior  fossa  which  radiate  from  the  foramen  magnum,  and  may 

*  'Traumatic  Lacerations  of  the  Brain.'     London:  Henry  Kimpton  ;   1898. 


746 


A  MANUAL  OF  SURGERY 


even  occasion  a  ring-shaped  fracture  around  it  (Fig.  347).  They 
result  from  faUing  on  the  vertex  into  a  soft  mass — e.g.,  a  bale  of  wool 
— or  by  alighting  from  a  height  on  the  heels  or  nates. 

The  fracture  may  run  in  any  direction,  longitudinal,  oblique,  trans- 
verse, etc.,  according  to  the  direction  of  the  compressing  or  fracturing 
force,  and  it  may  affect  any  part  of  the  base,  either  being  limited  to 
one  of  the  fossae  or  involving  all ;  it  may  follow  the  sutural  lines  in 
part,  but  it  is  no  uncom.mon  thing  to  see  even  the  dense  petrous  bone 
traversed  by  a  fissure  (Fig.  348).  Naturally,  transverse  fractures  are 
more  likely  to  be  limited  to  one  of  the  fossae,  whilst  a  longitudinal 
fissure  may  involve  them  all. 

Some  fractures  of  the  base  of  the  skull  are  simple  in  nature,  but 
the  majority  are  compound.     In  the  anterior  fossa  the  fissure  extends 


Fig.  347. — Fracture  of  the  Base  of  the 
Skull  from  Force  acting  against  the 
Occipital  Condyles,  and  producing 
almost  an  Annular  Fracture  around 
THE  Foramen  Magnum. 


Fig.  348.  —  Transverse  Frac- 
ture across  the  Base  of 
THE  Skull. 


through  the  cribriform  plate  and  nasal  mucosa,  and  then  lays  open 
the  nose ;  or  a  communication  may  be  established  with  the  external 
air  through  a  penetrating  wound  in  the  orbit,  or  through  the  ethmoidal 
or  sphenoidal  sinuses.  In  the  middle  fossa  a  fracture  through  the 
base  of  the  sphenoid  opens  the  roof  of  the  nasopharynx,  or  the  frac- 
ture may  involve  the  tympanic  cavity.  In  the  posterior  fossa  the 
basi-occipital  may  be  broken,  and  the  naso-pharynx  again  opened, 
although  the  fracture  here  is  more  commonly  simple. 

Fractures  of  the  base  of  the  skull,  though  very  serious,  are  by  no 
means  necessarily  fatal,  and  since  the  introduction  of  antiseptic  work 
the  results  have  immensely  improved.  The  main  dangers  to  be 
apprehended  are  :  (i.)  Damage  to  the  base  of  the  brain,  including  the 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  747 

pons  and  medulla,  especially  in  cases  where  the  foramen  magnum  is 
splintered  from  the  impact  of  the  spine  against  the  condyles ;  (ii.) 
haemorrhage  arising  either  from  the  venous  sinuses,  or  from  the 
meningeal  or  cerebral  arteries;  and  (iii.)  infective  meningitis,  due  to 
the  fact  that  the  injury  not  only  fractures  the  bones,  but  also  lays 
open  the  dura  mater,  a  grave  addition  to  a  compound  fracture. 

The  Signs  of  a  fractured  base  are  sometimes  exceedingly  equivocal, 
but  for  convenience  may  be  arranged  under  four  heads : 

(i)  Signs  of  severe  cerebral  mischief,  such  as  concussion  of  the  brain 
and  prolonged  unconsciousness.  This  is,  however,  by  no  means 
always  present ;  thus,  in  a  case  we  had  in  hospital  some  years  back, 
the  patient  was  capable  of  going  about  his  work  for  ten  days  after 
the  accident. 

(2)  Hmnorrhage  manifests  itself  in  various  directions,  according  to 
the  situation  of  the  fracture. 

In  the  anterior  fossa  there  may  be  free  bleeding  from  the  nose,  owing 
to  the  fracture  extending  through  the  cribriform  plate  of  the  ethmoid ; 
but  a  portion  of  the  blood  may  pass  backwards  into  the  pharynx,  and, 
being  swallowed,  is  perhaps  subsequently  vomited.  More  often,  how- 
ever, the  line  of  fracture  runs  across  the  roof  of  the  orbit,  causing 
escape  of  blood  into  the  areolar  tissue  of  this  cavity.  The  ecchymosis 
shows  itself  as  a  gradually  developing  subcutaneous  distension, 
involving  the  lower  lid,  bluish-purple  in  colour  at  first,  but  passing 
later  through  the  other  stages  of  a  bruise ;  there  is  probably  no  con- 
tusion of  the  skin,  as  in  the  ordinary  black  eye,  which  is  at  first 
reddish-purple  ;  the  ocular  conjunctiva  is  considerably  involved,  but 
the  effusion  rarely  extends  above  the  cornea,  and  its  posterior  limits 
cannot  be  seen.  The  bleeding  usually  arises  from  laceration  of  the 
dura  mater  and  bone,  but,  when  abundant,  may  come  from  the 
cavernous  sinus,  and  the  eye  may  even  be  pushed  forwards  (proptosis) ; 
in  some  cases  pulsation  is  to  be  felt  within  the  orbit,  and  then  a 
traumatic  orbital  aneurism  or  aneurismal  varix  is  present. 

In  the  middle  fossa  the  blood  may  enter  the  nose  or  mouth,  a  part 
being  swallowed,  but  more  commonly  it  escapes  from  the  ears.  If 
abundant,  it  probably  comes  from  one  of  the  vascular  channels  at  the 
base  of  the  brain  ;  but  if  only  slight  in  amount  and  of  short  duration, 
it  may  be  induced  by  any  of  the  following  lesions,  as  well  as  by  a 
fractured  base,  viz. :  (a)  A  simple  rupture  of  the  membrana  tympani ; 
{b)  separation  of  the  cartilage  of  the  pinna,  with  tearing  of  the  lining 
of  the  external  meatus  ;  (c)  fracture  of  the  anterior  and  lower  part  of 
the  tympanic  plate,  as  by  a  blow  on  the  jaw,  which  drives  the  condyle 
forcibly  against  it. 

In  the  posterior  fossa  the  bleeding  is  usually  subcutaneous,  showing 
itself  around  the  mastoid  process,  and  extending  downwards  amongst 
the  muscles  at  the  back  of  the  neck. 

(3)  Discharge  of  cerebrospinal  fluid  is  an  indication  that  a  communi- 
cation exists  with  the  subdural  space.  The  fluid  may  be  discharged 
from  one  or  both  ears,  but  has  also  been  met  with  coming  from  the 
nose    or    cranial   vault ;    when   from  the  ear,  the   dura   mater   has 


748  A  MANUAL  OF  SURGERY 

probably  been  laid  open  through  the  prolongation  which  accompanies 
the  auditory  nerve  in  the  internal  meatus  by  a  fracture  traversing  the 
petrous  bone.  It  is  watery  and  limpid  in  character,  with  a  specific 
gravity  of  about  1006  to  1008,  slightly  alkaline,  and  containing  a  fair 
quantity  of  chloride  of  sodium,  with  traces  of  albumen,  and  of  a 
substance  which,  like  grape-sugar,  reduces  cupric  salts  on  boiling. 
At  first  it  is  probably  blood-stained,  but  soon  becomes  quite  clear. 
The  amount  discharged  may  be  small,  but  not  unfrequently  it 
comes  away  in  large  quantities,  soaking  the  pillow  and  dressings, 
and,  indeed,  can  sometimes  be  caught  in  a  test-tube  as  it  trickles 
from  the  meatus.  As  a  rule,  the  flow  commences  soon  after  the 
injury,  and  quickly  ceases ;  but  some  years  back  a  curious  case 
occurred,  under  the  care  of  Lord  Lister  at  King's  College  Hospital, 
of  a  man  who  had  fallen  backwards  off  a  high  bed  upon  his  occiput ; 
he  was  temporarily  stunned,  but  returned  to  bed,  and,  on  awaking 
the  next  morning,  found  that  both  eyes  were'  black.  He  continued 
work  for  ten  days,  complaining,  however,  of  headache,  and  at  the 
end  of  that  time  of  earache,  which  grew  steadily  worse,  until  relieved 
by  something  giving  way  in  his  left  ear.  This  was  followed  by  a 
copious  discharge  of  cerebro-spinal  fluid,  which  was  maintained  for 
some  time,  and  from  the  after-history  there  can  be  no  doubt  that  it 
was  due  to  a  fractured  base. 

Escape  of  brain  substance  from  the  ear  has  also  occurred  in  a  few 
instances,  most  of  them  fatal. 

(4)  Lesions  of  the  nerves  issuing  from  the  base  of  the  skull  are 
occasionally  produced.  For  symptoms,  etc.,  see  Chapter  XV.  The 
nerve  most  commonly  involved  is  the  facial,  as  it  passes  through  the 
aqueductus  Fallopii ;  the  paralysis  may  develop  either  immediately, 
or  more  often  about  the  second  or  third  week  after  the  injury,  disap- 
pearing in  about  a  month,  and  then  evidently  due  to  its  implication 
in  the  callus.  A  certain  amount  of  deafness  is  often  associated  with 
it  from  injury  to  the  auditory  nerve. 

The  Prognosis  of  fractured  base  has  much  improved  during  recent 
years,  as  a  result  of  the  application  of  antiseptics  to  the  auditory 
meatus.  If  the  patient  escapes  death  from  cerebral  complications, 
the  bones  of  the  skull  unite  rapidly,  and  a  good  result  may  be 
expected,  although  troublesome  sequelae  may  follow,  from  the  injury 
sustained  by  nerves  or  vessels,  of  their  compression  in  callus  or 
new  bone. 

Treatment. — Seeing  that  the  chief  danger  to  the  patient  arises  from 
septic  contamination  of  the  meninges,  the  greatest  care  must  be 
directed  towards  preventing  decomposition  of  the  discharges.  Unfor- 
tunately, it  is  impossible  to  apply  dressings  to  the  naso-pharynx,  or 
even  to  wash  it  out  thoroughly  with  antiseptics,  and  the  only  satis- 
faction about  such  cases  is  that  the  rarity  of  the  loss  of  cerebro-spinal 
fluid  suggests  that  the  membranes  of  the  brain  are  not  very  often 
damaged  in  that  situation,  whilst  it  has  also  been  shown  that  in 
the  majority  of  cases  the  upper  part  of  the  nasal  cavity  is  aseptic 
(St.    Clair   Thomson).      With   the    ear,   however,   things   are   very 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  749 

different ;  the  meatus  should  be  well,  but  gently,  irrigated  with 
carbolic  lotion  (i  in  20),  and  a  strip  of  sterile  gauze  passed  down  it, 
a  large  pad  of  the  same  being  bandaged  over  the  affected  side  of  the 
head.  This  must  be  replaced  as  often  as  necessary.  Beyond  this, 
the  treatment  of  fractured  base  is  directed  to  the  cerebral  condition, 
and  does  not  differ  from  that  usually  applied  to  head  injuries,  viz., 
cold  to  the  shaved  head  (preferably  by  means  of  Leiter's  tubes),  a 
smart  calomel  purge  to  start  with,  low  diet,  and  absolute  quiet  in  a 
dark  room.  In  the  absence  of  signs  of  cerebral  irritation  or  inflam- 
mation (viz.,  increased  rapidity  of  pulse,  persistent  headache,  giddi- 
ness, etc.),  the  patient  may  be  allowed  to  sit  up  in  bed  at  the  end  of 
a  week,  and  his  diet  is  gradually  increased  ;  but  he  should  not  be 
allowed  to  get  out  of  bed  for  a  fortnight,  and  even  then  must  keep 
very  quiet,  and  not  think  of  returning  to  work  for  four  or  six  weeks. 

3.  Depressed  or  Punctured  Fractures  usually  involve  the  vault  of 
the  cranium,  and  are  due  to  direct  violence,  either  from  a  fall  or 
blow,  causing  a  simple  or  compound  fracture,  or  from  a  penetrating 
injury  occasioning  a  punctured  fracture.  In  both  cases  there  is  often 
a  considerable  amount  of  comminution. 

It  is  quite  possible  for  the  outer  table  to  be  broken  and  depressed, 
without  any  injury  to  the  inner,  where  an  air  cavity  exists  in  the 
bone,  or  if  the  diploe  is  very  thick ;  thus,  the  bone  may  be  driven 
in  over  the  frontal  sinus  without  injury  to  its  inner  wall,  or  the 
mastoid  may  be  similarly  affected.  The  inner  table  has  also  been 
broken,  and  fragments  even  separated,  as  a  result  of  a  simple 
depression  without  fracture  of  the  outer  table ;  this  rarely  occurs  in 
adults,  but  is  not  uncommon  in  children.  Amongst  the  latter,  it  is 
also  possible  for  a  considerable  depression  to  exist  without  any 
fracture  of  the  inner  table. 

More  usually  both  inner  and  outer  tables  are  involved,  and  when 
such  is  due  to  force  reaching  it  from  without,  the  inner  table  is 
always  more  damaged  than  the  outer,  especially  in  the  punctured 
variety  (Fig.  349,  A  and  B).  When,  however,  the  force  is  apphed 
from  within,  as  by  a  bullet  which  has  traversed  the  brain,  the  outer 
table  suffers  more  than  the  inner.  The  causes  of  this  condition  are 
similar,  from  whichever  side  the  force  comes,  but  need  only  be 
considered  when  the  violence  acts  from  without,  {a)  The  inner 
table  is  less  supported  than  the  outer,  having  merely  the  soft 
brain  and  dura  mater  within,  and  hence  is  extensively  splintered, 
just  as  a  nail  driven  through  an  unsupported  piece  of  wood  causes 
ripping  up  of  its  under  surface,  {b)  The  loss  of  momentum  of  the 
fracturing  body  will  assist  this ;  the  greater  the  momentum  of  a 
bullet,  the  more  cleanly  it  cuts,  a  smaller  momentum  breaking  or 
splintering  rather  than  cutting ;  of  course,  a  considerable  amount  of 
force  is  expended  in  penetrating  the  outer  table,  {c)  The  debris 
caused  by  the  injury  to  the  outer  table  will  add  to  the  bulk  of  the 
penetrating  body,  and  its  wedge-like  action  still  further  increases  the 
injury  to  the  inner  table,  (d)  All  force  tends  to  radiate  and  diffuse 
itself  from  the  spot  struck,  and   hence,  if   the  outer  table  is  first 


750 


A  MANUAL  OF  SURGERY 


injured,  the  force  will  be  disseminated  over  a  much  wider  area  of 
the  inner. 

The  Symptoms  and  Signs  arising  from  a  depressed  fracture  vary 

widely  in  their  nature, 
and  are  partly  due  to 
the  injury  inflicted  on 
the  bone,  partly  to 
that  sustained  by  the 
brain,  whilst  the  in- 
fection or  not  of  the 
wound  is  of  the  gravest 
significance. 

Locally,  when  an 
external  wound  is 
present,  one  sees  blood 
or  cerebro-spinal  fluid 
escaping,  or  even 
brain  substance  pro- 
truding. The  damage 
to  the  bone  may  be 
seen  or  felt,  and  the 
extent  of  the  depres- 
sion or  comminution 
ascertained.  When 
there  is  no  external 
wound,  a  hsematoma 
of  variable  size  forms 
under  the  scalp,  more 
or  less  obscuring  the 
fracture.  The  charac- 
ter of  the  lesion  is  a 
matter  of  considerable 
importance  from  a 
prognostic  point  of 
view.  When  the  bone 
shelves  evenly  in  all 
directions,  a  pond  or 
saucer  fracture  is  said 
to  be  present,  and  such 
is  tolerably  amenable 
to  treatment ;  when, 
however,  the  depres- 
sion is  sudden  and 
complete,  the  detached 
portion  lying  below  the 
level  of  the  rest  of  the 
bone,  it  is  termed  a  gtctier  fracture,  and  the  prognosis  is  increasingly 
grave.  The  two  forms  are,  however,  often  associated.  Necessarily, 
considerable  variations  are  met  with  in  this  type  of  fracture,  according 


Fig. 


349. — Depressed  Fracture  of  Skull  seen 
FROM  Without  and  from  Within.  (King's 
College  Hospital  Museum.) 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  75 1 

to  the  nature  of  the  injury  and  the  means  by  which  it  was  inflicted. 
Thus,  if  it  is  due  to  a  fall  on  the  vertex,  there  is  often  a  ragged,  irregular 
scalp  wound,  through  which  the  depression  can  be  seen  or  felt ;  if 
caused  by  the  puncture  of  a  sharp  tool,  such  as  a  pickaxe,  there  is 
only  a  small  external  opening  corresponding  to  the  hole  in  the  skull, 
in  which  the  point  of  the  instrument  may  be  found  embedded.  A 
slicing  cut  with  a  sabre  or  hatchet  produces  a  clean  incision  through 
the  scalp,  together  with  a  linear  groove  in  the  skull,  perhaps  some- 
what bevelled,  which  may  or  may  not  penetrate  its  whole  thickness. 
Sometimes  detached  portions  of  the  skull  are  raised  above  their 
ordinary  level,  constituting  an  elevated  fracture ;  it  is  usually  as- 
sociated with  depression  of  surrounding  parts. 

Gunshot  injuries  of  the  skull  manifest  any  degree  of  severity,  accord- 
ing to  the  velocity  and  angle  of  incidence  of  the  projectile.  A  non- 
penetrating wound  produces  either  a  severe  localized  contusion  or  a 
depression  with  or  without  comminution.  If  a  modern  conical  bullet, 
travelling  at  a  high  rate  of  speed,  strikes  the  skull,  it  will  probably 
penetrate,  and  possibly  may  traverse  both  sides  and  thus  escape, 
doing  comparatively  little  harm,  except  along  its  immediate  track. 
If,  however,  the  bullet  is  of  an  expanding  type,  or  if  it  is  travelling 
slowly,  it  may  cause  a  much  more  serious  lesion. 

In  a  simple  depressed  fracture  the  patient  usually  suffers  from  con- 
cussion, followed  almost  immediately  by  compression,  the  latter  due 
in  part  to  the  depressed  bone,  but  mainly  to  exudation  of  blood 
and  bruising  of  the  brain ;  if  this  is  at  all  extensive  and  remains 
unrelieved,  a  fatal  result  quickly  follows.  Where,  however,  the 
depression  is  but  slight,  the  symptoms  of  compression  may  be  absent 
or  not  marked,  and  the  patient  recovers,  perhaps  to  become  the 
subject  of  traumatic  epilepsy  or  insanity  at  a  later  date,  induced  by 
the  irritation  of  the  dura  mater  and  of  the  subjacent  cortex.  If  the 
depressed  fragments  irritate  the  motor  area,  convulsions,  spasms,  or 
paralysis  may  be  thereby  induced. 

In  a  compound  depressed  or  punctured  fracture  the  immediate  effects  are 
not  necessarily  severe,  the  patient  perhaps  not  even  suff'ering  from 
concussion,  though  brain  substance  presents  in  the  wound  ;  the  more 
limited  the  spot  injured,  the  less  the  concussion.  The  explanation  of 
this  fact  is  that  the  blow  has  expended  its  force  in  fracturing  the 
cranium,  and  hence  does  little  harm  to  the  brain,  in  the  same  way 
that  a  watch  may  receive  but  slight  damage  from  a  fall  if  the  glass  is 
broken,  whilst  if  the  latter  remains  intact  the  works  are  liable  to 
suffer. 

Left  to  itself,  such  a  fracture  is  sure  to  become  septic,  and  inflam- 
mation of  the  bone,  brain,  or  membranes  will  follow. 

Septic  osteitis  leads  to  necrosis  of  the  fragments,  which  may  be 
seen  lying  dead  and  yellow  at  the  bottom  of  the  wound,  whilst  the 
inflammation  may  either  spread  along  the  diploe  to  the  surrounding 
bone,  causing  extensive  necrosis  with  pyaemia,  or  between  the  bone 
and  the  dura  mater,  leading  to  a  subcranial  abscess. 

When  once  the  dura  mater  has  been  penetrated,  inflammation  is 


752  A   MANUAL  OF  SURGERY 

liable  to  spread  to  the  meninges,  and  then  a  diffuse  or  localized 
suppurative  meningitis,  accompanied  or  not  with  a  localized  suppura- 
tion of  the  brain,  will  ensue.  Even  if  the  dura  mater  has  not  been 
opened  by  the  injury,  the  irritation  of  depressed  spicules  of  bone  and 
the  presence  of  a  septic  exudation  often  lead  to  its  ulceration  at  a 
later  date.  If  there  is  a  free  external  opening,  allowing  a  ready  exit 
to  the  discharge,  and  thus  preventing  tension,  the  process  may  be 
quite  limited,  and  compression  of  the  brain  or  diffuse  septic  meningitis 
is  avoided  ;  but  if  the  bones  are  locked  together  as  well  as  depressed, 
and  the  external  wound  is  small,  retention  of  inflammatory  products 
may  lead  to  their  diffusion,  and  the  symptoms  of  compression  will 
soon  become  evident.     A  hernia  cerebri  may  also  form  subsequently. 

When  the  fragments  of  depressed  bone  are  early  removed,  even  if 
perfect  asepsis  is  not  attained,  the  patient  has  a  good  chance  of 
recovery ;  whilst  laceration  of  the  dura  need  not  result  in  menin- 
gitis, since  the  opening  in  the  subdural  space  can  be  shut  off  by 
adhesions  of  the  arachnoid  in  a  very  short  time. 

When  an  aseptic  condition  of  the  wound  is  obtained  by  early  inter- 
ference, and  depressed  fragments  of  bone  are  successfully  elevated  or 
removed,  the  prognosis  becomes  much  better,  and  the  case  may 
run  an  uncomplicated  course  towards  recovery,  unless  some  deeper 
cerebral  lesion  co-exists. 

The  Treatment  of  these  cases  has  been  much  changed  by  the 
introduction  of  antiseptics,  the  opinion  now  prevalent  being  that  a 
patient  runs  greater  risks  from  leaving  a  slight  depression  unrelieved 
than  by  making  even  what  may  prove  to  be  an  unnecessary  explora- 
tioii.  The  object  of  the  operation  in  all  cases  is  to  elevate  depressed 
bone  and  to  remove  sharp  edges  of  fragments  which  might  injure  the 
dura  mater.  The  indications  for  operation  may  be  epitomized 
thus : 

(i.)  In  all  punctured  fractures,  operate. 

(ii.)  In  all  compound  depressed  fractures,  operate. 

(iii.)  In  simple  depressed  fractures  :  In  adults,  always  operate  ; 
in  children,  if  gutter-shaped,  operate  ;  if  pond-shaped, 
wait  for  symptoms,  unless  the  fracture  is  a  bad  one. 

The  most  debatable  of  these  propositions  is  that  relating  to  the 
simple  depressed  fracture  in  an  adult.  It  may  be  objected  that  many 
such  cases  have  recovered  without  operation,  and  that  therefore  in 
shallow  depressions  one  should  wait  for  symptoms  ;  but,  whilst  the 
existence  of  such  cases  must  be  admitted,  the  fact  remains  that 
serious  after-effects,  such  as  traumatic  epilepsy  and  insanity,  are  not 
uncommon  sequelae  of  an  unrelieved  depression.  The  operation  in 
itself  is  slight,  and  the  risk  insignificant  when  asepsis  is  maintained, 
so  that  one  cannot  but  insist  that  the  patient  should  be  given  the 
benefit  of  an  exploration,  especially  since  one  can  never  be  certain  of 
the  amount  of  injury  sustained  by  the  inner  table. 

When  an  operation  has  once  been  decided  on,  the  sooner  it  is 
undertaken  the  better.     The  scalp  should  be  shaved  and  thoroughly 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM 


753 


purified.  An  anaesthetic  may  or  may  not  be  given,  according  to  the 
condition  of  the  patient.  In  a  simple  depressed  fracture  the  surgeon 
should  never  incise  the  skin  directly  over  the  wound,  but  should 
turn  down  a  flap  to  avoid  the  presence  of  a  cicatrix  over  the  lesion 
in  the  bone.  Having  cleared  away  blood-clot  and  exposed  the 
fracture,  some  loose  fragments  may  be  exposed,  and  the  removal  of 
these  may  permit  of  the  introduction  of  an  elevator  ;  if  more  room  is 
required,  Hoffmann's  bone  rongeur  will  suffice  to  enlarge  the  opening. 
If  there  are  no  loose  fragments,  it  is 
sometimes  possible  to  make  an  open- 
ing by  sawing  off  a  corner  of  bone 
with  a  Hey's  saw.  If  neither  of 
these  plans  is  feasible,  an  opening 
must  be  made  with  a  trephine.  The 
centre-pin  is  placed  upon  some  firm 
undepressed  bone  as  near  the  margin 
as  possible  (Fig.  350),  and  a  circle 
of  bone  removed.  An  elevator  can 
now  be  introduced,  the  fragments 
prised  up  into  position,  and  the  con- 
dition of  the  inner  table  investigated. 
Care  must  be  taken  in  removing 
loose  fragments  not  to  tear  the  dura 
mater  by  injudicious  violence,  espe- 
cially is  this  the  case  when  the  frac- 
ture lies  over  one  of  the  venous 
sinuses.  Sufficient  bone  must  be 
taken  away  to  allow  the  whole  of 
the  damaged  area  to  be  examined. 
The  bony  tissue  removed  during 
the  operation  should  be  kept  in 
warm  saline  solution,  or  may  be 
tucked  in  under  the  flap  and  thereby 
protected.  When  the  loss  of  sub- 
stance is  small,  there  is  no  need  to 
replace  the  fragments ;  but  when  it 
is  of  considerable  size,  it  is  wise  to  attempt  this,  wedging  them  accu- 
rately together,  so  that  none  lie  loose  in  the  wound.  An  opening 
for  drainage  may  be  left  between  them,  if  need  be.  In  other  cases 
they  may  be  chipped  up  into  small  pieces  and  powdered  over  the 
wound. 

If  the  dura  mater  has  been  injured,  brain  substance  mixed  with 
blood  may  escape  as  soon  as  the  flap  is  raised.  When  the  bone  has 
been  dealt  with,  any  protruding  portion  of  cerebral  material  is 
removed,  and  the  dura  mater  lightly  stitched  across  the  gap.  In  the 
majority  of  cases  no  attempt  should  be  made  to  replace  the  bony 
fragments,  as  they  would  certainly  interfere  with  free  drainage ;  but 
occasionally  it  may  be  possible  to  replace  them  as  indicated  alDove, 
with  a  small  opening  for  drainage  between  them.      If  the  dura  mater 

48 


^*>«vt 


^.r 


I'j*- 


Fig.  350. — Punctured  Fracture 
OF  Skull,  showing  Spot  for 
Application  of  Trephine. 


754  A  MANUAL  OF  SURGERY 

cannot  be  closed,  an  attempt  must  be  made  to  prevent  the  formation 
of  adhesions  between  the  brain  substance  and  the  superjacent  tissues 
by  introducing  a  piece  of  sterile  gold-foil  (or  some  similar  substance) 
between  the  brain  and  the  dura  mater. 

In  a  compound  depressed  fracture  the  conditions  vary  so  much  that  it 
is  only  possible  to  give  general  indications  for  treatment.  The  scalp 
is  first  shaved  and  purified  ;  a  flap  is  then  turned  down  so  as  to  expose 
the  bony  lesion.  Loose  fragments  of  bone  are  removed,  and  de- 
pressed portions  elevated  in  the  usual  way.  It  is  often  unwise  to 
replace  bone  in  these  cases,  as  they  are  probably  infected,  and  any 
attempt  to  purify  them  by  antiseptics  would  be  likely  to  destroy 
their  vitality.  The  margins  of  the  defect  are  carefully  cleansed, 
and  fragments  of  living  uncontaminated  bone  may  be  sown  over  the 
surface  of  the  dura  mater.  The  scalp  flap  is  replaced,  and,  if  possible, 
the  original  wound  sutured  after  trimming  up  or  excising  its  edges. 
An  opening  for  drainage  may  be  made  through  the  lower  part  of 
the  flap. 

Exposed  or  protuberant  brain  substance  is  dealt  with  as  in  simple 
fractures,  except  that  it  is  necessary  to  purify  it  by  washing  with 
some  efficient  antiseptic,  such  as  5  per  cent,  carbolic  lotion,  or  a 
I  in  2,000  sublimate  solution  ;  of  course,  drainage  is  essential  in 
these  cases,  but  the  drainage-tube  should  be  removed,  if  possible,  in 
forty-eight  hours,  so  as  to  minimize  the  chances  of  hernia  cerebri. 

In  a  punchired  fracUire,  although  the  opening  in  the  bone  may  be 
small,  a  large  circle  is  removed,  since  the  inner  table  is  almost 
always  extensively  damaged.  The  centre-pin  should  rest  on  sound 
bone,  as  near  the  opening  as  possible  (Fig.  350),  and  care  must  be 
taken  to  include  all  depressed  fissures  in  the  field  of  operation.  If 
need  be,  the  dura  mater  must  be  opened  up  and  the  brain  explored. 

In  all  cases  the  patient  should  be  confined  to  bed  with  the  head 
slightly  raised  on  a  single  pillow,  and  the  general  rules  suitable  to 
head  injuries  followed.  It  is  by  no  means  certain  that  elevation  of 
the  depressed  bone  will  relieve  the  symptoms,  as  they  may  be  due  to 
hasmorrhagic  effusion  into  the  brain  which  cannot  be  reached. 

For  treatment  of  gunshot  injuries  of  the  skull,  see  pp.  245  and  772. 

The  symptoms  and  treatment  of  the  intracranial  complications  of 
head  injuries  are  dealt  with  in  the  next  chapter. 

Affections  of  the  Frontal  Sinuses. 

These  sinuses  are  cavities  in  the  frontal  bones  lined  with  a  mucous 
membrane  continuous  with  that  of  the  nose.  They  can  hardly  be 
said  to  exist  in  children,  not  developing  much  before  the  age  of 
puberty.  In  adults  they  vary  much  in  size  and  shape,  and  are  often 
very  asymmetrical ;  the  prominence  of  the  superciliary  ridges  is  no 
guide  to  their  extent.  A  good  deal  of  information  as  to  these  points 
may  be  gained  by  radiography,  the  rays  being  directed  from  behind, 
and  the  plates  placed  in  front.  The  presence  of  pus  and  of  tumours 
may  sometimes  be  determined  in  this  way,  whilst  transillumination 
(p.  812)  is  also  useful. 


AFFECTIONS  OF  THE  SCALP  AND  CRANIUM  755 

Fracture  of  the  anterior  wall  is  not  uncommon  as  the  result  of  a 
direct  blow,  depression  of  the  fragments  being  produced,  but  with- 
out cerebral  complications.  If  the  mucous  membrane  is  torn, 
surgical  emphysema  of  the  scalp  and  face  may  follow,  and  is  naturally 
increased  on  blowing  the  nose.  In  compound  fractures,  suppuration 
usually  occurs,  leading  to  septic  osteitis  and  necrosis  of  the  frontal 
bone,  and,  if  the  posterior  wall  is  involved,  to  a  subcranial  or  even 
a  cerebral  abscess.  In  rare  cases,  when  the  anterior  wall  has  been 
destroyed,  a  localized  collection  of  air  may  form  under  the  skin,  and 
remain  as  a  permanent  tumour,  constituting  what  is  known  as  a 
pneumatocele  capitis ;  it  rises  and  falls  with  forced  respirations.  A 
similar  condition  may  also  result  from  a  fracture  into  the  mastoid 
cells ;  in  either  situation  it  should  be  treated  by  compression,  or, 
failing  this,  incision. 

Inflammation  of  the  frontal  sinus  is  caused  by  extension  of  catarrh 
from  the  nose,  by  penetrating  wounds  or  fractures,  by  foreign  bodies, 
or  it  may  be  secondary  to  disease  of  neighbouring  bones. 

Acute  Inflammation  is  usually  of  a  catarrhal  type,  and  produces 
frontal  headache,  tenderness  and  pain  on  pressure  both  above  and 
below  the  eyebrow,  and  a  feeling  of  dulness  or  apathy.  Constitutional 
conditions,  pyrexia,  etc.,  may  also  be  present.  In  such  cases  the 
forehead  should  be  constantly  fomented,  and  the  patient  inhales 
steam  from  hot  water  to  which  eucalyptus  and  menthol  have  been 
added ;  rest  in  bed  and  suitable  purgatives  are  also  necessary. 

Acute  Suppuration  of  the  sinus  is  generally  traumatic,  and  then 
is  liable  to  extend  into  the  frontal  bone,  giving  rise  to  an  acute 
osteo-myelitis,  which  may  spread  rapidly.  The  posterior  wall  of  the 
sinuses  is  extremely  thin,  so  that  the  membranes  of  the  brain  are 
easily  invaded,  and  an  abscess  may  develop  in  the  frontal  lobe. 
Occasionally  extension  of  mischief  to  the  cavernous  or  other  venous 
sinuses  may  follow. 

The  case  must  be  treated  by  laying  the  cavity  open  and  draining 
it.  For  this  purpose  a  curved  incision  is  made  along  or  immediately 
below  the  eyebrow,  and  the  soft  parts  stripped  from  the  bone,  through 
which  a  sufficient  opening  is  made  with  a  gouge  close  to  the  middle 
line ;  the  pus  or  mucus  is  removed,  and  the  passage  into  the  nose 
explored  and  dilated  so  as  to  allow  of  free  drainage.  The  cavity  is 
syringed  out  for  some  days,  and  the  wound  usually  closes  readily, 
although  a  fistula  occasionally  remains,  A  median  vertical  incision 
is  useful  if  there  is  any  doubt  as  to  which  sinus  is  involved,  or  if 
both  are  affected. 

Should  acute  osteo  -  myelitis  develop,  vigorous  measures  are 
necessary.  In  a  case  of  this  type  under  treatment,  incisions  were 
made  along  each  eyebrow  from  the  middle  line,  and  a  vertical  one 
extending  from  the  hair  to  the  root  of  the  nose.  The  flaps  thus 
formed  were  thrown  back,  the  sinuses  freely  opened,  and  their 
anterior  walls  entirely  removed  :  a  large  amount  of  the  frontal  bone 
was  also  taken  away  until  healthy  diploe  free  from  purulent  infiltra- 
tion was  reached.     During  the   process   the  posterior  wall  of   the 


756  A   MANUAL  OF  SURGERY 

right  sinus  was  removed,  and  a  large  cerebral  abscess  opened.  The 
patient  made  a  good  recovery,  although  a  considerable  amount  of 
dead  bone  had  subsequently  to  be  taken  away. 

Chronic  Empyema  of  the  frontal  sinus  may  be  the  outcome  of  an 
acute  catarrhal  inflammation,  or  may  be  chronic  from  the  first, 
extending  upwards  from  the  nose.  Pus  is  constantly  found  in  the 
anterior  portion  of  the  middle  meatus,  and  its  discharge  is  not  much 
influenced  by  the  position  of  the  head.  Frontal  headache  is  often  com- 
plained of,  and  there  may  be  some  localized  tenderness  on  pressure. 
If  the  infundibulum  becomes  blocked,  the  pus  may  collect  and  lead 
to  distension  of  the  ca^'ity,  the  bony  walls  gradually  thinning  and 
yielding  before  the  pressure.  A  similar  condition  occasionally  results 
from  distension  of  the  coxity  with  mucus  {hydrops).  When  the 
walls  are  sufficiently  thinned,  '  eggshell  crackling '  may  be  noticed. 
Owing  to  its  anatomical  relations  to  the  lower  orifice  of  the  infundi- 
bulum, the  maxillary  antrum  is  often  involved  secondarily,  if  it  has 
not  been  already  infected. 

In  the  Treatment  of  chronic  empyema  external  operation  must,  if 
possible,  be  avoided,  since  experience  has  shown  that  it  is  associated 
with  a  definite  mortality,  due  to  acute  osteo-m3'-elitis.  The  intranasal 
condition  is  carefully  treated ;  the  anterior  portion  of  the  middle 
turbinal  is  removed  so  as  to  give  a  better  exit  to  the  discharge,  and. 
a  skilled  rhinologist  is  usuall)^  able  to  pass  a  tube  up  the  infundi- 
bulum and  wash  out  the  cavity.  Should  these  measures  fail  to  give 
relief,  and  should  urgent  sym.ptoms  appear,  then  the  cavity  must  be 
opened  as  described  above,  and  a  tube  passed  through  into  the  nose, 
the  external  wound  either  being  closed  at  once  (Luc),  or  left  open  for 
a  few  days  and  packed  with  gauze. 

The  chief  Tumours  growing  from  the  frontal  sinuses  are  mucous 
cysts  or  polypi,  and  ivory  osteomata ;  the}^  may  also  be  involved  in 
diffuse  sarcoma  or  carcinoma,  but  the  disease  is  then  not  limited  to 
the  sinus.  The  main  symptoms  and  signs  restilt  from  distension  of 
the  walls  of  the  cavity,  which  may  yield  anteriorly,  causing  a  large 
frontal  swelling  ;  or  the  posterior  wall  is  absorbed,  leading  to  cerebral 
compression ;  or  the  upper  wall  of  the  orbit  may  be  depressed,  causing 
dislocation  of  the  eyeball,  and  possibly  blindness  (Fig.  54,  p.  201). 
Tumours  which  have  attained  considerable  dimensions  can  rarely 
be  removed,  death  then  resulting  from  cerebral  compression ;  but 
occasionally  bony  masses  may  necrose,  and  become  loosened  by 
suppuration  around  them,  and  in  a  few  cases  they  have  been  taken 
away  successfully. 


CHAPTER  XXVI. 
AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES. 

Cranio-Cerebral  Topography. 

It  is  scarcely  necessary  or  desirable  in  a  students'  manual  to  deal 
exhaustively  with  this  subject.  The  main  facts  can  alone  be  referred 
to,  and  larger  text-books  of  operative  surgery  or  surgical  anatomy 
referred  to  for  further  details.* 

The  Fissure  of  Rolando  may  be  found  topographically  by  the  follow- 
ing methods  :  {a)  The  upper  extremity  of  the  fissure  corresponds  to 
a  point  I  centimetre  (or  f  inch)  behind  the  centre  of  the  line  extend- 
ing from  the  f  ronto-nasal  suture  to  the  external  occipital  protuberance. 
The  direction  of  the  sulcus  is  downwards  and  forwards  at  an  angle 
of  about  67°  to  the  middle  line.  This  may  be  indicated  by  laying  a 
half-sheet  of  letter-paper  over  the  skull,  the  long  side  corresponding 
to  the  middle  line,  and  with  its  centre  over  the  upper  limit  of  the 
fissure  ;  the  anterior  half  is  now  folded  over  obliquely  from  this 
point,  leaving  an  angle  of  45°  between  the  front  of  the  paper  and  the 
middle  line  of  the  skull ;  and  then  the  same  process  is  again  repeated, 
bisecting  the  angle  and  leaving  one  of  about  67°,  so  that  the  anterior 
limit  of  the  folded  paper  corresponds  to  the  line  of  the  fissure,  which 
is  about  3I  inches  in  length,  A  '  Rolandometer,'  consisting  of  two 
strips  of  flexible  metal  united  at  the  appropriate  angle,  is  now  sold 
by  many  instrument-makers.  As  a  general  rule  this  '  Rolandic 
line '  crosses  the  fissure  about  its  centre,  being  in  front  of  the  fissure 
above  and  a  little  behind  it  below  ;  but  it  is  sufficiently  accurate  for 
practical  purposes,  {h)  A  less  exact  method  is  that  defined  by 
Dr.  Reid,  the  measurements  for  which  are  all  worked  from  the  so- 
called  Reid's  base-line,  which  is  one  drawn  on  the  skull  from  the 
lower  margin  of  the  orbit  backwards  through  the  centre  of  the 
external  auditory  meatus,  reaching  the  middle  line  behind  just  below 
the  occipital  protuberance  (Fig.  351).  From  it  are  drawn  upwards 
two  perpendiculars,  one  (C  D)  corresponding  to  the  £,mall  depression 
in  front  of  the  external  auditory  meatus,  the  other  (E  F)  to  the 
posterior  border  of  the  mastoid  process.     The  fissure  of  Rolando 

*  For  a  review  of  the  relative  accuracy  of  various  methods,  see  a  paper  by 
Berry  and  Shepherd,  Brit.  Med.  Journ.,  p.  1382,  November  19,  1904. 

757 


758 


A  MANUAL  OF  SURGERY 


extends  from  the  upper  limit  of  the  posterior  vertical  line   to  the 
point  where  the  anterior  line  intersects  the  fissure  of  Sylvius. 

To  map  out  the  Fissure  of  Sylvius,  ( i )  Reid  utilizes  a  line  drawn 
from  a  point  i\  inches  directly  behind  the  external  angular  process 
of  the  frontal  bone  (Fig.  351,  A),  and  about  the  same  distance  above 
the  zygoma,  to  a  spot  f  inch  below  the  most  prominent  part  of  the 
parietal  eminence.    The  undivided  portion  of  the  fissure  is  represented 

by  the  first  f  inch,  and 
from  here  the  anterior 
limb  (Sy.  A.  Fiss.)  rises 
vertically  upwards  for 
about  an  inch,  whilst 
the  posterior  limb  ex- 
tends backwards  for 
the  rest  of  the  line. 
If  prolonged  to  the 
middle  line  behind,  it 
indicates  with  toler- 
able accuracy  the 
situation  of  the 
parieto  -  occipital  fis- 
sure (P.  O.  Fiss.). 
Careful  investigation, 
however,  has  shown 
that  no  great  relia- 
bility can  be  placed 
on  this  method. 

(2)  Hare  and  Thane 
suggest  the  following 
measurements,  which 
in  the  majority  of 
adult  skulls  may  be 
looked  on  as  substan- 
tially accurate :  To 
find  the  Sylvian  point 
{i.e.,  the  point  of  bifur- 
cation of  the  fissure), 
a  line  is  drawn  hori- 
zontally backwards 
from  the  fronto-malar 
suture  for  a  distance 
of  35  millimetres,  and  from  the  posterior  end  of  this  a  vertical  line 
upwards  for  12  millimetres  ;  the  upper  extremity  of  this  line  is  the 
Sylvian  point.  The  posterior  limb  of  the  Sylvian  fissure  is  indicated 
by  a  line  drawn  backwards  from  the  fronto-malar  suture  through 
the  Sylvian  point  to  the  lower  part  of  the  parietal  eminence. 

The  external  limb  of  the  parieto -occipital  fissme  corresponds  almost 
exactly  to  the  lambda. 

(3)  Kronlein's  method  (Fig.   352)  of  locating  the    Rolandic  and 


Fig.  351. — Diagram  of  Head  to  indicate  Method 
of  finding  the  fissures  of  rolando  and 
Sylvius  by  Reid's  Method. 

Sy.  A.  Fiss.,  Anterior  branch  of  Sylvian  fissure, 
P.  O.  Fiss. ,  parietooccipital  fissure ;  Trans.  Fiss., 
transverse  fissure  along  line  of  tentorium  ;  A,  ex- 
ternal angular  process  of  frontal  bone  ;  B,  occipital 
protuberance  ;  CD,  anterior  perpendicular  in  front 
of  tragus ;  EF,  posterior  perpendicular  through 
back  of  mastoid  process. 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES 


759 


Sylvian  fissures  is  useful,  and  not  so  complicated  as  many  others. 
Two  horizontal  lines  are  drawn  round  the  skull,  one  the  lower  (AB) 
through  the  infra-orbital  border  and  upper  margin  of  the  external 
auditory  meatus ;  the  other  (CD)  above  it  and  passing  through  the 
supra-orbital  margin.  Perpendiculars  are  carried  upwards  from  the 
lower  of  these  (i)  through  the  centre  of  the  zygoma,  (2)  through  the 
condyle  of  the  lower  jaw,  and  (3)  at  the  posterior  border  of  the  mastoid 
process.  The  posterior  of  these  is  prolonged  to  the  vertex  at  R ;  the 
anterior  cuts  the  upper  horizontal  line  at  S  ;  and  the  middle  perpen- 
dicular intersects  the  line  joining  S  and  R  at  R'.  The  angle  RSD  is 
finally  bisected  by  a  line 

SS'     which      represents  ^^^^.^-^^^^^^^^j^ 

the  posterior  limb  of  the 
Sylvian  fissure,  whilst 
RR'  corresponds  to  the 
fissure  of  Rolando. 

Methods  of  Opening 
the  Cranium. 

In  the  old  days  but 
one  instrument  was  em- 
ployed for  this  purpose, 
viz.,  the  trephine ;  but 
our  increasing  know- 
ledge of  cerebral  lesions 
and  the  security  given 
by  aseptic  methods  have 
necessitated  a  consider- 
able elaboration  in  the 
methods  of  operating  on 
the  cranium. 

I.  Simple  trephining  is 
still  employed  in  dealing 
with  many  traumatic 
lesions  where  an  extensive  exposure  of  the  brain  is  not  required. 
The  modern  trephine  is  often  fitted  with  a  solid  metal  handle  to 
render  sterilization  easy,  and  the  crown  is  usually  bevelled  and 
not  straight,  so  as  to  check  the  liability  to  slip  inwards  and  wound 
the  dura.  The  scalp  is  incised  and  turned  aside  by  raising  a  flap 
which  has  its  base  downwards,  so  as  to  ensure  its  vitality.  The 
pericranium  is  stripped  from  the  bone,  and  the  trephine  applied  with 
the  centre-pin  projecting.  As  soon  as  a  well-marked  groove  has 
been  made,  the  centre-pin  is  withdrawn  or  removed,  and  the  instru- 
ment carried  through  the  cranium.  An  increased  flow  of  blood  will 
often  indicate  when  the  diploe  is  reached,  and  care  must  be  taken 
not  to  injure  the  dura.  To  this  end  the  groove  in  the  bone  is  care- 
fully examined  from  time  to  time  by  a  flattened  probe  or  the  blunt 
end  of  a  needle,  and  the  more  so  when  the  operation  is  undertaken 
in  a  region  where  the  bone  is  known  to  be  of  irregular  thickness. 


Fig.  352. — Kronlein's  Method  of  locating  the 
Fissure  of  Rolando  (RR').  and  the  Posterior 
Limb  of  the  Fissure  of  Sylvius  (SS'). 


76o  A  MANUAL  OF  SURGERY 

The  disc  is  removed  by  an  elevator.  Considerable  bleeding  some- 
times takes  place  from  the  section  of  the  bone,  but  can  usually  be 
controlled  by  crushing  the  spot  with  powerful  forceps,  or  by  rubbing 
in  Horsley's  wax  (carbolic  acid,  i  part ;  oil,  2  parts ;  wax,  7  parts). 
If  the  opening  is  not  sufficiently  large,  it  may  be  increased  by  the 
bone  rongeur,  Hey's  saw  or  cutting  pliers,  or  even  by  the  trephine. 

2.  In  many  cases  of  cerebral  abscess  the  trephine  is  unnecessary, 
as  the  causative  focus  (e.g.,  mastoid  disease  or  frontal  sinus  empyema) 
can  be  opened  up,  and  the  cranial  cavity  reached  by  removing  portions 
of  bone  with  a  gouge.  When  well  inside  the  skull,  a  bone  rongeur 
or  de  Vilbiss'  punch  will  suffice  to  enlarge  the  opening.  Even  when 
the  cranium  is  intact,  the  gouge  is  used  by  some  in  preference  to  the 
trephine  to  make  the  first  opening. 

3.  When  a  considerable  area  of  the  brain  needs  exposure,  as  in  the 
case  of  cerebral  tumours,  various  plans  are  adopted : 

(a)  Some  surgeons  utilize  a  large  2-inch  trephine,  but  this  is 
obviously  undesirable  owing  to  the  irregular  thickness  of  the  skull, 
and  the  difficulty  which  attends  the  equal  deepening  of  the  groove 
in  all  directions  over  such  a  large  circumference. 

(b)  When  there  is  no  likelihood  of  being  able  to  replace  the  bones,  a 
small  trephine  hole  and  enlargement  by  the  rongeur  should  be  adopted. 

(c)  Of  late,  however,  some  form  of  Wagner's  osteoplastic  method 
has  been  chiefly  used.  In  this  a  flap  of  scalp  tissues  is  turned  down 
together  with  the  underlying  bone,  laying  bare  the  dura  mater. 
Some  surgeons  divide  the  bone  along  the  line  of  incision  with  a  chisel 
and  wooden  mallet ;  this  requires  great  care  and  skill,  as  the  dangers  of 
concussion  of  the  brain  from  such  a  plan  are  not  to  be  overlooked. 
Others  use  a  circular  saw ;  but  probably  the  simplest  way  is  to  make 
four  small  trephine  openings  at  the  corners  of  the  flap,  and  connect 
these  either  by  the  use  of  a  Hey's  saw,  or  by  a  Gigli  saw  {i.e.,  a 
piano-wire  with  a  screw-thread  turned  on  it,  and  with  handles  attached 
at  each  end),  passed  by  means  of  a  probe  under  the  bone  from  one 
opening  to  another,  or  by  the  use  of  a  rongeur  on  two  sides,  whilst 
the  upper  end  is  sawn  through  by  a  Hey's  saw  set  on  the  slant,  so 
that  the  incision  is  bevelled,  thereby  preventing  the  bone  from  slipping 
in  when  replaced,  and  the  base  is  divided  by  a  Gigli  saw.  This 
procedure  is  a  serious  one,  attended  by  considerable  shock  and 
haemorrhage,  and  therefore  is  often  undertaken  as  a  preliminary 
measure  a  week  or  ten  days  before  the  lesion  in  the  brain  is  attacked. 

Lumbar  Puncture  in  Cerebral  Lesions. 

The  removal  of  cerebro-spinal  fluid  from  the  lumbar  region  has 
been  much  employed  of  recent  years  in  connection  with  injuries  and 
diseases  of  the  cranium  and  its  contents,  and  its  value,  both  from  the 
diagnostic  and  therapeutic  standpoints,  is  of  importance. 

The  method  of  withdrawal  is  quite  simple.  A  stout  antitoxin  or 
exploring  needle  should  be  selected  and  sterilized  by  boiling,  and  the 
skin  in  the  region  of  the  third  and  fourth  lumbar  interspaces  (the 
spinous  process  of  the  fourth  vertebra  is  on  a  line  joining  the  iliac 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  761 

crests)  is  to  be  carefully  sterilized.  The  patient  sits  or  lies  with  the 
body  well  flexed.  The  needle  is  then  inserted  in  the  fourth  inter- 
space, either  in  the  middle  line,  or  a  third  of  an  inch  from  it;  it  must 
be  pointed  forwards,  with  a  very  slight  inclination  upwards.  In 
most  cases  the  needle  will  go  straight  into  the  spinal  canal  below  the 
termination  of  the  cord,  and  the  fluid  will  escape.  If  bone  is 
encountered,  it  is  advisable  to  withdraw  the  needle  and  re-insert  it 
at  a  slightly  different  angle.  In  cases  of  repeated  failure  the  third 
interspace  may  be  tried. 

Normal  cerebro-spinal  fluid  is  slightly  alkaline  and  as  clear  as 
water,  with  a  specific  gravity  of  1006  to  1008 ;  it  contains  a  trace 
of  albumen  and  of  a  copper-reducing  substance,  but  practically  no 
cells.  It  is  calculated  that  from  100  to  130  c.c.  are  present  in  the 
normal  adult. 

In  amte  meningitis,  due  to  organisms  other  than  the  tubercle 
bacillus,  the  fluid  is  turbid  and  contains  much  albumen.  There  are 
numerous  cells  present,  most  of  which  are  polynuclear  leucocytes. 
Bacteria  may  be  detected  by  suitable  methods  of  staining  or  by 
cultures. 

In  tuberculous  meningitis  the  fluid  is  almost  clear,  and  contains  a 
slight  excess  of  albumen  and  of  cells ;  the  latter  are  almost  all 
lymphocytes.  Tubercle  bacilli  are  rarely  found.  In  all  varieties  of 
meningitis  the  fluid  is  secreted  under  pressure,  and  usually  issues  from 
the  needle  in  a  stream. 

In  cerebral  abscess  and  lateral  sinus  thrombosis  the  fluid  is  normal,  but 
may  be  under  excessive  pressure.  Lumbar  puncture  is  not  only  a 
most  important  adjunct  in  diagnosis,  but  may  also  be  of  service  in 
the  treatment  of  such  conditions. 

In  fracture  of  the  base  of  the  skull  or  of  the  spinal  column,  and  in 
injuries  of  the  surface  of  the  brain  blood  usually  appears  in  the 
cerebro-spinal  fluid  within  a  few  hours  of  the  accident  and  is  inti- 
mately mixed  with  it. 

The  Therapeutic  value  of  this  procedure  has  not  been  so  fully 
recognised  as  its  use  in  diagnosis.  In  many  cases  of  meningitis  the 
coma  is  due  mainly  to  excessive  cerebro-spinal  fluid,  and  if  the 
amount  of  this  can  be  diminished  the  symptoms  often  abate.  The 
value  of  lumbar  puncture  will,  therefore,  depend  on  whether  or  not  it 
is  possible  to  influence  the  intracranial  tension  thereby,  and  that,  in 
turn,  is  dependent  on  the  situation  and  character  of  the  adhesions 
present.  The  puncture  must,  therefore,  be  obviously  experimental, 
as  one  can  never  be  certain  as  to  the  adhesions  ;  but  it  is  a  simple 
proceeding,  and  may  well  be  employed  in  all  cases  of  meningitis,  in 
the  hope  that  some  good  may  follow.  In  traumatic  conditions  it 
may  be  useful  when  the  lesion  is  not  very  serious,  and  the  pressure 
on  the  brain  not  hopelessly  exaggerated. 

G-eneral  Conditions  of  the  Brain  after  Head  Injuries. 

Concussion  of  the  Brain,  or  stunning,  is  a  clinical  condition 
characterized  by  a  more  or  less  complete  suspension  of  its  functions 


762  A  MANUAL  OF  SURGERY 

as  a  result  of  injury  to  the  head,  which  leads  to  some  commotion  of 
the  cerebral  substance,  and  may  or  may  not  be  associated  with 
haemorrhage.  It  varies  with  the  severity  of  the  cause  from  a  slight 
momentary  giddiness  and  confusion  of  thought  to  the  most  complete 
insensibility,  and  is  closely  allied  to  shock,  from  which  it  is  often 
distinguished  with  difficulty. 

In  fatal  cases,  one  finds  on  post-mortem  examination  merely  the 
same  conditions  as  obtain  in  shock,  viz.,  engorgement  of  the  lungs, 
viscera,  and  the  right  side  of  the  heart,  whilst  the  brain  presents  some 
lesion  of  varying  severity,  from  mere  punctiform  ecchymoses  to 
actual  disintegration  and  disorganization.  The  symptoms  are 
supposed  to  be  due  either  to  a  paralysis  of  the  vasomotor  centres  in 
the  medulla,  or  to  a  reflex  inhibition  of  the  heart  through  the  vagus. 
More  recently  Duret  has  suggested  that  the  blow  on  the  skull  causes 
a  temporary  localized  depression  of  the  bone,  and  this  leads  to  com- 
pression of  a  cone-shaped  area  of  the  brain  substance.  As  a  result, 
the  cerebro-spinal  fluid  is  displaced  and  forced  downwards  to  the  base 
of  the  skull,  where  it  collects,  particularly  in  the  fourth  ventricle, 
and  thus  the  vital  centres  grouped  around  this  space  are  compressed. 
This  explanation  of  concussion  is  very  feasible. 

The  Symptoms  vary  considerably  in  degree,  but  in  a  well-marked 
case  the  stage  of  concussion  is  evidenced  by  unconsciousness,  more 
or  less  complete,  although  the  patient  can  sometimes  be  roused  by 
shouting  ;  he  lies  on  his  back,  with  the  muscles  relaxed  and  flaccid ; 
the  eyelids  are  closed,  and  the  conjunctivae  may  be  insensitive ;  the 
pupils  vary,  but  are  equal  and  often  contracted,  usually  reacting  to 
light ;  but  in  bad  cases  they  are  dilated,  and  do  not  contract  when 
light  is  admitted.  The  surface  of  the  body  is  pale,  cold,  and  clammy. 
The  respirations  are  slow,  shallow,  and  sighing,  whilst  the  pulse  is 
rapid,  weak,  fluttering,  and  scarcely  sensible  to  the  fingers  ;  the 
temperature  is  at  first  subnormal ;  the  sphincters  are  relaxed,  with 
perhaps  unconscious  evacuations  from  both  bladder  and  bowel. 
The  reflexes  are  present  in  the  milder  cases,  though  sluggish  *  in 
the  more  severe  they  may  be  entirely  absent. 

This  condition  may  last  for  a  considerable  time,  and  then  pass 
slowly  into  more  profound  unconsciousness  and  death,  or  be  followed 
by  the  phenomena  of  inflammation,  compression,  or  cerebral  irritation. 
In  the  simpler  cases,  however,  reaction  soon  begins  to  manifest 
itself.  The  patient  is  presumably  put  to  bed,  and  warmth  carefully 
applied  to  the  extremities.  The  first  sign  of  reaction  is  probably  a 
slightly  increased  rate  of  both  breathing  and  pulse,  whilst  he  may 
be  able  to  tell  his  name  and  address ;  sometimes  he  turns  on  his 
side,  and  pulls  the  bedclothes  up  to  his  face,  since  he  feels  cold 
and  chilly  as  a  result  of  the  cutaneous  anaemia.  Gradually  he 
becomes  more  and  more  rational,  and  the  functions  of  both  mind 
and  body  are  restored,  reaction  being  fully  established  by  the  occur- 
rence of  vomiting,  due  to  a  condition  of  cerebral  hyperaemia  follow- 
ing the  anaemia.  Probably  he  suff'ers  from  headache  for  some  days, 
and  a  slight  amount  of  fever  will  follow ;  but  this  passes  off,  and 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  763 

leaves  the  patient  either  quite  well,  or  with  a  somewhat  irritable 
brain  requiring  prolonged  rest.  Subsequent  events  may,  however, 
prove  that  more  mischief  has  been  done  than  appears  at  first.  Thus, 
some  special  function  of  the  brain  may  be  permanently  lost  or 
impaired,  such  as  memory,  hearing,  or  vision  ;  a  patient  may  forget 
the  names  of  places  or  persons,  or  may  lose  all  memory  of  time ; 
speech  may  become  defective  or  stammering,  or  a  certain  amount  of 
asthenopia  (weakness  of  vision)  may  supervene.  Such  individuals 
are  very  liable  to  develop  signs  of  mental  instability,  and  even 
delusional  insanity  or  melancholia,  if  placed  in  positions  of  responsi- 
bility or  strain.  Others  seem  to  suffer  from  a  general  loss  of  nerve 
tone  (neurasthenia),  rendering  them  incapable  of  fulfilling  their 
ordinary  duties  in  life.  In  all  the  more  severe  cases  there  is  a 
complete  lapse  of  memory  as  to  the  accident,  and  even  as  to  the 
events  which  preceded  and  followed  it,  extending  sometimes  to  a 
fortnight  or  more,  and  perhaps  including  a  period  during  which  the 
patient  was  apparently  quite  rational. 

The  Treatment  of  concussion  very  closely  resembles  that  of  shock, 
viz.,  the  patient  is  at  once  put  to  bed,  with  the  head  low,  and  is 
covered  with  warm  blankets  ;  hot-water  bottles  may  be  applied  to  the 
extremities,  and  friction  to  the  surface.  Any  needless  stimulation 
must  be  avoided  for  fear  of  exciting  haemorrhage ;  an  enema  of  hot 
coffee  may  be  given,  or,  if  in  extremis,  brandy,  or  a  hypodermic  injec- 
tion of  strychnine.  A  good  purge,  such  as  5  grains  of  calomel,  or  a 
drop  or  two  of  croton  oil  on  sugar,  should  be  administered  after 
reaction  in  the  milder  cases,  but  whilst  still  unconscious  in  the 
graver  forms,  and  the  patient  is  then  kept  for  some  days  in  bed  on  a 
restricted  diet,  with  the  bowels  freely  open  and  all  sources  of  excite- 
ment excluded. 

When  the  unconsciousness  is  prolonged,  and  no  signs  of  fracture 
of  the  cranium  exists,  lumbar  puncture  should  be  employed, 
and  may  be  most  beneficial.  Thus,  a  lady  who  had  attempted 
suicide  by  throwing  herself  from  a  window  lay  for  two  or  three  days 
on  the  borderland  of  unconsciousness,  frequently  relapsing  into  a 
comatose  state.  Lumbar  puncture  resulted  in  the  drawing  off  of 
some  drachms  of  blood-stained  fluid,  and  at  once  restored  her  to 
complete  consciousness,  which  was  not  again  lost.  Should  this 
treatment  fail,  the  head  should  be  shaved,  and  an  icebag  or 
Leiter's  tubes  applied  ;  the  bowels  are  opened  regularly,  and  the  state 
of  the  bladder  attended  to  ;  the  room  must  be  kept  dark  and  quiet, 
the  attendants  making  as  little  noise  in  walking  and  talking,  etc.,  as 
possible  ;  sufficient  nourishment  must  be  given  either  by  a  spoon  if 
the  patient  can  thus  take  it,  or  by  nutrient  enemata  or  a  nasal  tube. 

Cerebral  Irritation. — By  cerebral  irritation  is  meant  a  clinical  con- 
dition which  sometimes  follows  concussion,  characterized  by  great 
irritability  of  both  mind  and  body.  It  usually  results  from  blows  or 
falls  on  the  temple,  forehead,  or  occiput,  and  is  probably  due  to  a 
superficial  laceration  of  the  brain,  possibly  in  the  frontal  region,  and 
to  the  hyperaemia  caused  by  its  subsequent  repair. 


764  A  MANUAL  OF  SURGERY 

The  Symptoms  are  very  characteristic,  and  usually  manifest  them- 
selves two  or  three  days  after  the  injury.  They  may  be  divided  into 
two  groups,  (a)  Bodily  Symptoms  :  The  patient  lies  on  his  side  in  a 
condition  of  general  flexion,  the  back  arched,  the  legs  drawn  up  to 
his  abdomen  with  the  knees  bent,  and  the  hands  and  arms  drawn  in. 
He  is  restless,  and  may  toss  about,  but  never  extends  himself  fully 
or  lies  supine.  The  eyes  are  closely  shut,  and  he  resists  all  attempts 
to  open  them  ;  the  pupils  are  contracted  ;  the  temperature  is  usually 
a  little  raised,  but  the  surface  of  the  body  and  head  are  both  cool ;  the 
pulse  is  quiet  but  weak  ;  the  sphincters  are  usually  in  a  normal  con- 
dition', and  the  excreta  are  often  passed  in  the  bed,  but  the  bladder 
may  occasionally  need  to  be  emptied  by  catheter.  In  some  mild 
instances  the  patient  may  get  up  to  empty  his  bladder  and  then 
return  to  bed.  (b)  Mental  Condition  :  The  patient  is  by  no  means 
unconscious,  but  he  takes  no  heed  of  what  is  passing  around,  and  is 
intensely  and  morbidly  irritable.  When  disturbed,  he  will  gnash  his 
teeth,  frown,  swear,  and  resent  the  intrusion  in  the  most  expressive 
manner.  At  the  end  of  a  few  days,  or  perhaps  after  a  week  or  two, 
a  marked  alteration  in  the  condition  of  the  patient  usually  shows 
itself.  He  is  less  irritable,  begins  to  stretch  himself  out,  and  with 
this  is  conjoined  an  improvement  in  both  pulse  and  temperature. 
Sometimes  he  becomes  childish,  and  needs  to  be  taught  the  names  of 
persons  and  things ;  at  other  times  he  is  garrulous,  perhaps  giving  a 
fresh  story  of  his  accident  every  day,  but  generally  there  is  an 
absolute  lapse  of  memory  in  this  direction.  Usually  the  brain  recovers 
more  or  less,  but  serious  after-effects  are  likely  to  ensue.  Sometimes 
the  symptoms  pass  over  into  those  of  subacute  or  chronic  meningitis. 

Treatment. — The  patient  is  kept  quiet  and  free  from  all  noise  or 
excitement ;  his  diet  must  be  light  and  nourishing.  The  head 
should  be  placed  low  and  shaved,  and  Leiter's  tubes  fitted  on,  if  the 
patient  will  permit  it ;  but  it  is  better  to  omit  this  entirely  than  to 
apply  cold  intermittently.  The  bowels  are  kept  well  open,  and 
possibly  small  doses  of  bromide,  or  even  opium,  may  be  useful.  If 
any  signs  of  meningeal  inflammation  follow,  such  as  rise  of 
temperature  and  pulse,  heat  of  head,  and  great  sleeplessness, 
blisters  or  leeches  may  be  applied  locally,  and  mercury  administered 
internally. 

Compression  of  the  Brain. — Compression  is  the  term  given  to  a 
clinical  condition  due  to  some  abnormal  and  excessive  intracranial 
pressure  which  disturbs  the  functions  of  the  brain.  In  the  earlier 
stages  a  displacement  of  cerebro-spinal  fluid  from  the  cranium  to  the 
vertebral  canal  may  relieve  the  symptoms ;  but  as  the  pressure 
increases,  the  brain  substance  itself  suffers,  the  cortical  centres  being 
involved  first,  and  the  medulla  last.  When  of  traumatic  origin,  it 
may  arise  from  the  following  causes :  (a)  Depressed  bone  or  the 
presence  of  a  foreign  body,  m  which  case  the  symptoms  of  concussion 
merge  directly  into  those  of  compression,  and  usually  without  any 
interval  of  consciousness  It  is  probable,  however,  that  in  these 
cases  the  symptoms  are  due  more  to  the  associated  haemorrhage  than 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  765 

to  the  actual  cranial  lesion,  (b)  Extravasation  of  blood  within  the 
cranium,  either  outside  the  membranes,  or  on  the  surface  of  the 
brain,  or  within  its  substance.  If  the  bleeding  is  extradural,  there 
will  probably  be  a  short  interval  of  consciousness  between  the  con- 
cussion and  the  compression ;  if  the  bleeding  is  cerebral,  the  symptoms 
of  compression  may  manifest  themselves  at  once  without  any  interval 
being  noticed,  (c)  It  may  be  due  to  an  acute  spreading  oedema,  the 
explanation  of  which  is  subsequently  given  (p.  768).  (d)  It  may 
arise  from  the  pressure  of  inflammatory  exudation  or  pus,  in  which 
case  the  symptoms  are  preceded  by  those  of  inflammation,  and  at  the 
earliest  will  not  manifest  themselves  before  the  third  day,  whilst  they 
may  be  deferred  for  a  week  or  two. 

Compression  also  arises  as  a  result  of  idiopathic  haemorrhage, 
tumours,  gummata,  or  abscesses — e.g.,  of  middle-ear  origin. 

The  Symptoms  of  compression  are  essentially  those  of  coma.  When 
the  condition  is  well  established,  the  patient  lies  on  his  back  absolutely 
unconscious,  and  cannot  be  roused  either  by  shouting  or  shaking. 
His  breathing  is  slow,  laboured,  and  stertorous,  the  lips  and  cheeks 
being  puffed  in  and  out.  The  stertor  arises  from  paralysis  of  the  soft 
palate,  and  the  puffing  of  the  cheeks  from  paralysis  of  the  facial 
muscles.  In  the  later  stages  the  respirations  may  be  more  rapid  and 
irregular,  somewhat  approaching  the  Cheyne-Stokes  type.  Death 
arises  from  cessation  of  the  respiratory  act.  The  pulse  is  full  and  slow 
at  first  from  irritation  of  the  vagus  and  vasomotor  centres,  but  later 
on  becomes  rapid  and  irregular,  owing  to  increased  pressure  upon 
and  exhaustion  of  these  medullary  centres.  The  surface  of  the  body 
may  either  be  cool,  hot,  or  perspiring  ;  the  body  temperature  similarly 
varies,  in  some  cases  being  very  high,  in  others  low,  and  where 
the  compressing  force  is  unilateral,  there  may  be  some  difference  on 
the  two  sides  of  the  body.  The  p^lpils  become  dilated  without 
responding  to  light,  but  vary  according  to  the  degree  of  compression 
and  the  situation  of  the  compressing  agent.  If  the  cerebral  pressure 
is  equally  diffused,  both  pupils  first  contract,  and  then  gradually 
dilate  and  become  reactionless ;  but  if  one  hemisphere  is  affected 
more  than  the  other,  the  pupil  on  that  side  passes  rapidly  through 
these  changes,  whilst  on  the  opposite  side  they  are  not  developed 
until  later.  Thus,  it  is  a  common  thing  to  find  the  pupils  unequal 
in  size,  and  reacting  differently  to  light.  The  whole  body  in  the 
later  stages  is  in  a  condition  of  motor  paralysis,  but  at  an  earlier  period 
of  the  case  there  may  be  some  difference  on  the  two  sides,  if  the 
lesion  is  unilateral ;  thus,  if  the  left  side  of  the  brain  is  primarily 
affected,  a  right-sided  hemiplegia  is  likely  to  be  present  at  a  time 
when  the  muscles  on  the  left  side  can  still  respond  to  cerebral  stimuli. 
A  localized  compression  involving  the  motor  area  may  lead  to  con- 
vulsions in  the  corresponding  group  of  muscles.  The  bladder  is 
paralyzed,-  and  hence  retention  ensues,,  whilst  the  sphincter  ani  is 
relaxed,  and  fseces  pass  involuntarily,  although  marked  constipation 
is  usually  present. 

The  symptoms  in  some  cases  are  ushered  in  by  severe  pain  or 


766  A  MANUAL  OF  SURGERY 

headache,  which  is  partly  due  to  pressure  upon  and  tearing  of  the 
dura  mater,  and  partly  to  the  altered  vascular  conditions  of  the 
brain  ;  the  brain  substance  itself  is  not  sensitive,  and  hence  the  pain 
is  not  directly  referable  to  any  lesion  of  or  pressure  upon  it. 
Naturally,  the  clinical  picture  is  modified  according  to  the  cause  of 
the  compression,  and.  it  is  impossible  to  discuss  here  more  than  the 
general  features.  The  course  of  the  case,  too,  varies  widely  accord- 
ing to  whether  or  not  the  compressing  agent  can  be  removed  by  the 
surgeon,  or  absorbed  by  natural  processes.  Patients  not  uncommonly 
recover  from  small  cerebral  and  intrameningeal  haemorrhages  causing 
temporary  compression,  but  rarely  do  so  without  operation  if  the 
symptoms  are  due  to  depressed  bone,  the  presence  of  a  foreign  body, 
or  large  exudations  of  blood,  serum,  or  pus. 

The  Diagnosis  of  coma  from  compression,  when  a  complete  history 
of  the  case  can  be  obtained,  is  often  easy,  and,  indeed,  the  whole 
clinical  aspect  may  be  so  typical  that  no  question  as  to  the  cause  of 
unconsciousness  can  be  raised.  But  when  a  person  is  found  in  the 
streets  unconscious,  and  no  history  either  of  the  patient  or  of  an 
accident  is  obtainable,  and  no  serious  lesion  of  the  skull  is  present, 
the  diagnosis  is  often  extremely  obscure,  since  coma  may  be  due  to 
many  other  causes,  e.g. :  (a)  Cerebral  lesions,  such  as  apoplexy, 
whether  the  result  of  haemorrhage,  embolus,  or  thrombosis  ;  or  it 
may  be  the  consequence  of  a  preceding  epileptic  fit,  or  due  to  a 
rapidly  spreading  oedema  in  cases  of  cerebral  tumour  or  abscess. 
(b)  Various  toxic  agents  may  induce  coma. ;  they  may  be  introduced 
into  the  system  from  without,  as  in  the  case  of  alcohol,  opium,  or 
other  narcotics,  or  may  be  developed  within  the  body,  as  in  uraemia 
or  diabetic  coma,  (c)  Heatstroke  or  exposure  to  cold  may  also  lead 
to  unconsciousness.  In  the  latter  case  there  can  be  but  little  doubt 
as  to  the  cause,  since  the  patient  is  cold,  pale,  and  in  a  state  of 
severe  prostration  ;  in  the  former  the  diagnosis  may  for  a  time  be 
doubtful,  (d)  Lastly,  it  must  not  be  forgotten  that  two  or  more  of 
these  conditions  may  co-exist.  Thus,  a  drunken  man  may  fall  and 
break  his  skull,  and  then  the  smell  of  liquor  in  his  breath  may  lead 
to  an  erroneous  diagnosis. 

It  is  therefore  evident  that  a  very  careful  examination  of  the  patient 
is  required  before  any  conclusion  can  be  arrived  at  as  to  the  cause  of 
the  coma,  and  it  is  often  impossible  to  make  an  immediate  diagnosis. 
In  such  cases  the  patient  should  be  carefully  tended  and  watched, 
and  not  shut  up  for  the  night  in  a  police-cell  without  attendance. 

The  following  points  should  always  be  observed  in  the  examina- 
tion :  (i)  A  rapid  note  should  be  made  as  to  the  surroundings  of 
the  patient — whether  there  is  blood  or  vomit  near  him,  how  the 
body  is  lying,  and  the  nature  of  the  ground.  (2)  The  depth  of  the 
coma  should  be  ascertained,  and,  if  possible,  the  man  should  be 
roused,  and  asked  to  give  an  account  of  himself.  (3)  A  most 
thorough  and  complete  investigation  should  be  made  as  to  his  con- 
dition. His  skull  must  be  first  examined,  to  settle  if  possible 
whether  or  not  a  fracture  is  present ;  the  surface  temperature  of  the 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  767 

body  is  noted,  as  also  the  character  of  the  pulse  and  respirations. 
The  tongue  should  be  looked  at,  as  it  is  often  bitten  in  an  epileptic 
fit,  and  the  smell  of  the  breath  should  also  be  noted.  The  condition 
of  the  pupils  may  throw  some  light  on  the  case  ;  in  opium-poisoning 
they  are  small  and  equal,  a  condition  also  seen  in  haemorrhage  into 
the  pons  ;  in  alcoholism  they  are  often  dilated  and  fixed,  but  vary 
considerably  in  different  cases.  The  amount  of  power  and  the  state 
of  the  reflexes  are  then  observed,  any  inequality  probably  indicating 
a  unilateral  lesion  in  the  brain.  The  urine  must  be  drawn  off,  and 
carefully  examined  for  albumen  and  sugar.  (4)  In  dubious  cases, 
and  especially  where  there  is  any  suspicion  of  drunkenness  or  poison, 
the  stomach  should  be  emptied  and  washed  out.  (5)  Finally,  if  the 
cause  is  still  uncertain,  the  patient  should  be  put  to  bed  and  carefully 
watched. 

The  Treatment  of  compression  must  be,  where  possible,  directed 
to  removing  the  cause.  When  it  is  due  to  depressed  bone  or  a 
foreign  body,  immediate  operation  is  required ;  collections  of  pus 
should  be  opened,  and  blood-clots  removed.  Failing  such  measures, 
and  if  lumbar  puncture  gives  no  relief,  the  treatment  of  the  con- 
dition resolves  itself  into  keeping  the  patient  quiet,  with  the  head  low 
and  cool,  the  room  dark  and  noiseless,  the  bowels  open  (using  croton 
oil  on  sugar,  or  enemata,  for  this  purpose),  and  the  bladder  empty. 
The  patient  may  have  to  be  fed  by  the  rectum,  and  if  the  breath- 
ing or  pulse  is  very  laboured,  and  cyanosis  begins  to  show  itself, 
venesection  may  be  advisable.  Considerable  interference  with  the 
respiration  arises  from  falling  back  of  the  tongue,  as  often  occurs 
in  profound  anaesthesia  during  surgical  operations,  and  if  due  to  this 
cause  the  head  may  be  rolled  over  to  one  side,  or  the  tongue  pulled 
forwards.  Occasionally  patients  remain  in  this  condition  for  weeks 
or  months. 

Laceration  of  the  Brain. — Injuries  to  the  brain  and  its  membranes 
are  frequent  complications  of  head  injuries,  and  all  the  most  serious 
results  of  these  accidents  arise  from  this  source.  They  are  produced 
in  many  different  ways,  and  cause  varied  symptoms ;  but  the  most 
important  distinction  to  draw  is  between  those  wounds  which  com- 
municate with  the  exterior  and  those  which  do  not. 

I.  Non-penetrating  Wounds  of  the  Brain  result  from  blows  and 
falls,  which  may  or  may  not  produce  simple  fissured  or  depressed 
fractures  of  the  skull,  but  not  unfrequently  the  most  serious  cerebral 
symptoms  follow  injuries  in  which  the  bones  do  not  participate.  In 
depressed  fractures  the  brain  is  usually  most  contused  or  torn  imme- 
diately below  the  injured  spot ;  but  in  cases  where  there  is  no 
depression,  the  greatest  mischief  is  frequently  found  at  a  point 
exactly  opposite  to  that  struck  (point  of  contrecoup),  whilst  the  local 
bruise  may  be  much  slighter.  Thus,  in  the  case  of  one  of  our 
students  who,  in  an  epileptic  fit,  fell,  striking  the  left  occipital 
region  on  a  stone  pavement,  we  found  post-mortem  a  fissured  fracture 
at  the  spot  struck  and  a  bruise  on  the  left  occipital  convolution, 
whilst  the  anterior   portion   of   the  right  frontal  lobe  was  severely 


768 


A  MANUAL  OF  SURGERY 


contused,  and,  indeed,  disintegrated.  The  explanation  of  this  fact 
is  that  the  force  of  the  injury  is  transmitted  to  the  brain  substance 
in  a  wave  which  concentrates  its  violence  against  the  opposite  side 
of  the  skull.  In  very  sharp  sudden  localized  blows,  as  from  a  spent 
bullet,  local  bruising  of  the  subjacent  brain  may  be  alone  produced. 

Pathological  Anatomy. — The  immediate  effects  of  such  an  injury 
vary  considerably.  There  may  be  a.  mere  bruise,  evidenced  by  a  few 
points  of  extravasation,  on  the  surface  or  in  the  gray  matter ;  or  the 
more  superficial  parts  of  the  brain  may  be  totally  disintegrated  and 
mixed  with  clots  ;  or,  if  laceration  has  occurred,  clots  may  be  found 
adhering  to  the  injured  spot,  or  extending  from  it  widely  into  the 
subarachnoid  space,  or  even,  under  rare  circumstances,  into  the 
lateral  ventricle.  The  later  effects  in  cases  where  the  wound  does 
not  communicate  with  the  exterior  are  mainly  those  of  inflammation 
or  degeneration.  Soon  after  the  accident  considerable  exudation 
follows,  causing  the  ecchymosed  brain  substance  to  swell  and 
become  cedematous;  this  may  speedily  subside,  but  in  the  more 
serious  cases  a  spreading  oedema  may  be  caused,  owing  to  the  pressure 
of  the  swollen  tissues  upon  the  superficial  veins  in  the  pia  mater; 
the  circulation  in  these  is  hindered,  and  increased  exudation  follows, 
leading  to  general  cerebral  pressure  and  even  death,  a  con- 
sequence hastened  by  the  excess  of  cerebro-spinal  fluid  usually 
induced  by  the  process.  Under  such  circumstances  the  greater  part 
of  the  brain  is  cedematous  and  glistening,  the  injured  area  being 
yellowish-red  m  colour,  with  evident  points  of  extravasation  scattered 
through  it.  Still  later,  degeneration  of  the  brain  substance  may 
follow  owing  to  the  disturbance  of  its  circulation,  and  is  indicated 
by  the  presence  of  a  pulpy  yellowish  mass,  soft  enough  to  be  washed 
away  by  a  stream  of  water,  and  containing  fat  globules  and  granular 
cells,  with  debris  of  nerve  fibres  {yellow  softening).  If  the  area 
involved  is  small  and  unimportant,  the  patient  may  recover  perfectly, 
the  softened  tissue  being  absorbed ;  if  large  or  implicating  important 
centres,  death  or  paralysis  must  ensue.  In  cases  of  laceration 
of  the  brain  which  recover,  a  tough  depressed  cicatrix  is  formed, 
'usually  adherent  to  the  membranes,  and  containing  haematoidin 
crystals,  whilst  extravasated  blood  may  be  organized  into  a  dirty 
brownish  lamina,  adherent  to  the  pia  mater,  or  into  an  arachnoid  cyst. 

Clinical  History. — -The  symptoms  necessarily  differ  with  the 
severity  and  locality  of  the  lesion. 

Whenever  concussion  occurs  after  a  head  injury,  and  the  patient 
recovers  slowly  from  it,  the  surgeon  will  rightly  suspect  contusion 
or  laceration  of  the  brain.  In  the  slighter  cases  recovery  is  often 
inaugurated  by  an  attack  of  vomiting,  and  this  is  followed  by  a  rise 
of  temperature  to  about  ioo°  F.  for  a  few  days,  whflst  the  patient 
complains  of  fixed  pain  and  headache,  which  under  suitable  treatment 
may  entirely  disappear.  Some  impairment  of  sense  or  function  may, 
however,  persist. 

More  serious  lesions  give  rise  to  various  symptoms  resulting  from 
haemorrhagic  effusion,  and  these  will  manifest  themselves  either  at 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  769 

once  or  within  twenty-four  to  forty-eight  hours  of  the  injury.  Thus, 
if  the  phenomena  of  compression  supervene  at  once,  without  any 
interval  of  consciousness,  a  diagnosis  of  depressed  bone  or  a  serious 
haemorrhage  into  the  cerebral  substance  may  be  safely  made.  If,  on 
the  other  hand,  the  patient  rallies  for  a  time  before  the  incidence 
of  compression  phenomena,  an  extradural  haemorrhage  from  the 
meningeal  vessels  or  venous  sinuses  may  be  suspected,  or  a  rapidly 
spreading  oedema. 

Haemorrhage  into  the  cortex  is  characterized  by  irritative  or 
paralytic  phenomena,  which  vary  with  the  cortical  area  involved. 
The  degree  of  unconsciousness  depends  on  the  amount  of  the 
hsemorrhagic  effusion. 

In  the  Upper  and  Middle  Frontal  Convolutions  neither  motor  nor 
sensory  symptoms  are  noted,  but  cerebral  irritation  and  subsequent 
weak-mindedness  are  likely  to  follow,  especially  if  the  left  side  is 
involved ;  lesions  to  the  right  frontal  lobe  do  but  little  harm  to  a 
right-handed  individual.  Apparently,  the  intellectual  faculties  are 
limited  to  one  side  of  the  brain,  in  the  same  way  as  the  power  of  speech. 

Wounds  of  the  Third  Left  Frontal  Convolution  lead  to  motor  aphasia 
— i.e.,  the  inability  to  produce  or  articulate  words,  in  right-handed 
individuals ;  in  left-handed  people  wounds  of  the  right  side  have  a 
similar  result.  Injury  to  the  opposite  convolution  has  no  effect.  If 
only  one  side  is  damaged,  the  other  convolution  can  after  a  time  be 
educated  so  as  to  take  on  the  function  of  the  damaged  region. 

Haemorrhage  into  the  Motor  Area  (Fig.  353)  results  in  localized 
convulsions  or  paralysis,  according  to  the  degree  of  mischief.  If  the 
bleeding  is  progressive,  a  regular  extension  of  the  convulsions  may 
be  witnessed,  the  movements  commencing,  perhaps,  in  some  region 
which  is  at  the  time  incapable  of  voluntary  movement,  and  spreading 
to  other  parts  of  the  body.  Thus,  if  bleeding  is  occurring  into  the 
cortical  centres  for  the  face  on  the  left  side  of  the  brain,  paralysis  of 
the  right  side  of  the  face  may  be  present,  and  it  is  here  that  the 
convulsions  will  start,  spreading  regularly  to  the  right  side  of  the 
neck,  arm,  and  leg,  and  then  involving  the  left  leg,  arm,  and  side  of 
the  head  in  order,  finally  becoming  general,  as  in  an  epileptic  fit. 
After  each  convulsion  the  paralysis  is  found  to  have  spread. 

It  is  sometimes  very  difficult  to  diagnose  between  a  true  cortical 
haemorrhage  and  one  which  extends  diffusely  over  the  cortex  in  the 
subarachnoid  space  from  the  rupture  of  a  vein  in  the  pia  mater.  In 
the  latter,  however,  the  symptoms  develop  earlier,  the  paralysis  is 
less  marked  and  the  convulsions  are  less  regular,  though  perhaps 
more  generalized. 

An  irritative  lesion  of  the  motor  area  for  the  head  and  eyes  causes 
a  conjugate  deviation  of  the  eyes  towards  the  other  side  ;  a  destruc- 
tive lesion  causes  both  eyes  to  be  deflected  towards  the  injured  side. 

Wounds  of  one  Occipital  Lobe  may  cause  a  temporary  hemiopia, 
but  no  persistent  loss  of  vision,  unless  the  angular  gyrus  is  also 
destroyed.  Lesions  of  the  latter  region  are  always  associated  with 
permanent  disturbances  of  vision. 

49 


770 


^   MANUAL  OF  SURGERY 


The  Upper  Tempovo- sphenoidal  Lobe  contains  the  cortical  auditory 
centre,  and  lesions  in  this  region  cause  deafness.  The  sense  ot 
smell  is  located  in  the  anterior  portion  of  the  lower  temporo- 
sphenoidal  lobe  which  constitutes  the  uncinate  process.      _ 

Injury  to  the  Corona  Radiata  leads  to  paralysis  of  the  regions  repre- 
sented by  the  overlying  cortex,  but  without  convulsions  or  other 
irritative  phenomena.  If  the  corpus  striatum  or  internal  capsule  is 
torn  or  involved  in  a  hsemorrhage,  coma  rapidly  supervenes,  accom- 
panied by  hemiplegia  and  perhaps  hemianaesthesia.     Occasionally 


Fig.  333. Arrangement  of  the  Motor  Cortical  Centres  around  the 

Fissure  of  Rolando  is,  indicated. 

P.  O.  F.,  Parieto  occipital  fissure;  T.  T.,  tentorium,  below  which  is  seen  the 
cerebellum.     The  sutural  lines  of  the  bones  are  also  visible. 


the  effused  blood  bursts  into  the  lateral  ventricle,  and  causes  a  rapid 
rise  of  temperature,  increasing  until  the  patient's  death,  together 
with  a  very  rapid  weak  pulse  and  increased  respiratory  rate  (40  to 
60  per  minute). 

Wounds  of  the  Cerebelhim  cause  giddiness,  vertigo,  and  ataxy,  the 
patient  reeling  about  in  characteristic  cases,  as  if  drunk. 

A  wound  of  the  Cnis  Cerebri  occasions  more  or  less  complete 
hemiplegia  of  the  opposite  side  of  the  body,  associated  with  some 
amount  of  hemiansesthesia,  and  total  paralysis  of  the  3rd  (oculo- 
motor) nerve  on  the  side  of  the  injury. 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  77 1 

Laceration  or  contusion  of  the  Pons  Varolii,  if  not  immediately  fatal, 
may  lead  to  paralysis  of  the  opposite  side  of  the  body  to  the  injury,, 
together  with  paralysis  of  the  5th,  6th,  7th,  or  9th  nerves,  on  the 
same  side  as  the  lesion,  constituting  the  so-called  '  crossed  paralysis.' 
Marked  contraction  of  the  pupils  (myosis)  may  also  be  present. 

Wounds  of  the  Medulla  are  usually  fatal.  If,  however,  the  patient 
should  escape,  he  is  liable  to  suffer  from  disturbed  functions  of  the 
circulatory  and  respiratory  centres,  with  perhaps  Cheyne-Stokes 
respiration  and  glycosuria. 

The  later  resiilts  of  a  cerebral  laceration  vary  much.  The  patient 
may  recover  perfectly  after  a  more  or  less  prolonged  period  of  un- 
consciousness, but  not  unfrequently  some  loss  of  power  persists, 
which  will  seriously  impair  the  patient's  subsequent  usefulness. 

The  febrile  phenomena  already  mentioned  as  characteristic  of  the 
first  few  days  of  convalescence  after  an  attack  of  concussion  may  pass 
into  a  condition  of  subacute  or  chronic  localized  inflam.mation  of  the 
injured  area,  as  indicated  by  pain  and  headache.  In  such  cases  the 
inflammatory  effusion  may  be  so  abundant  as  to  determine  the  onset 
of  unconsciousness  in  four  or  five  days.  Occasionally  an  abscess  forms 
deeply  in  the  white  substance,  and  this  will  be  indicated  by  the  usual 
phenomena  of  such  a  condition,  coming  on  ten  or  fourteen  days  after 
the  injury. 

The  formation  of  cicatrices  between  the  brain  and  membranes  may 
determine  the  development  of  traumatic  epilepsy  or  insanity  at  a 
later  period. 

The  Treatment  of  these  cases  is  always  an  exceedingly  anxious 
matter  for  the  surgeon.  In  the  majority  of  instances  it  is  merely 
symptomatic,  following  the  usual  course  adopted  in  concussion,  com- 
pression, cerebral  irritation,  etc.,  as  indicated  elsew'here.  The  patienl 
is  kept  absolutely  quiet  in  bed,  with  an  icebag  to  the  head,  and  a 
purge  administered.  Depressed  bone,  if  present,  will,  of  course,  be 
dealt  with  by  operation.  Early  convulsions  and  paralysis  are  care- 
fully watched  to  see  if  any  indication  as  to  the  site  of  the  bleeding 
can  be  obtained,  since  it  is  possible  that  trephining  over  the  injured 
spot  and  removing  blood-clots  or  securing  bleeding-points  might  be 
advisable ;  but  the  clinical  records  as  to  such  treatment  are  not  very 
encouraging.  Late  convulsions  and  paralysis  due  to  inflammation 
are  best  treated  by  shaving  the  head  and  applying  an  ice-cap,  and 
by  lumbar  puncture.  If  the  pulse  is  full  and  hard,  and  the  patient 
otherwise  young  and  healthy,  general  venesection  may  be  adopted; 
the  bowels  must  be  moved  by  a  smart  purgative,  such  as  croton 
oil,  whilst  bromide  in  full  doses  may  be  administered.  If  the  con- 
vulsions continue  in  spite  of  such  treatment,  and  become  more  severe 
and  extensive,  the  patient  will  almost  certainly  die  of  coma ;  tre- 
phining over  the  injured  area  is  then  distinctly  indicated,  the  surgeon 
hoping  to  find  and  remove  some  clot,  or,  at  any  rate,  to  relieve  tension 
within  the  dura. 

II.  Penetrating  Wounds  of  the  Brain  result  from  blows  or  falls,  as 
in  compound  depressed  fractures  ;  or  from  the  entrance  of  foreign 


772  A  MANUAL  OF  SURGERY 

bodies,  such  as  bullets ;  or  from  stabs  or  punctures,  which  most 
commonly  occur  in  the  weaker  parts  of  the  cranium — e.g.,  the  temple 
or  upper  wall  of  the  orbit ;  or  from  sabre- cuts  or  axe- wounds,  in 
which  an  oblique  or  almost  valvular  incision  is  made  through  the 
scalp  and  cranium,  laying  bare  and  wounding  the  brain  and  its  mem- 
branes. 

In  these  cases  the  general  disturbance  is  often  slight,  compared 
with  the  extent  of  the  local  injury,  so  that,  although  brain  substance 
may  protrude  from  the  wound,  there  is  sometimes  but  little  con- 
cussion. Any  of  the  conditions  due  to  haemorrhage  detailed  below 
may  follow,  but  they  may  be  less  severely  felt  since  the  blood  can 
escape  from  the  wound.  The  inflammatory  phenomena  following 
such  lesions  are  mainly  septic  in  origin,  and  may  be  localized  or 
diffuse.  In  the  latter  instance  general  meningo-encephalitis  manifests 
itself  in  the  course  of  two  or  three  days,  and  is  rapidly  fatal ;  in  the 
former  case  adhesions  prevent  the  extension  of  the  trouble  beyond 
the  neighbourhood  of  the  wound.  Hernia  cerebri  is  very  likely 
to  follow,  and  not  unfrequently  a  deep  cerebral  abscess  will  com- 
plicate matters  at  a  later  date.  In  cases  that  have  been  successfully 
rendered  aseptic,  the  course  is  similar  to  that  run  by  a  non-penetrating 
wound,  except  that,  if  anything,  the  immediate  prognosis  is  better, 
since  the  opening  in  the  skull  and  the  possible  removal  of  damaged 
brain  substance  diminishes  the  likelihood  of  compression  from 
simple  or  spreading  cedema.  Where  the  lesion  has  involved  the 
motor  area,  permanent  monoplegia  may  persist,  and  traumatic 
epilepsy  is  always  liable  to  result  owing  to  the  possible  formation  of 
cortical  adhesions. 

The  Symptoms  arising  from  a  penetrating  wound  of  the  brain  have 
been  in  measure  indicated  already.  In  the  worst  cases  immediate 
death  may  result,  or  severe  concussion,  passing  quickly  into  com- 
pression, from  which  the  patient  never  recovers.  In  the  less  serious 
cases  there  will  be  a  varying  degree  of  concussion,  followed  after  a 
short  interval  by  the  phenomena  of  inflammation,  localized  or  diffuse, 
which  will  be  subsequently  described.  Focal  symptoms  may  also 
arise  from  destruction  of  the  cortical  centres. 

Treatment. — In  all  cases  of  punctured  or  compound  depressed 
fracture,  a  thorough  exploration  of  the  wound  should  be  made,  and 
all  depressed  or  injured  bone  removed.  Foreign  bodies  should  be 
taken  away,  if  found  close  to  the  wound ;  but  it  is  doubtful  whether 
a  bullet  should  be  sought  for,  if  it  has  penetrated  deeply  into  the 
brain,  or  if  it  has  traversed  the  brain  and  fractured  the  bone  on  the 
other  side.  Probably  an  aseptic  incision,  with  removal  of  the 
splintered  fragments  and  a  limited  search  for  the  bullet,  is  the  best 
treatment  to  adopt,  and,  even  if  unsuccessful,  will  do  but  little  harm,  if 
the  patient's  general  state  warrants  an  operation.  Protruding  brain 
tissue  is  gently  removed,  and  the  whole  wound  thoroughly  purified 
with  carbolic  lotion ;  even  the  i  in  20  solution  may  be  used  without 
fear.  The  dura  mater  should,  if  possible,  be  drawn  together  by  one 
or  two  sutures,  and  a  small  drain-tube  or  a  gauze  wick  inserted 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  773 

within  it.  It  is  often  advisable  to  introduce  a  portion  of  sterilized 
gold  foil  between  the  cortex  and  the  dura,  so  as  to  prevent  the  forma- 
tion of  adhesions.  The  scalp-wound  is  closed,  except  at  the  drain 
opening ;  the  gauze  or  tube  should  be  removed,  if  all  is  going  well,  in 
about  two  days'  time.  If  the  temperature  rises  as  a  result  of  septic 
infection,  the  wound  must  be  reopened,  and  every  effort  made  to 
relieve  tension,  and  thus  localize  the  mischief.  Should  diffusion 
occur,  as  indicated  by  an  increasing  severity  of  the  symptoms,  the 
patient  must  be  treated  in  accordance  with  the  general  principles 
laid  down  for  dealing  with  acute  meningitis. 

In  this  description  of  lacerations  of  the  brain  we  have  purposely 
omitted  any  mention  of  the  fact  that  symptoms  may  arise  from  in- 
flammatory conditions  affecting  the  bones  (p.  742).  In  actual  prac- 
tice the  course  of  events  is  often  considerably  modified  by  such  com- 
plications. 

Injuries  to  the  Intracranial  Bloodvessels. 

1.  Wounds  of  the  Venous  Sinuses  are  by  no  means  uncommon, 
being  torn  across  in  fractures,  or  punctured  either  by  some  sharp 
instrument,  or  by  spicules  of  bone.  The  superior  longitudinal, 
petrosal,  lateral,  and  cavernous  sinuses  are  those  most  frequently  in- 
volved, especially  the  first,  because  it  is  more  intimately  connected 
with  the  bones  than  any  of  the  others.  Not  unfrequently  a  depressed 
fragment  of  bone  is  driven  into  a  sinus,  and  no  bleeding  occurs  until 
the  fragment  is  displaced  with  a  view  to  elevating  it,  when  a  serious 
gush  of  dark  venous  blood  will  follow.  When  there  is  no  external 
wound,  and  the  outer  wall  of  the  sinus  has  been  torn,  the  hcemorirhage 
may  strip  up  the  dura  mater  and  compress  the  brain,  producing 
effects  resembling  those  due  to  a  wound  of  a  meningeal  artery  ;  but 
generally  the  bleeding  is  not  great,  since  comparatively  little 
pressure  suffices  to  arrest  it  by  determining  thrombosis.  If,  how- 
ever, the  inner  wall  of  the  sinus  is  torn  across,  the  blood  finds 
its  way  between  the  meninges,  and  gives  rise  to  the  symptoms  of 
diffuse  intrameningeal  haemorrhage.  When  an  external  wound 
exists,  there  is  the  usual  evidence  of  venous  bleeding,  but  it  is  readily 
checked  and  rarely  fatal.  Infective  thrombosis  and  pyemia  are  the 
chief  dangers,  but  entrance  of  air  has  also  led  to  a  fatal  issue  in  a 
few  cases.  Treatment,  when  practicable,  consists  in  plugging  the 
sinus  with  aseptic  gauze,  and  applying  an  antiseptic  compress,  pos- 
sibly removing  fragments  of  bone  in  order  to  expose  it.  Where  the 
outer  wall  alone  has  been  torn,  it  may  be  possible  to  suture  it  with- 
out interfering  with  its  continuity.  For  symptoms  and  treatment  of 
infective  thrombosis,  see  p.  781. 

2.  Wounds  of  the  Middle  Meningeal  Artery. — This  vessel  enters 
the  skull  at  the  foramen  spinosum,  and  subsequently  divides  into  two 
branches  which  ramify  between  the  skull  and  the  dura  mater.  The 
anterior  branch  is  most  frequently  torn  as  it  crosses  the  antero- 
inferior angle  of  the  parietal  bone,  as  the  result  of  any  type  of 
fracture  in  that  locality.    The  artery  is,  however,  sometimes  ruptured 


774 


A  MANUAL  OF  SURGERY 


by  a  blow  on  the  side  of  the  head,  sufficiently  severe  to  detach  the 
dura  mater,  but  without  causing  any  injury  to  the  bone ;  this  mem- 
brane always  carries  the  vessel  with  it,  and  if  it  emerges  from  a 
bony  canal  just  at  that  spot,  as  so  often  happens,  the  artery  is  torn 
across  by  the  projecting  inner  lip  of  the  canal.  Whether  or  not  the 
dura  is  primarily  detached,  the  blood  soon  collects  between  it  and 
the  bone,  pressing  the  brain  inwards,  and  burrowing  down  towards 
the  base  of  the  skull  (Fig.  354)  This  is  due  mainly  to  the  force- 
pump-like  action  of  the  arterial  pressure,  for  when  fluid  is  driven  into 
a  closed  cavity,  the  power  of  the  jet  is  multiplied  by  the  area  occupied. 
The  clot  rarely  measures  more  than  4  inches  in  diameter.      The 

posterior  division  is  only 
wounded  in  about  5  to  10 
per  cent,  of  the  cases. 

The  Symptoms  are,  unfor- 
tunately, often  obscured  by 
some  CO  -  existent  cerebral 
lesion  or  complication  ;  but 
in  a  typical  case  three 
stages  should  be  present, 
viz. :  {a)  A  primary  concus- 
sion, as  the  result  of  the 
blow ;  (b)  a  temporary  re- 
turn to  consciousness  ;  and 
(c)  the  gradual  supervention 
of  coma  within  twenty-four 
hours,  and  that  usually  with- 
out any  considerable  rise  of 
temperature.  The  interval 
of  consciousness  varies 
widely,  but  it  is  not  often 
Ijnger  than  an  hour  or  two, 
whilst  in  many  cases  it  is 
scarcely  recognisable.  As 
accessory  signs,  the  follow- 
ing may  be  mentioned  : 
(i)  Since  the  blood-clot  is  situated  clos3  to  the  motor  area  of  the 
cortex,  and  especially  over  the  centres  of  the  head  and  arm,  twitching 
of  these  parts,  followed  perhaps  by  paralysis,  may  be  a  well-marked 
feature,  and  usually  supervenes  before  the  onset  of  coma ;  (2)  when 
the  clot  extends  to  the  base  of  the  skull,  it  presses  on  the  cavernous 
sinus,  and  may  induce  passive  congestion  of  the  eyeball,  paresis  of 
some  of  the  ocular  muscles,  and  proptosis,  with  possibly  a  dilated  pupil 
and  high  temperature  ;  and  (3)  when  a  fissure  exists  in  the  bone,  blood 
may  filter  through  into  the  temporal  fossa,  and  cause  a  marked  fulness 
in  that  region.  The  Prognosis  is  extremely  unfavourable.  Von  Berg- 
mann  stating  that  out  of  ninety-nine  cases  only  sixteen  recovered. 

The  Diagnosis  of  extra-dural  haemorrhage  is  easy  if  there  is  an 
open  wound,  or  if  the  symptoms  are  at  all  typical ;  but  even  then 


Fig.  354. — Meningeal  H/emorrhage 
(From  Specimen  in  College  of  Sdr- 
GEONS'  Museum.) 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  775 

one  cannot  be  certain  that  the  middle  meningeal  artery  has  given 
way,  and  that  the  symptoms  are  not  due  to  venous  bleeding.  An 
examination  of  the  injured  part,  and  the  rapidity  of  onset  of  the 
symptoms,  may  help  in  this  matter,  but  it  is  often  impossible  to 
make  a  diagnosis  with  certainty. 

The  Treatment  consists  in  trephining  in  order  to  remove  the 
blood-clot  and  secure  the  artery,  if  still  bleeding.  The  spot  selected 
for  dealing  with  the  anterior  division  of  the  artery  is  1^  inches 
behind  the  external  angular  process  of  the  frontal  bone,  and  1^ 
inches  above  the  zygoma  (Fig.  357,  F),  and  this  point  should  be 
marked  on  the  bone  with  a  bradawl  through  the  scalp  before 
commencing  the  operation.  The  scalp  is  shaved  and  thoroughly 
purified,  and  a  flap  turned  down,  including  everything  as  far  as  the 
pericranium  (Fig.  105,  A).  A  crucial  incision  is  then  made  over  the 
selected  spot,  and  the  pericranium  reflected  sufficiently  to  allow 
a  I -inch  trephine  to  be  applied.  On  removing  the  disc  of  bone, 
a  mass  of  blood-clot  presents,  which  should  be  broken  up  with  the 
finger  and  washed  or  scraped  away.  If  the  artery  is  seen  bleeding 
on  the  dura  mater,  it  may  be  possible  to  pick  it  up,  and  tie  or  twist 
it,  or  a  fine  curved  needle  threaded  with  catgut  may  be  passed 
under  it,  and  thus  a  ligature  applied.  If,  however,  the  blood  comes 
from  a  canal  in  the  bone,  the  outer  table  must  be  clipped  away 
sufficiently  to  enable  the  canal  to  be  seen  and  plugged  by  a  small 
piece  of  aseptic  wax,  sponge,  or  gauze,  which  may  be  left  without 
danger.  The  flap  is  then  replaced,  and  stitched  dovm,  a  drain-tube 
being  inserted  for  a  time. 

The  posterior  branch  of  the  artery  can  be  reached  by  trephining 
immediately  below  the  parietal  eminence  at  the  same  level  as  for  the 
anterior  branch — i.e.,  i|-  inches  above  Reid's  base-line;  or,  again, 
it  can  be  exposed  nearer  its  origin  at  a  spot  if  inches  behind  the 
external  angular  process  of  the  frontal  bone,  and  J  inch  above  the 
upper  margin  of  the  zygoma  (Fig.  357,  G). 

3.  Wounds  of  the  Internal  Carotid  Artery,  m  its  intracranial 
portion,  are  rare,  but  if  complete  are  necessarily  fatal.  They  usually 
result  from  penetrating  wounds  of  tha  orbit,  or  from  a  gunshot 
wound,  or  the  vessel  may  be  torn  by  a  splinter  of  bone  in  a  fracture 
of  the  base  of  the  skull.  Mere  fissures  through  the  carotid  canal  do 
little  harm,  since  there  is  plenty  of  room  within  it  around  the  artery. 
Occasionally,  however,  the  artery  is  slightly  torn,  and  an  aneurismal 
varix  develops  between  it  and  the  cavernous  sinus.  Of  seventy-five 
cases  of  pulsating  exophthalmos,  Rivington  found  that  forty-one 
were  caused  by  trauma,  and  were  probably  of  this  nature.  Treat- 
ment.— The  injury  is  fatal  in  the  majority  of  cases  before  help  can 
be  obtained  ;  if  not,  compression  of  the  carotid  trunk  or  ligature  of 
the  internal  carotid  in  the  neck  is  the  only  hope.  See  also  on  intra- 
orbital aneurism  (p.  324). 

4.  Intrameningeal  Hsemorrliage  arises  from  wounds  of  the  cerebral 
cortex  or  membranes  in  cases  of  fractured  skull,  or  from  concussion 
without  fracture.      The  blood  may  be  derived  from  the  veins  and 


776  A  MANUAL  CF  SURGERY 

capillaries  so  abundantly  present  in  the  pia  mater,  or  from  lesions  oi 
the  inner  wall  of  venous  sinuses,  or  even  from  the  middle  meningeal 
^artery,  if  the  dura  mater  is  also  opened.  It  may  be  widely  diffused 
over  the  surface  of  the  hemispheres,  or  be  more  localized.  It  is 
often  but  slowly  absorbed,  and  may  become  encapsuled,  constituting 
what  is  known  as  an  arachnoid  cyst — i.e.,  a  closed  cavity  containing 
serum,  the  walls  of  which  are  formed  of  fibrous  tissue  stained  brown 
with  hsematin. 

The  Symptoms  are  those  of  cerebral  compression,  supervening 
directly  on  concussion,  though  sometimes  after  a  conscious  interval. 
When  the  bleeding  is  not  very  severe,  the  coma  is  often  of  long 
duration,  though,  as  a  rule,  not  of  great  intensity.  Perfect  recovery 
may  ensue,  even  though  unconsciousness  is  prolonged  for  weeks ;  but 
adhesions  may  form  as  the  result  of  a  chronic  meningitis  lighted  up 
by  the  accident,  and  these  may  lead  to  subsequent  trouble.  No 
focal  symptoms  are  produced  unless  the  haemorrhage  arises  from  or 
presses  upon  the  motor  area,  when  convulsions,  or  later  on  paralysis, 
may  ensue.  If,  however,  the  blood  escapes  from  one  of  the  large 
venous  sinuses  in  the  base  of  the  skull — e.g.,  the  cavernous,  which 
may  be  torn  in  a  fractured  base — the  patient  may  pass  into  a  condition 
of  deep  coma  in  a  few  hours,  and  may  die  in  a  few  days. 

The  Treatment  is  symptomatic,  the  patient  being  kept  absolutely 
quiet,  and  all  excitement  and  noise  which  might  induce  cerebral 
congestion  excluded.  Should  there  be  any  focal  symptoms  indicating 
the  position  of  greatest  pressure,  or  should  there  be  some  concurrerlt 
lesion  of  the  skull,  the  trephine  may  be  applied  at  this  spot.  It 
must  not  be  forgotten,  however,  that  the  chief  haemorrhage  often 
occurs,  not  at  the  point  to  which  the  injury  was  directed,  but  at  an 
exactly  opposite  spot  on  the  other  side  of  the  cranium,  and  hence 
considerable  uncertainty  may  arise  both  as  to  the  advisability  of  an 
operation  and  as  to  its  site.  Should  the  right  locality  have  been 
exposed,  the  dura  mater  will  probably  bulge  into  the  wound,  after 
the  circle  of  bone  has  been  removed ;  it  is  blackish-blue  in  colour, 
owing  to  the  clot  lying  beneath  it,  and  the  cerebral  pulsations  will 
not  be  detected.  It  is  carefully  incised,  and  the  blood-clot  removed ; 
any  bleeding-points  should  be  tied  or  compressed,  and  it  may  be 
necessary  to  insert  a  small  wick  of  aseptic  gauze  for  a  day  or  two, 
in  order  to  drain  off  serum  and  blood. 

5.  Cerebral  Hsemorrliage  occurs  more  frequently  from  idiopathic 
causes  than  from  trauma,  except  in  the  case  of  severe  lacerations. 
In  the  more  aggravated  forms,  death  is  almost  certain  to  follow  in 
a  short  time  from  coma. 

p;''  Intracranial  Inflammation. 

Inflammation  of  the  cranial  contents  is  almost  always  bacterial  in 
origin,  and  may  follow  a  great  variety  of  lesions,  e.g. :  (i)  Injuries 
of  J  all  types,  but  especially  compound  or  punctured  fractures. 
(2T  Middle-ear  disease  is  perhaps  the  most  frequent  origin  of  these 
affections,  the    infection  reaching  the  brain  through  an  opening  in 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  777 

the  tegmen  tympani,  or  spreading  from  the  mastoid  process  along 
the  sigmoid  groove  in  which  lies  the  lateral  sinus.  (3)  It  may  extend 
inwards  from  scalp,  face,  nose,  or  neck  by  way  of  the  emissary  veins, 
or  even  along  the  sheaths  of  nerves.  (4)  It  may  accompany  simple 
contusion  of  the  cranial  bones  (p.  744),  as  a  result  of  an  auto- 
infective  inflammation  in  these  structures.  (5)  It  may  develop  as  a 
complication  of  pyaemia,  pneumonia,  scarlet  fever,  small-pox,  and 
other  general  infective  diseases. 

The  causative  bacteria  are  generally  of  the  usual  pyogenic  type, 
viz.,  staphylococci  and  streptococci,  when  the  inflammation  is  due  to 
traumatism  ;  but  the  pneumococcus  is  present,  as  a  rule,  when  the 
mischief  extends  from  the  middle  ear  or  accessory  nasal  sinuses.  In 
the  pus  of  cerebral  abscesses  the  B.  pyocyaneus  and  B.  coli  are  occa- 
sionally found.  In  the  so-called  idiopathic  form  of  diffuse  meningitis 
the  Diplococcus  intracellulans  of  Weichselbaum  is  generally  the  causa- 
tive organism. 

It  must  be  remembered  that  in  actual  practice  the  different  forms 
of  inflammation  described  below  run  into  one  another,  and  that 
the  resulting  symptoms  are  often  a  complex  mixture  of  several  types. 
For  descriptive  purposes  the  following  groups  may  be  differentiated  : 

(i.)  Subcranial  Inflammation  manifests  itself  either  as  a  simple 
thickening  of  the  dura  (pachymeningitis),  or  as  an  effusion  of  pus 
between  the  dura  and  the  bone  (subcranial  abscess). 

Simple  Pachymeningitis  results  either  from  a  slight  simple 
depressed  fracture,  or  from  a  contusion  with  or  without  a  fissured 
fracture,  or  from  the  gradual  spread  of  a  mild  infective  inflammation 
from  the  overlying  bone.  The  process  is  really  protective  in 
character,  the  dura  becoming  thickened.  It  may  extend  to  the  under 
surface  of  the  dura,  and  lead  to  a  localized  lepto-meningitis,  charac- 
terized by  adhesions  between  the  cortex  and  the  dura.  If  the  process 
extends  no  further,  the  clinical  manifestations  are  slight,  consisting 
merely  of  pain  and  localized  headache.  For  treatment,  see  chronic 
meningitis  (p.  781). 

In  some  forms  due  to  infection,  the  process  continues  and  leads  to 
an  acute  or  subacute  diffuse  meningitis. 

Subcranial  (or  Extradural)  Abscess  results  from  either  a  compound 
depressed  or  a  punctured  fracture,  in  which  the  dura  mater  is  only 
separated  from  the  bone  and  not  lacerated,  especially  when  the 
external  wound  is  small  and  efficient  drainage  is  not  obtained.  It 
sometimes  occurs,  however,  in  consequence  of  a  simple  contusion  or 
fracture  of  the  skull,  leading  to  a  detachment  of  the  membranes  and 
a  collection  primarily  of  blood  and  later  of  inflammatory  fluids  in  the 
cavity  thus  produced.  Microbic  invasion  is  here  due  to  auto-infec- 
tion, or  to  the  passage  of  organisms  through  the  bone.  Any  form 
of  osteo-myelitis  of  the  cranial  bones  may  determine  its  onset,  but 
apart  from  injury,  its  most  common  cause  is,  without  doubt,  exten- 
sion of  inflammation  from  the  middle  ear. 

A  perforation  of  the  tegmen  tympani  allows  of  the  invasion  of  the 
cran  al  cavity,  and  an  abscess  forms  above  the  attic,  which  perhaps 


778 


A  MANUAL  OF  SURGERY 


discharges  through  the  ear ,  in  other  cases  the  suppuration  extends 
along  the  groove  for  the  lateral  sinus.  In  the  former  instance  a 
localized  subdural  abscess  may  subsequently  develop,  limited  by 
meningeal  adhesions,  and  the  intervening  dura  mater  may  slough; 
in  the  latter,  thrombosis  of  the  lateral  sinus  may  follow. 

The  Symptoms  produced  are  (i)  those  generally  characteristic  of 
suppuration,  viz.,  a  high  temperature,  with  perhaps  rigors.  (2)  The 
signs  of  intracranial  pressure  in  the  form  of  fixed  headache  followed 
by  coma  are  also  present.  (3)  If  there  is  no  open  wound,  an  oedema- 
tous  swelling  of  the  scalp,  known  as  Potfs  puffy  tumour,  may  develop 
over  the  site  of  the  abscess  (Fig.  355).  When  there  is  a  compound 
fracture  of  the  skull,  the  margins  of  the  wound  look  unhealthy,  and 


Inflamed     CEdematous 
bone.        scalp  tissue. 


Subdural  space. 


Brain  covered 
by  pia  mater 
and  arachnoid. 


Fi*^'  355- — Subcranial  Suppuration,  involving  Overlying  Bone  and  causing 
AN  CEdematous  Condition  of  the  Scalp — Pott's  Puffy  Swelling  (Semi- 
diagrammatic).     (From  Treves'  '  System  of  Surgery.') 

at  its  base  may  be  seen  bare  bone,  yellow  and  dry,  from  which  the 
pericranium  has  separated,  with  perhaps  pus  oozing  out  between  the 
fragments.  If  the  pus  burrows  towards  the  base  of  the  skull,  optic 
neuritis  may  develop.  (4)  Focal  symptoms  of  spasm  or  paralysis 
may  complicate  the  case  if  the  dura  over  the  motor  area  is  involved. 
The  Treatment  of  such  a  condition  consists  in  evacuating  the  abscess 
cavity  through  a  sufficient  opening  made  by  trephining,  or  by  remov- 
ing loose  or  diseased  portions  of  bone,  and  providing  for  drainage. 
Sometimes  more  than  one  opening  is  required  for  this  purpose. 

When  the  affection  follows  middle-ear  mischief,  the  mastoid 
antrum  is  usually  opened  up,  as  also  the  attic,  and  a  sufficient 
amount  of  bone  gouged  or  cut  away  to  give  effective  drainage. 

(ii.)  Acute  Diffuse  Meningitis  (lepto -meningitis)  is  always  infective 
in  nature.  The  symptoms  vary  considerably  in  their  intensity 
according  to  the  site  and  method  of  inoculation  and  the  activity  of 
the  organisms,  but  the  whole  pio-arachnal  space  is  quickly  involved. 
The  superficial  part  of  the  brain  is  also  invaded  in  the  inflammation 
as  well  as  the  meninges,  and  the  term  *  meningo- encephalitis  '  would 
perhaps  be  the  better  appellation. 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  779 

The  Symptoms  appear  about  forty-eight  hours  after  an  injury, 
although  sometimes  infection  may  be  delayed  beyond  this  period.  In 
the  early  stages  the  patient  complains  of  severe,  constant,  and  in- 
creasing headache,  associated  with  heat  of  head,  a  forcible  pulsation 
of  the  carotids,  a  quick  pulse,  and  general  irritability  of  the  brain, 
as  indicated  by  vomiting,  intolerance  of  light  and  sound,  delirium,  ' 
and  perhaps  convulsive  twitchings  of  the  muscles,  not  only  of  the 
head  and  back,  but  also  of  the  extremities.  The  vomiting  is  of  the 
usual  cerebral  type — i.e.,  it  occurs  apart  from  nausea,  and  has  no  rela- 
tion to  the  ingestion  of  food.  High  fever  is  generally  present,  and 
possibly  a  rigor  may  occur  at  the  onset.  As  the  disease  progresses, 
the  patient  gradually  becomes  comatose,  the  pulse  slow  and  full,  the 
respirations  laboured,  and  death  usually  ensues  in  three  or  four  days. 

According  to  the  site  of  infection,  the  inflammatory  phenomena 
may  manifest  themselves  more  acutely  over  one  part  than  another,  and 
for  descriptive  purposes  two  chief  varieties  have  been  distinguished, 
viz.,  meningitis  of  the  convexity  and  meningitis  of  the  base.  The 
general  symptoms  are  alike  in  both  forms,  but  when  the  convexity  is 
involved,  convulsions  are  a  more  prominent  feature  in  the  case,  and 
may  at  first  be  limited  to  localized  groups  of  muscles  ;  whilst  in  basal 
meningitis  the  temperature  tends  to  run  higher,  the  head  and  neck 
are  more  retracted,  optic  neuritis  is  more  frequent,  and  some  form  of 
squint  is  not  uncommonly  observed. 

On  post-mortem  examination  the  skull-cap  is  separated  from  the 
meninges  with  some  difficulty ;  the  dura  mater  is  thick  and  congested, 
and  the  subjacent  veins  are  manifestly  distended ;  the  cerebro-spinal 
fluid  is  increased  in  amount,  and  turbid  from  admixture  with  lymph 
or  pus ;  the  arachnoid  is  thick  and  opaque ;  the  surface  of  the  con- 
volutions is  flattened  and  oedematous,  and  lymph  occupies  all  the 
sulci,  matting  them  together ;  the  cortical  gray  matter  is  usually  red 
and  congested ;  the  underlying  white  substance  ot  the  centrum  ovale 
is  injected,  numerous  puncta  cruenta  being  evident ;  the  ventricles 
are  distended  with  cerebro-spinal  fluid,  and  the  choroid  plexuses  are 
engorged  with  blood. 

The  Treatment  consists  in  shaving  the  head  and  applying  cold 
by  means  of  an  icebag  or  Leiter's  tubes,  care  being  taken  that  the 
application  is  continuous,  and  not  intermittent.  In  the  robust  general 
venesection  is  useful,  but  in  weaker  individuals  cupping  or  leeching 
may  replace  it.  The  bowels  are  freely  opened  and  a  bland  diet 
ordered.  The  patient  should  be  kept  absolutely  quiet  in  a  darkened 
room,  and  every  source  of  irritation  and  excitement  removed.  Even 
if  recovery  ensues,  it  is  somewhat  delayed,  and  similar  precautions 
as  to  quiet,  etc.,  must  be  maintained  for  some  time.  In  the  later 
stages,  blistering  of  the  scalp  or  neck,  and  the  administration  of 
mercury,  are  advisable. 

If  the  condition  is  due  to  a  localized  infective  lesion,  this  must, 
of  course,  be  dealt  with  by  suitable  means — e.g.,  the  middle  ear  must 
be  opened  up  and  diseased  bone  removed,  depressed  fractures  must 
be  operated  on,  and  localized  drainage  effected,  etc.     Apart  from  this, 


78o  A  MANUAL  OF  SURGERY 

attempts  have  been  frequently  made  to  relieve  che  symptoms  and 
determine  a  cure  by  means  of  operative  measures,  directed  towards 
reducing  the  intracranial  tension  ;  the  subarachnoid  space  has  been 
opened  below  the  tentorium,  whilst  others  have  successfully  employed 
lumbar  puncture,  repeating  it  frequently  (p.  761).  When  one  con- 
siders the  intricate  character  of  the  space  to  be  drained,  the  fact  that 
it  is  sure  to  be  subdivided  into  separate  cavities  by  deposits  of  lymph, 
and  especially  when  it  is  remembered  that  the  brain  substance  is 
itself  swollen,  and  that  the  important  fourth  ventricle  only  communi- 
cates with  the  subarachnoid  space  through  the  small  foramen  of 
Magendie,  which  is  certain  to  be  blocked  early  in  the  case — all  these 
considerations  go  to  prove  that  it  is  unlikely  that  much  success  will 
follow^  such  treatment. 

Collection  rf 
pus  Leneath 


'.rain  with 

ia  innlf-r 

nd  ar^icliiioid. 


Fig.  356. — Superficial  Abscess  of  Brain,  spreading  from  Subdural  Space 
(Semi-diagrammatic).     (From  Treves'  '  System  of  Surgery.') 

Acute  Meningo- encephalitis  is  sometimes  limited  in  character.  It 
can  only  occur  in  the  absence  of  tension,  diffusion  along  the  meninges 
being  prevented  by  the  formation  of  adhesions.  It  usually  results 
from  a  iocahzed  inflammation  of  bone  (Fig.  356),  due  to  a  contusion, 
a  penetrating  wound,  or  possibly  to  middle-ear  mischief.  The  pro- 
cess ends  in  the  formation  of  adhesions  between  the  brain  and  its 
membranes,  preceded  or  not  by  suppuration.  Of  course,  where  pus 
forms,  a  cure  can  only  be  established  by  operation. 

(iii.)  A  Subacute  form  of  meningitis  is  occasionally  met  with, 
coming  on  at  a  somewhat  later  date.  The  patient  may  have  ap- 
parently recovered  from  his  injury,  with  the  exception  of  a  fixed  pain 
in  the  head.  The  onset  of  the  symptoms  is  often  due  to  some  in- 
discretion, and  may  be  gradual  or  sudden.  In  all  probability  this 
affection  is  also  microbic  in  origin,  and  the  delay  in  its  appearance 
depends  either  on  the  small  number  of  bacteria  present,  or  on  their 
being  in  a  low  state  of  virulence  ;  or  possibly  they  have  been  latent 
for  a  time,  and  are  aroused  into  activity  by  secondary  causes  ;  or, 
again,  they  may  have  gradually  worked  their  way  inwards  along 
lymphatics  or  vessels  from   the   periphery  to  the   meninges.     The 


AFFECTIONS  OF  THE  BRAIN  AND  TTS  MEMBRANES  781 

symptoms  are  similar  in  character  to  those  of  acute  meningitis, 
though  somewhat  less  severe ;  but  a  fatal  result  is  very  apt  to  follow. 
In  the  treatment  of  this  form,  no  active  antiphlogistic  measures  should 
be  adopted,  since  the  patient's  condition  is  somewhat  asthenic. 
Absolute  rest  and  quiet  are  essential ;  counter-irritation  should  be 
applied  to  the  scalp  and  neck,  and  possibly  mercury  administered,  or 
some  absorbent  organic  salt  of  iodine. 

(iv.)  Ckronic  Lepto-meningitis  arises  from  very  similar  causes  to  the 
pachymeningitis  already  described  (p.  777),  but  in  addition  may  be 
associated  with  deep  lesions,  and  may  serve  to  limit  the  spread  of 
infection  ;  it  is  usually  of  a  protective  character.  Syphilitic  patients 
are  perhaps  more  liable  to  its  development  than  others.  It  is 
evidenced  by  infiltration  and  thickening  of  the  membranes,  which 
are  usually  adherent  to  one  another  and  to  the  cerebral  cortex.  It 
gives  rise  to  a  localized  headache,  which  is  constant,  and  increased 
on  excitement  or  the  injudicious  use  of  stimulants,  whilst  tenderness 
is  often  noted  on  deep  pressure,  and  traumatic  epilepsy  may  ensue. 
The  treatment  consists  in  attention  to  the  general  health,  free  action 
of  the  bowels,  abstinence  from  excitement  or  stimulants,  the  local 
application  of  counter-irritants,  and  the  administration  of  mercury 
or  iodolysin  (p.  644).  For  the  question  of  operating  for  traumatic 
epilepsy,  see  p.  792. 

(v.)  Tuberculous  Meningitis  is  a  condition  usually  seen  in  children, 
due  to  an  invasion  of  the  meninges  with  tubercle.  The  pial  vessels 
are  chiefly  affected,  and  the  base  of  the  brain  is  mainly  involved. 
Inflammatory  adhesions  follow,  and  the  free  circulation  of  the 
cerebro-spinal  fluid  is  checked  by  the  blocking  of  the  foramina  of 
Magendieand  Monro,  so  that  the  ventricles  are  often  distended.  For 
symptoms  and  clinical  history,  medical  text-books  must  be  consulted. 

Many  attempts  have  been  made  to  deal  with  this  affection  by 
surgical  means,  especially  by  trephining  through  the  occipital  region 
and  draining  away  the  cerebro-spinal  fluid,  so  as  to  relieve  pressure 
on  the  fourth  ventricle,  or  by  lumbar  puncture.  One  or  two  cases 
have  recovered  post  hoc,  but  the  prospects  of  success  are  poor. 

(vi.)  Infective  Thrombosis  of  the  Sinuses,  though  occasionally  seen 
after  injuries,  is  more  commonly  associated  with  suppurative  diseases 
of  the  bone  apart  from  trauma,  and  one  variety,  viz.,  that  affecting 
the  lateral  sinus,  is  almost  exclusively  caused  by  disease  of  the 
middle  ear.  It  is  also  induced  by  extension  from  scalp  injuries  as  a 
complication  of  subaponeurotic  cellulitis,  or  may  spread  inwards  from 
erysipelatous  or  pyogenic  lesions  of  the  face,  or  suppurative  conditions 
of  the  nose.  Putting  aside  the  results  of  chronic  otorrhoea,  the 
cavernous  sinus  is  much  more  frequently  involved  than  any  other, 
and  the  affection  is  often  secondary  to  suppuration  in  the  sphenoidal 
sinus. 

Pathologically,  the  same  manifestations  are  observed  as  in  any 
case  of  infective  phlebitis.  The  sinus  becomes  impervious  owing  to 
thrombosis,  and  the  clot  becomes  disintegrated  and  gives  rise  to 
multiple  emboli,  whilst  various  inflammatory  conditions  of  the  sur- 


782  A  MANUAL  OF  SURGERY 

rounding  tissues  necessarily  result — e.g.,  necrosis  or  caries  of  bones; 
subcranial  abscess  ;  meningitis,  simple  and  localized,  or  septic  and 
diffuse  ;  or  even  cerebral  or  cerebellar  abscess. 

The  symptoms  are  mainly  of  a  pysemic  nature.  The  temperature 
is  high,  but  with  remissions,  and  often  with  repeated  rigors  ;  fixed 
headache  and  early  and  continuous  vomiting  are  also  marked  features 
of  the  case.  With  these  may  be  associated  evidences  of  meningeal 
mischief,  or  of  pulmonary  trouble  in  the  shape  of  dyspncea,  but 
sometimes  diarrhoea  and  septicaemic  manifestations  may  be  the  more 
prominent. 

If  the  cavernous  sinus  is  involved,  marked  exophthalmos,  with 
congestion  of  the  orbit,  and  even  of  the  eyelids  and  face,  may  result, 
and  ptosis  or  squint  may  also  be  set  up  by  implication  of  the  nerves 
which  lie  in  the  walls  of  the  sinus. 

If  the  superior  longitudinal  sinus  is  affected,  there  may  be 
turgescence  of  the  veins  of  the  scalp  and  forehead,  together  with 
tenderness  along  the  line  of  the  sinus  and  epistaxis,  whilst  convul- 
sions may  be  induced  by  irritation  of  the  neighbouring  motor  area. 

For  local  results  and  treatment  of  thrombosis  of  the  lateral  sinus, 
see  p.  895. 

Treatment,  except  for  the  lateral  sinus,  is  but  rarely  possible,  and 
hence  the  importance  of  preventing  this  disease  by  a  most  careful 
attention  to  asepsis  in  the  surgery  of  the  face  and  of  the  nasal  cavity. 
For  the  lateral  sinus  much  can  be  done,  but  for  the  other  sinuses  all 
that  is  feasible  is  attention  to  general  measures. 

Abscess  of  the  Brain. 

Causes. — Pyogenic  infection  is,  of  course,  the  ultimate  cause  of  all 
cerebral  suppuration,  but  the  manner  in  which  the  organisms  lind 
their  way  to  the  brain  varies  considerably, 

(i.)  it  may  be  due  to  traumatism,  either  in  the  early  or  late  stages 
of  head  injuries.  In  the  early,  it  is  usually  superficial,  and  connected 
with  some  infective  lesion  of  the  scalp,  cranium,  or  membranes,  with 
or  without  a  penetrating  wound  (Fig.  356).  In  the  later  stages  the 
pus  forms  deeply  in  the  white  substance.  It  may  be  due  to  a  pene- 
trating wound,  whether  a  foreign  body  is  present  or  not,  the  microbes 
finding  their  way  into  the  interior  of  the  brain  either  through  the 
track  of  the  missile,  or  along  bloodvessels  or  lymphatics.  Some- 
times it  occurs  apart  from  penetration,  and  then  one  can  only  suppose 
that  it  is  due  to  auto-infection  of  a  contused  or  lacerated  area. 
Chronic  abscess  of  this  type  is  most  frequently  seen  on  the  same 
side  of  the  brain  as  the  lesion,  and  the  parietal  and  frontal  lobes  are 
most  often  affected  ;  occasionally,  however,  it  may  occur  on  the  oppo- 
site side  in  the  same  way  as  a  contusion. 

(ii.)  It  arises  by  extension  of  an  infective  lesion  from  without,  the 
organisms  reaching  the  brain  by  direct  continuity  of  tissue,  or  by  way 
of  the  bloodvessels  or  lymphatics.  The  commonest  cause  of  all 
abscesses  in  the  brain  is  chronic  otorrhasa,  and  the  cerebellum  is  nearly 
as  frequently  involved  as  the  cerebrum.     In  the  former  the  abscess 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  783 

is  usually  in  the  anterior  portion  of  the  lateral  lobe,  close  to  the  back 
of  the  petrous  bone,  whilst  in  the  latter  the  posterior  portion  of  the 
temporo-sphenoidal  lobe  is  most  frequently  affected.  The  inflamma- 
tion may  spread  directly  from  the  tympanic  cavity  or  inner  aspect 
of  the  mastoid  process  through  the  bone  to  the  membranes,  which 
become  adherent  to  the  brain,  and  then  into  the  cerebral  substance. 
Occasionally  a  subcranial  abscess  is  first  developed,  and  the  cerebral 
affection  follows  ;  sometimes  a  direct  opening  has  been  found  through 
the  tegmen  tympani  into  an  abscess  cavity,  and  the  abscess  has 
even  discharged  itself  and  b^en  drained  in  this  direction.  More 
commonly  a  layer  of  brain  tissue  intervenes  between  the  membranes 
and  the  pus,  and  then  infection  will  have  been  carried  along  vessels 
and  lymphatic  sheaths  running  from  the  meninges  to  the  brain,  or 
vice  versa. 

Abscesses  of  a  similar  type  occur  in  connection  with  suppuration 
in  the  frontal  sinus,  the  abscess  being  usually  acute  and  secondary 
to  a  frontal  osteo-myelitis,  and  occupying  the  anterior  portion  of  the 
frontal  lobe :  it  may  also  follow  purulent  infection  of  the  sphenoidal 
and  ethmoidal  sinuses,  or  thrombosis  of  the  cavernous  sinus. 

(iii.)  The  infective  material  may  be  brought  to  the  brain  by  the 
blood  in  pyaernia,  or  after  some  of  the  exanthemata,  such  as  scarlatina, 
typhoid,  etc.  Abscess  of  the  occipital  lobe  is  almost  always  of 
pyaemic  origin. 

(iv.)  A  chronic  abscess  of  tuberculous  origin  may  also  occur. 

A  cerebral  abscess  is  usually  single ;  occasionally  more  than  one 
is  present,  e.g.,  a  cerebral  and  cerebellar  may  co  exist  in  connection 
with  middle-ear  mischief.  The  course  taken  by  the  case  is  generally 
chronic,  and  then  the  pus  is  encapsuled ;  in  acute  cases  there  is 
usually  no  limiting  membrane.  A  chronic  case  not  uncommonly 
terminates  in  an  outbreak  of  acute  symptoms,  due  either  to  the 
abscess  bursting  into  one  of  the  lateral  ventricles,  or  to  the  super- 
vention of  spreading  oedema. 

The  Symptoms  vary  somewhat  with  the  method  of  onset  and  the 
characters  of  the  abscess.  If  traumatic  and  due  to  infection  from 
without,  the  case  runs  an  acute  course,  associated  with  intense  pain 
in  the  head,  recurrent  rigors,  and  rapid  development  of  coma. 
Diffuse  meningitis  is  often  present,  and  the  two  conditions  can 
scarcely  be  distinguished.  In  not  a  few  of  the  cases  of  chronic 
abscess,  all  that  the  patient  complains  of  is  headache,  until  suddenly 
the  temperature  rises  with  a  bound ;  he  becomes  unconscious  and 
dies  within  a  day  or  two.  Such  a  course  of  events  is  probably  due 
to  the  bursting  of  the  abscess  into  the  lateral  ventricle  or  meningeal 
cavity,  or  to  the  onset  of  an  acute  spreading  cedema. 

When  the  symptoms  are  more  characteristic.  Sir  W.  Macewen 
describes  them  in  three  well-marked  stages,  (i.)  In  the  Initiatory 
Stage,  which  lasts  from  twelve  hours  to  two  or  three  days,  the  patient 
is  suddenly  seized  with  severe  pain  in  the  region  of  the  ear,  radiating 
perhaps  throughout  the  head,  and  accompanied  by  a  rigor  of  some 
severity.     The  temperature  and  pulse  are  both  raised,  and  vomiting 


7S4  ^   MAIWAL  OF  SURGERY 

of  a  cerebral  type  is  presenc ;  the  tongue  is  foul,  whilst  anorexia  and 
constipation  are  well  marked.  During  this  period  the  otorrhoea 
diminishes,  or  ceases  entirely. 

(ii.)  In  the  Fully-developed  Stage  the  patient  lies  quietly  in  bed  in  a 
dull,  apathetic  condition,  able  to  answer  questions  but  slowly,  and 
with  his  brain  evidently  in  a  torpid  state.  The  headache  has  to  a 
great  extent  ceased,  but  tenderness  over  the  temporo-mastoid  region 
still  remains.  The  temperature  gradually  falls  and  becomes  sub- 
normal ;  the  pulse  is  slow  and  full ;  and  respiration  is  usually  slow. 
The  vomiting  and  constipation  continue,  and  the  patient's  mouth  and 
breath  become  very  offensive.  The  power  of  movement  usually 
remains,  but  focal  symptoms  may  manifest  themselves,  though  in 
many  cases  of  temporo-sphenoidal  abscess  they  are  not  marked.  If 
the  cortex  is  mainly  involved,  the  face  is  first  affected,  then  the  arm, 
and  finally  the  leg ;  but  if  the  abscess  is  deeper  and  presses  on  the 
motor  fibres  in  the  internal  capsule,  the  order  in  which  these  parts 
are  involved  is  reversed.  Motor  aphasia  is  sometimes  well  marked 
when  the  abscess  is  on  the  left  side.  If  the  abscess  is  placed  pos- 
teriorly, it  may  press  on  the  cerebellum  through  the  tentorium,  and 
cause  symptoms  of  a  cerebellar  type.  Optic  neuritis  is  a  somewhat 
unreliable  sign,  but  if  present  is  more  marked  on  the  affected  side, 
whilst  the  corresponding  pupil  is  dilated  and  fixed. 

(iii.)  The  Terminal  Stage  is  marked  by  a  gradually  increasing  un- 
consciousness and  death ;  or  the  abscess  may  burst  into  the  lateral 
ventricle,  causing  sudden  coma,  a  rapid  rise  of  temperature  and  pulse, 
irregular  respirations  (often  of  a  Cheyne-Stokes  type),  and  death  ;  or 
it  may  burst  into  the  subarachnoid  space,  and  then  death  is  preceded 
by  symptoms  of  diffuse  lepto-meningitis. 

The  signs  connected  with  a  small  Cerebellar  Abscess  are  often  very 
indefinite  and  vague,  but  if  the  abscess  increases  in  size,  the  symptoms 
may  become  very  characteristic.  The  patient  complains  of  giddiness, 
and  staggers  when  attempting  to  walk,  falling  towards  the  opposite 
side.  The  head  and  neck  are  retracted  ;  respiration  is  irregular  and 
feeble  ;  the  pulse  is  often  slow  and  weak  ;  paralysis  may  be  noted  on 
one  or  both  sides  of  the  body,  and  may  only  affect  the  upper 
extremity  ;  of  course,  vomiting,  optic  neuritis,  and  a  low  temperature 
are  present. 

Diagnosis. — 'From,  meningitis,  a  cerebral  abscess  is  usually  recognised 
by  the  fact  that  in  the  former  condition  irritative  phenomena,  such  as 
acute  and  active  delirium,  contraction  of  the  pupil,  photophobia, 
rigidity  and  spasm  of  muscles,  especially  in  the  back  of  the  neck,  and 
severe  pain,  are  more  evident  and  are  produced  earlier.  The  tem- 
perature is  usually  high,  and  mental  dulness  comes  on  within  three 
or  four  days  of  an  injury,  whereas  an  abscess  rarely  forms  before  the 
end  of  the  first  week.  Extradural  abscess  (subcranial)  is  associated 
with  a  high  temperature,  earlier  onset  after  an  injury  in  traumatic 
cases,  and  more  rapid  compression  symptoms  ;  optic  neuritis  is  un- 
usual, and  the  vomiting  is  less  troublesome.  There  is  also  likely 
to  be  some  localized  oedema  or  tenderness  on  deep  pressure.     In 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  785 

throinbosts  of  the  lateral  sinus  the  temperature  is  high  and  oscillating, 
optic  neuritis  may  be  absent,  and  there  may  be  the  characteristic 
tenderness  in  the  neck  along  the  course  of  the  internal  jugular;  in 
abscess  symptoms  of  compression  are  associated  with  a  low  tem- 
perature and  marked  optic  neuritis.  It  must  not  be  forgotten  that 
the  two  conditions  may  co-exist.  It  is  often  impossible  to  diagnose 
between  a  chronic  abscess  and  a  tumour  of  the  brain ;  the  symptoms 
in  the  latter  usually  come  on  more  slowly  than  in  the  former,  but  the 
progress  is  steady  and  unrelenting  ;  the  temperature  remains  near 
the  normal,  and  there  is  less  gastric  disturbance.  The  history  of  the 
case  may  throw  some  light  upon  its  nature,  since  in  cases  of  cerebral 
abscess  there  is  generally  some  causative  septic  focus.  Tumour  is 
more  common  in  the  frontal  and  parietal  regions,  abscess  in  the 
temporo-sphenoidal  lobe.  Optic  neuritis  is  more  marked  and  more 
common  in  tumour  than  in  abscess. 

Treatment  necessarily  follows  the  usual  rule,  viz.,  to  give  an  exit 
to  the  pus  as  soon  as  possible  ;  no  delay  is  permissible  when  once  the 
diagnosis  is  certain.  The  patient  is  prepared  in  the  same  way  as  for 
operation  on  a  cerebral  tumour  (p.  789).  A  flap  of  scalp  tissue  is 
raised,  and  in  such  a  manner  as  will  most  effectually  serve  for  subse- 
quent drainage  purposes.  The  trephine  is  applied  according  to  the 
rules  given  below,  or  in  accordance  with  the  special  indications  given 
by  the  symptoms  of  the  case.  Sir  W.  Macewen  recommends  that, 
(vhen  the  circle  of  bone  has  been  removed,  the  exposed  surface  and 
cut  edge  should  be  well  rubbed  over  with  powdered  iodoform  and 
boracic  acid,  so  as  to  guard  them  from  infection.  The  dura  mater, 
which  bulges  into  the  wound  and  does  not  pulsate,  is  then  carefully 
incised.  A  mere  slit  often  suffices,  and  this  may  open  the  abscess  ; 
but  more  usually  the  brain  substance  protrudes.  It  is  carefully 
explored  with  a  pair  of  sinus  forceps,  which  is  passed  directly  into 
it  in  various  directions,  or  with  a  fine  trocar  and  cannula.  In  a 
temporo-sphenoidal  abscess  the  most  likely  direction  to  explore  is 
downwards  and  inwards  towards  the  tegmen  tympani.  Pus,  when 
discovered,  is  allowed  to  escape  by  opening  the  blades  of  the  sinus 
forceps.  Sloughs  are  not  uncommonly  present  in  the  cavity,  and  are 
removed  by  the  gentle  introduction  of  a  curette,  whilst  it  is  wise  to 
wash  out  the  interior  by  gentle  irrigation  with  sterilized  salt  solution. 
A  drainage-tube  is  advisably  inserted,  and  may  be  kept  in  position  by 
stitching  it  to  the  margins  of  the  incision  in  the  dura,  which  is  closed 
except  for  the  passage  of  the  tube.  Sometimes  it  is  wiser  not  to 
close  the  flaps  around  the  tube,  but  to  pack  gauze  round  it,  thereby 
determining  the  formation  of  adhesions,  which  will  serve  to  shut  off 
and  guard  from  infection  the  meningeal  cavity.  The  scalp  flap  is 
replaced  in  position,  the  tube  being  brought  out  through  its  centre, 
if  need  be.  The  tube  is  retained  in  position  for  two  or  three  days, 
and  is  then  removed.  Symptoms  of  re-accumulation  or  of  extension 
of  the  mischief  to  the  meninges  will,  of  course,  necessitate  a  re-open- 
ing of  the  wound,  and  the  institution  of  free  and  effective  drainage. 

50 


786  A  MANUAL  OF  SURGERY 

Occasionally  a  hernia  cerebri  develops  as  the  result  of  opening  a- 
cerebral  abscess. 

For  an  abscess  in  the  temporo-sphenoidal  lobe,  the  centre-pin  of 
the  trephine  may  be  placed  i^  inches  above  Reid's  base-line,  and 
directly  above  the  external  auditory  meatus  ;  but  a  better  situation 
is  a  spot  I  inch  above  the  posterior  root  of  the  zygoma,  and  directly 
above  the  posterior  border  of  the  osseous  meatus  (Macewen ; 
Fig.  357,  D).  For  an  abscess  in  the  cerebellum  the  point  selected 
is  i^  inches  behind  the  centre  of  the  external  auditory  meatus,  and 
^  inch  below  the  base-line  (Fig.  357,  E).  In  the  latter  case  the  soft 
parts,  including  the  muscles  and  periosteum,  should  be  stripped  off 
the  occipital  bone,  and  turned  downwards,  and  it  is  usually  inadvisable 
to  apply  a  trephine,  as  the  bone  is  very  thin,  and  may  be  broken 
through  with  a  gouge.  It  is  often  necessary  to  carry  through  the 
cerebellar  operation  rapidly,  as  the  respirations  sometimes  stop  under 
an  anaesthetic,  though  the  heart  continues  to  beat  forcibly  ;  as  soon 
as  the  dura  is  opened,  the  respirations  recommence. 

In  middle-ear  disease  the  diagnosis,  both  as  to  the  presence  of  an 
abscess  and  its  situation,  is  often  doubtful.  The  antrum  and  attic 
are  then  opened  and  explored  thoroughly,  and  according  to  whether 
the  disease  is  more  marked  in  the  former  or  latter,  the  further  steps 
of  the  operation  are  directed  towards  the  cerebellum  or  cerebrum. 
By  carefully  removing  bone  behind  and  above  the  antrum,  the  lateral 
sinus  is  exposed  ;  and  by  working  above  or  below  it,  the  cerebrum 
or  cerebellum  can  be  examined,  and,  if  need  be,  incised.  A  similar 
result  can  be  obtained  by  applying  a  |-inch  trephine  to  a  spot  i  inch 
behind  the  meatus  and  ^  inch  above  the  base-line  (H.  P.  Dean). 
The  lateral  sinus  lies  in  the  lower  portion  of  the  opening,  and  the 
dura  over  the  temporo-sphenoidal  lobe  in  the  upper  ;  by  enlarging  the 
opening  downwards  by  Hoffman's  rongeur,  the  cerebellum  can  also 
be  explored. 

Cerebral  Tumours. 

The  chief  Varieties  of  new  growth  met  with  in  the  brain  are  as 
follows :  (i.)  Glioma,  which  consists  of  a  small  round-celled  neoplasm 
with  a  very  delicate  intercellular  substance,  similar  in  character  to 
the  neuroglia  (p.  205) ;  it  may  occur  in  any  part  of  the  brain.  It 
is  always  continuous  with  the  surrounding  cerebral  tissue,  and  is 
scarcely  ever  encapsuled,  so  that  to  the  naked  eye  it  may  be  indistin- 
guishable from  brain  substance,  although  rather  harder,  and  hence 
its  limits  can  seldom  be  accurately  defined.  (ii.)  Sarcomata  also 
occur,  and  occasionally  psammomata  (p.  221)  and  secondary  carcino- 
matous deposits,  (iii.)  Tuberculous  foci  are  met  with  either  associated 
with  or  apart  from  any  meningeal  infiltration,  varying  in  size  con- 
siderably, and  may  be  either  firm  and  caseous,  or  with  a  diffluent 
centre,  (iv.)  Gummata  of  the  brain  usually  spring  from  the  meninges, 
and  are  more  irregular  in  shape  than  tuberculous  masses,  (v.)  Occa- 
sionally hydatid  cysts  are  found,  as  also  other  less  common  conditions. 


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788  A  MANUAL  OF  SURGERY 

Cerebral  tumours  are  more  often  observed  in  males  than  in 
females,  and  the  different  forms  occur  at  varying  periods  of  life. 
Thus,  glioma  and  sarcoma  are  most  common  at  puberty  or  in  middle 
life ;  tuberculous  foci,  in  children ;  gummata,  in  the  fourth  or  fifth 
decade ;  carcinomata,  in  middle  or  late  life ;  and  parasitic  tumours 
in  the  second  and  third  decades. 

The  local  effects  of  a  cerebral  tumour  may  be  to  cause  some  amount 
of  sclerosis  of  the  surrounding  brain  substance,  whilst,  if  super- 
ficial, the  membranes  may  become  adherent  and  the  overlying  bone 
thickened  or  eroded.  Erosion  and  enlargement  of  the  sella  turcica 
can  be  shown  by  the  X  rays  in  cases  of  tumour  of  the  pituitary  body. 

The  Symptoms  of  a  cerebral  tumour  can  be  classified  as  follows : 
(i)  Those  due  to  increased  intracranial  pressure,  such  as  fixed  head- 
ache, giddiness,  epilepsy,  loss  of  memory,  and  stupor,  finally  ending 
in  coma.  The  headache  varies  much  in  character,  but  is  usually 
localized,  occurs  in  severe  paroxysmal  attacks,  and  is  often  asso- 
ciated with  tenderness  on  deep  pressure  over  the  scalp.  It  is  increased 
by  anything  that  causes  passive  congestion  of  the  brain,  such  as 
coughing,  and  it  is  most  important  to  note  that  the  sites  of  the 
maximum  pain  and  of  the  tumour  often  correspond.  Occasionally 
coma  and  a  fatal  issue  supervene  suddenly  as  a  result  of  acute 
spreading  oedema  (p.  768).  (2)  Vomiting  and  constipation  are  also 
very  marked  phenomena,  associated  with  loss  of  appetite,  foul  breath, 
and  great  emaciation.  The  vomiting  bears  no  relation  to  the  ingestion 
of  food,  and  is  not  preceded  by  nausea.  It  often  develops  concur- 
rently with  the  pain,  or  may  relieve  it,  and  is  most  common  in 
subtentorial  tumours.  The  temperature  is  usually  subnormal,  but 
if  there  is  any  basal  meningitis  it  may  be  elevated.  (3)  Optic 
neuritis  is  generally  present,  and  is  supposed  to  be  due  either  to  the 
increased  intracranial  pressure,  causing  obstruction  to  the  return  of 
blood  from  the  eye  to  the  cavernous  sinus,  or  to  a  descending  neuritis, 
or  possibly  to  both.  In  some  cases  this  condition  may  be  more 
marked  on  the  side  of  the  lesion,  but  is  generally  bilateral.  In  the 
early  stages,  the  clear  definition  of  the  disc  margin  becomes  obscured, 
and  the  retinal  veins  congested  and  tortuous;  the  retina  is  oedematous, 
so  that  the  vessels  are  only  seen  at  intervals,  and  linear  ecchymoses 
may  also  occur.  If  the  patient  lives  long  enough,  atrophy  of  the  disc 
follows.  In  the  early  stages  vision  may  be  but  little  affected,  but,  as 
a  rule,  it  is  considerably  impaired  towards  the  end.  The  occur- 
rence of  this  result  must  not  be  overlooked  in  giving  a  prognosis, 
because  even  in  cases  that  recover  (as  by  encapsulation  of  a  tuber- 
culous focus  or  disappearance  of  a  gumma  after  large  doses  of 
iodide)  considerable  impairment,  or  even  total  loss,  of  vision  may  per- 
sist. (4)  Focal  symptoms  are  of  great  value  for  localizing  the  lesion. 
Irritative  phenomena  are  first  produced,  and  subsequently  paralysis. 
If  the  cortex  of  the  motor  area  is  involved,  Jacksonian  epilepsy  often 
follows,  with  an  aura  corresponding  to  the  centre  mainly  affected ; 
the  convulsions  spread  in  a  regular  order,  and  may  involve  the 
opposite  side  of  the  body  and  even  produce  unconsciousness.     At  a 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  789 

later  date  localized  paralysis  may  occur.  When  the  subcortical  white 
substance  is  the  focal  point,  paralysis  ensues  early,  apart  from  spas- 
modic phenomena.  Affections  of  the  functions  of  sensation,  vision, 
speech,  hearing,  etc.,  are  produced  when  other  parts  of  the  brain  are 
involved ;  but  we  must  refer  students  to  text-books  of  medicine  for 
a  further  consideration  of  these  lesions.  The  surgeon  is  seldom 
called  upon  to  make  a  diagnosis  in  these  cases,  and  therefore  the  full 
details  of  this  intricate  subject  will  not  be  considered  here. 

Treatment. — In  every  case,  the  possibility  of  the  symptoms  being 
due  to  gummatous  disease  must  not  be  forgotten,  and  hence  a 
Wassermann's  reaction  should  always  be  undertaken  ;  if  positive,  an 
intravenous  injection  of  salvarsan  may  be  given,  or  large  and 
increasing  doses  of  iodide  of  potassium  (even  up  to  40  or  60  grains 
three  or  four  times  a  day)  should  be  administered,  together  with  the 
inunction  of  mercury,  before  undertaking  operative  proceedings. 
Symptoms  of  gastric  irritation  must  be  prevented  by  giving  some 
alkaline  carbonate  (especially  the  ammonium  or  soda  salts),  whilst 
the  dose  should  be  freely  diluted  with  water. 

Operation. —  It  is  most  desirable  that  this  should  be  undertaken  as 
early  as  possible,  since,  even  if  no  tumour  exists,  the  patient  runs 
but  little  serious  risk,  whilst  delay  until  all  the  classical  symptoms 
are  well  marked  may  prevent  the  total  removal  of  the  growth. 

The  scalp  should  be  entirely  shaved  a  day  or  two  previously,  and 
very  thoroughly  purified.  A  quarter  of  a  grain  of  morphia  is  injected 
about  half  an  hour  before  the  operation,  with  the  idea  both  of 
reducing  the  vascularity  of  the  brain  and  of  dulling  the  patient's 
sensations,  so  that  a  smaller  amount  of  anaesthetic  is  subsequently 
needed.  Chloroform  should  be  employed  rather  than  ether,  as  it 
produces  less  congestion  of  the  head.  The  surgeon  marks  the 
supposed  site  of  the  growth  on  the  skull  with  a  bradawl  through  the 
scalp.  A  large  semicircular  flap  is  then  turned  down,  exposing  a 
considerable  area  of  the  calvarium,  so  that,  if  a  larger  amount  of  bone 
than  is  expected  needs  to  be  removed,  no  fresh  scalp  incisions  are 
required ;  moreover,  the  cicatrix  will  in  this  way  be  prevented  from 
tormmg  over  the  opening.  One  of  the  methods  of  opening  the 
cranium  already  described  (p.  759)  is  then  employed  ;  the  further 
proceedings  on  the  brain  are  carried  out  at  once,  or  the  intracranial 
portion  of  the  procedure  is  delayed  for  a  week  or  so.  Under 
such  circumstances  the  wound  is  re-opened,  and  the  dura  mater 
exposed. 

The  dura  mater  when  laid  bare  under  normal  conditions  is  firm, 
but  yields  slightly  to  the  finger,  and  allows  the  pulsation  of  the  sub- 
jacent brain  to  be  felt,  if  the  latter  is  healthy  and  no  undue  pressure 
is  present  within ;  but  if  the  intracranial  tension  is  markedly  increased, 
the  dura  mater  bulges  into  the  wound,  feels  firm  and  unresisting, 
and  the  cerebral  pulsations  are  diminished  or  absent. 

The  dura  mater  is  next  incised  crucially,  or  a  flap  turned  down, 
care  being  taken  to  avoid,  if  possible,  the  main  meningeal  vessels ;  the 
brain  substance  protrudes  if  the  intracranial  pressure  is  excessive. 


790  A  MANUAL  OF  SURGERY 

The  region  is  gently  explored  by  the  finger,  and  any  areas  of 
abnormal  hardness  or  softening  noticed ;  failing  this,  a  grooved 
needle  is  inserted  in  different  directions,  or  a  fine  trocar  and  cannula. 
In  introducing  such  instruments,  care  must  be  taken  to  make  direct 
stabs,  and  never  any  lateral  movements,  -which  necessarily  lead  co 
laceration  of  the  brain.  The  opening  of  the  skull  may  be  enlarged, 
if  need  be,  either  by  the  use  of  the  bone  rongeur  or  by  additional 
small  trephine  holes.  It  is  but  rarely  that  a  cerebral  tumour  is  so 
placed  that  enucleation  is  possible ;  it  is  estimated  that  not  more  than 
lo  per  cent,  of  all  cerebral  tumours  are  removeable.  If,  however,  a 
cortical  neoplasm  is  found,  it  is  isolated  from  the  surrounding  brain 
substance  by  blunt  instruments — e.g.,  the  handle  of  a  scalpel,  or  a 
flexible  knife,  made  of  platinum,  as  suggested  by  Horsley — and  the 
mass  freely  removed.  Hsemorrhage  is  controlled  b}'  the  application 
of  fine  ligatures,  or  by  pressure  with  a  hot  sponge  for  a  few^  minutes. 
The  dura  mater  is  then  loosely  stitched  together,  and  a  drainage- 
tube  inserted,  reaching  to  the  bottom  of  the  wound,  and  brought  out 
at  one  angle  of  the  incision  in  the  skin,  which  may  be  closed  by 
a  continuous  suture.  If  a  small  tumour,  and  presumably  non- 
malignant,  has  been  satisfactorily  enucleated,  the  disc  of  bone  may 
be  replaced,  room,  however,  being  left  for  the  passage  of  the  tube ; 
but  if  there  is  any  doubt  as  to  its  complete  removal,  the  opening  in 
the  bone  is  left.  After  the  operation,  the  patient  must  be  kept 
absolutely  quiet,  with  the  head  slightly  raised.  The  drainage-tube 
is  removed  in  twenty-four  or  forty-eight  hours,  and  the  scalp  wound 
is  usually  healed  in  six  or  seven  days. 

Even  if  the  tumour  is  inaccessible  or  irremoveable,  temporary 
benefit  often  results  from  an  exploratory  operation  which  may  be 
enlarged  in  its  scope  so  as  to  constitute  a  decompression.  Thus  in  a 
case  of  irremoveable  tumour  of  the  cerebellum,  almost  the  whole 
of  the  occipital  bone  w-as  removed,  the  gap  reaching  forwards  to  the 
mastoid  process  on  either  side,  and  nearly  down  to  the  foramen 
magnum.  The  dura  mater  was  opened,  and  a  large  subcutaneous 
hernia  cerebri  was  allowed  to  form.  By  such  a  measure  intracranial 
tension  is  relieved,  as  evidenced  by  an  improved  mental  condition 
and  loss  of  pain  :  optic  neuritis  may  be  hindered  in  its  progress, 
blindness  prevented,  and  the  patient's  life  appreciably  pro- 
longed. Sooner  or  later  the  continued  growth  of  the  tumour 
will  lead  to  death  from  cerebral  compression. 

The  Surgical  Treatment  of  Epilepsy. 

It  would  be  w^aste  of  time  to  discuss  the  many  surgical  procedures 
which  have  been  suggested  in  this  connection,  mainly  with  the  idea  of 
modifying  the  cerebral  circulation.  The  onl}'  operation  now  seriously 
considered  is  that  dealing  directly  with  the  cerebral  cortex,  a  proceed- 
ing dependent  on  the  supposition  that  the  epileptic  convulsion  is  a 
symptom,  and  not  in  itself  a  disease,  and  that  it  results  from  an 
irritable  condition  of  the  cortex,  which  may  be  excited  into  convul- 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  791 

sive  accivity  by  various  stimuli,  originating  either  in  the  brain  or 
elsewhere.     Sir  Victor  Horsley*  classifies  epilepsy  as  follows  : 
(i)  Idiopathic  (with  no  gross  lesion). 

{a)  Onset  localized  (focal). 

(b)  Onset  generalized. 

(2)  Jacksonian  (always  some  gross  lesion  or  traumatism). 

(a)  Traumatic  (with  local  or  general  convulsion). 

(b)  Congenital. 

(c)  Neoplastic  (tumour,  abscess,  aneurism). 

(3)  Reflex  (injury  of  spine,  nerves,  etc.). 

(4)  Hystero-epilepsy. 

As  regards  the  characteristic  symptoms  and  pathological  pheno- 
mena found  in  many  of  these  conditions^  students  must  refer  to 
medical  text-books. 

Before  discussing  the  individual  groups  from  the  surgical  stand- 
point, one  or  two  general  considerations  must  be  noted.  In  the  first 
place,  the  prognosis  is  gravely  modified  by  the  length  of  time  that  the 
epileptic  habit  has  persisted,  and  if  traumatic  cases  have  lasted  two 
years  the  outlook  is  very  unsatisfactory.  A  careful  study  should  also 
be  made  of  the  family  history  as  to  the  existence  or  not  of  a  neurotic 
predisposition  ;  in  many  cases  of  traumatic  epilepsy  this  is  well- 
marked,  and  then  the  outlook  is  correspondingly  bad. 

It  is  now  generally  recognised  that  operation  is  useless  in  the 
idiopathic  variety,  even  when  the  onset  is  accompanied  by  focal 
symptoms. 

Congenital  epilepsy  is  often  more  or  less  of  the  Jacksonian  type, 
and  usually  depends  on  some  injury  sustained  during  birth.  It  is 
frequently  associated  with  other  evidences  of  cerebral  mischief 
(spasm,  paralysis,  etc.)  and  with  defective  growth.  If  taken  early, 
and  if  the  convulsions  still  remain  localized,  some  good  may  follow 
operation ;  but  if  allowed  to  persist  too  long,  the  disease  is  irremedi- 
able by  surgical  means. 

When  due  to  tumours,  abscess,  etc.,  epilepsy  is  accompanied  by 
other  manifestations,  which  should  guide  the  surgeon  to  a  correct 
opinion  as  to  the  nature  of  the  case  and  the  operative  outlook. 

Reflex  epilepsy  is  rare,  and  may  perhaps  be  cured  by  dealing  with 
the  causation  focus.  As  regards  hystero-epilepsy,  the  surgeon  must 
never  be  tempted  to  undertake  such  a  measure  as  double  oophorec- 
tomy, which  has  been  tried  again  and  again,  and  found  wanting. 

Traumatic  Epilepsy  is  the  term  applied  to  an  epileptic  condition 
resulting  from  injuries.  It  may  arise  from  any  of  the  following  con- 
ditions:  (i)  A  neuralgic  and  irritable  cicatrix  in  the  scalp;  (2)  a 
slight  unrelieved  depression  of  the  skull ;  (3)  excessive  formation  of 
callus  after  a  fissured  fracture,  or  chronic  thickening  of  the  bone 
from  osteitis  after  a  contusion,  whereby  the  dura  mater  is  pressed 
upon  and  irritated  ;  (4)  chronic  meningitis,  usually  associated  with 
an  adherent  cicatrix  in  the  brain,  and  particularly  liable  to  occur  in 

*  Trans.  Medical  Society  of  London,  February  9,  1903. 


792  A  MANUAL  OP  SURGEliV 

syphilitic  patients  ;  (5)  a  single  depressed  spicule  of  bone  projecting 
into  the  cerebral  substance. 

The  Symptoms  produced  are  epileptic  seizures  of  the  Jacksonian 
type,  the  exact  manifestations  varying  with  the  portion  of  cerebral 
cortex  which  is  involved.  Localization  of  the  lesion  depends  partly 
on  the  character  of  the  aura,  partly  on  the  associated  symptoms, 
such  as  a  fixed  headache  or  the  presence  of  a  cicatrix.  The  convul- 
sions are  locahzed  to  begin  with,  but  often  become  general. 

Operative  Treatment  is  only  applicable  in  those  cases  in  which  the 
convulsions  remain  localized ;  general  convulsions  place  the  patient 
in  the  category  of  idiopathic  epileptics  with  a  focal  onset.  The  skull 
is  opened  over  the  site  of  the  supposed  injury,  and  it  may  be  that 
some  depressed  fragment  or  spicule  of  bone  is  found ;  it  will,  of 
course,  be  removed.  If,  however,  nothing  is  found  but  an  adherent 
cicatrix  between  the  membranes  and  the  underlying  brain,  it  is  still 
an  open  question  as  to  whether  the  surgeon  should  proceed  further. 
In  a  considerable  number  of  cases  the  cicatrix  and  underlying  brain 
substance  have  been  removed  ;  the  fits  ceased  for  a  time,  but  in  most 
instances  recurrence  followed  sooner  or  later  from  the  formation  of  a 
fresh  adherent  cicatrix.  Possibly  the  introduction  of  a  sheet  of 
sterilized  gold  or  silver  foil  between  the  brain  substance  and  the 
membranes  will  suffice  to  prevent  this  occurrence.  The  locality  of 
the  lesion  has  a  considerable  influence,  according  toHorsley,  on  the 
result,  since  the  prognosis  is  good  in  the  motor  area,  middling  in  the 
sensory  (parieto-occipital)  region,  and  bad  in  the  frontal.  The  obvious 
difficulty  of  dealing  with  epileptic  conditions  emphasizes  the  state- 
ments already  made  (p.  752)  as  to  the  importance  of  dealing  with  all 
depressed  fractures  of  the  skull,  simple  or  compound,  slight  or  severe, 
by  immediate  operation,  so  as  to  prevent,  as  far  as  possible,  the 
development  of  the  mischief.  When  there  is  a  history  of  tubercle 
or  syphilis,  or  of  both,  medicinal  treatment  directed  to  the  absorption 
of  cicatricial  tissue  should  certainly  precede  operation. 

Traumatic  Insanity  is  sometimes  produced  by  slight  depressions  or 
lesions,  similar  in  nature  to  those  causing  epilepsy,  and  can  occa- 
sionally be  relieved  by  operation.  Certainly,  when  a  distinct  history 
of  injury  precedes  the  mental  aberration,  and  when  there  is  any 
localizing  lesion  or  symptom,  an  exploratory  operation  is  justifiable, 
and  in  a  number  of  cases  excellent  results  have  followed.  The  type 
of  insanity  is  not  constant,  but  varies  with  the  condition  and 
environment  of  the  individual. 

Hernia  Cerebri. 

By  hernia  cerebri  is  meant  a  protrusion  of  the  brain  substance 
through  an  acquired  opening  in  the  skull.  It  thus  differs  from  an 
encephalocele,  which  consists  in  the  protrusion  of  brain  substance 
through  some  congenital  defect. 

It  is  always  an  evidence  of  increased  intracranial  pressure,  and 
may  be  looked  upon  as  Nature's  safety-valve  for  the  relief  of  com- 
pression.    It  is  met  with  in  two  distinct  forms  : 


AFFECTIONS  OF  THE  BRAIN  AND  ITS  MEMBRANES  793 

1.  When  an  opening  has  been  made  by  the  surgeon  for  the  treat- 
ment of  a  cerebral  tumour,  which  is  subsequently  found  to  be  irre- 
moveable.  The  disc  of  bone  is  not  replaced,  and  the  brain  substance 
protrudes  through  the  opening  under  the  scalp  ;  by  this  means  a 
temporary  relief  of  intracranial  tension  is  brought  about,  the  patient's 
life  prolonged,  and  possibly  consciousness  for  a  time  restored.  The 
tumour,  however,  continues  growing,  and  sooner  or  later  the  patient 
dies  comatose. 

2.  The  other  variety,  due  to  a  compound  depressed  or  punctured 
fracture,  is  the  result  of  sepsis  in  the  underlying  brain  substance,  and 
the  increased  pressure  within  the  skull  thereby  induced  leads  to  a 
protrusion  of  inflamed  and  oedematous  cerebral  tissue  through  the 
v/ound  in  the  dura,  which  is  usually  of  small  size.  The  tumour  is 
soft  and  dusky  in  colour,  and  pulsates  synchronously  with  the  heart, 
the  pulsations  being  often  evident  to  the  naked  eye,  and  it  usually 
increases  in  size  somewhat  rapidly.  At  first  the  mental  condition  of 
the  patient  is  unimpaired,  but  sooner  or  later  coma  follows,  if  the 
hernia  progresses,  ending  in  the  patient's  death.  To  begin  with,  the 
mass  consists  mainly  of  oedematous  granulation  tissue  covered  by 
blood-clot,  without  much  brain  substance,  but  later  on  cerebral  tissue 
itself  may  protrude.  The  condition  is  usually  fatal,  though  recovery 
is  occasionally  seen.  Treatment. — Prevention  of  this  affection  must 
always  be  aimed  at  by  endeavouring  to  render  any  wound  involving 
the  meninges  aseptic  and  providing  for  drainage.  Punctured  wounds 
and  depressed  fractures  of  the  skull,  even  when  giving  rise  to  no 
urgent  symptoms,  should  always  be  operated  upon,  since  free  relief 
of  tension  may  prevent  the  formation  of  a  hernia  cerebri,  even  should 
absolute  asepsis  not  be  attained.  If,  however,  protrusion  occurs,  it 
may  be  possible  in  a  few  cases  to  apply  a  dry  dressing  and  elastic 
pressure,  and  thus  prevent  it  increasing  in  size ;  this,  however,  must 
not  be  attempted  when  the  inflammatory  symptoms  are  at  all 
marked.  In  such  cases  it  is  of  little  use  to  slice  off  the  tumour  and 
apply  pressure,  and  possibly  the  best  treatment  that  has  been 
suggested  is  to  paint  the  projecting  mass  once  or  twice  a  day  with 
absolute  alcohol,  which  is  an  efficient  antiseptic,  and  also  tends  by  its 
dehydrating  power  to  diminish  the  size  of  the  hernia.  If  such  treat- 
ment is  successful,  the  tumour  slowly  granulates  over  and  cicatrizes. 
Traumatic  epilepsy  may,  however,  ensue. 


CHAPTER  XXVII. 
AFFECTIONS  OF  THE  LIPS  AND  JAWS. 

Affections  of  the  Lips. 

Hare-lip. — By  hare-lip  is  meant  a  congenital  fissure  of  the  upper  lip, 
which  may  extend  for  a  variable  distance  through  the  soft  tissues 
alone,  or  may  also  implicate  the  bony  alveolus  and  the  floor  of  the 


Fig.  358.— *Single  Incomplete  Hare- 
lip, INVOLVING  MERELY  THE  TISSUES 

OF    THE   Lip,    and   not    extending 
INTO  the  Nose. 


Fig.  359. — Double  Hare-lip  :  Com- 
plete ON  the  Left  Side,  Incom- 
plete ON  the  Right. 


Fig,  360.— Double  Complete  Hare-lip,  with  Displacement  Forwards 

OF  THE  Central  Portion  of  the  Intermaxilla  (Os  Incisivum). 

A,  Front  view  ;  B,  seen  in  profile. 

nose,  and  extend  backwards  through  the  palate.  The  name  is  not 
a  good  one,  since  a  hare's  lip  is  cleft  in  a  Y-shaped  manner,  the 
fissure  being  central  below,  and  bifurcating  above  into  each  nostril, 

794 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


79i 


Varieties. — A  hare-lip  is  complete  or  incomplete,  according  to  whether 
or  not  it  extends  into  the  nostril.  It  is  termed  simple  if  limited  to 
the  soft  parts ;  alveolar,  if  the  bony  alveolus  is  also  involved ;  complicated, 
if  associated  with  a  cleft  palate.  The  defect  may  exist  on  one  or 
both  sides  of  the  middle  line;  if  unilateral  or  single,  it  is  most  common 
on  the  left  side,  in  the  proportion  of  two  to  one  ;  if  double  or  bilateral, 
it  is  usually,  but  not  invariably,  alveolar,  and  accompanied  by  a 
complete  cleft  of  the  palate.  The  central  portions  of  the  lip  and 
alveolus  (os  incisivum)  may  either  retain  their  normal  position,  or, 
as  is  more  frequently  the  case  in  the  bilateral  type,  project  forwards 
at  the  end  of  the  nose,  forming  a  proboscis-like  appendage  (Fig.  360, 
A  and  B).      Even  in  simple  cases  the  nose  is  deformed,  being  broad 


\ 


Fig.  361. — Head  of  Fcetus  of  about 
Five  Weeks,  from  Ventral  Aspect 
(after  His),  showing  the  Primi- 
tive Stomod^um  Bounded  Above 
BY  (A)  THE  Undivided  Fronto- 
nasal Process,  Laterally  by  (B) 
the  Maxillary,  and  Below  by 
(C)  THE  still  Separate  Mandi- 
bular Processes. 

The  quinque-radiate  appearance  is 
well  represented. 


Fig.  362. — Head  of  Fcetus  of  Six  to 
Seven  Weeks,  from  the  Ventral 
Aspect.     (After  His.) 

The  mandibular  processes  (E)  have  now 
united ;  the  ocular  vesicle  (C)  is  seen 
on  either  side  towards  the  upper  end 
of  the  orbito-nasal  fissure,  and  the 
fronto  -  nasal  process  has  developed 
(A)  internal  and  (B)  external  nasal 
processes  on  either  side  of  (F)  the  still 
unclosed  anterior  nares;  (D)  maxillarj' 
process. 


and  flattened,  a  condition  which  becomes  much  more  marked  when 
the  alveolus  and  floor  of  the  nose  are  widely  fissured.  Hare-lip  is 
not  uncommonly  associated  with  other  deformities — e.g.,  spina  bifida 
and  talipes — and  it  is  frequently  transmitted  from  one  generation  to 
another.  Occasionally  a  thin  red  line,  as  of  a  cicatrix,  is  seen 
occupying  the  position  of  a  hare-lip  cleft,  and  is  probably  due  to 
a  persistence  of  the  raphe  of  union  of  the  labial  segments ;  a  slight 
groove  in  the  alveolus  may  also  be  observed  at  a  corresponding 
point. 


796 


A  MANUAL  OF  SURGERY 


Development.  * — The  bony  and  fleshy  parts  of  the  face  originate  from  the  out- 
growth of  processes  around  the  cavity  formed  by  the  bending  forward  of  the 
primitive  cerebral  vesicle  over  the  end  of  the  notochord.  At  about  five  weeks  after 
conception  the  primitive  buccal  cavity  or  stomodseum  has  a  quinque-radiate  ap- 
pearance, due  to  the  manner  in  which  these  processes  are  formed  (Fig.  361).  A 
broad  median  lappet  (fronto-nasal  process)  descends  from  above  ;  this  is  separated 
by  a  fissure  on  each  side  from  the  symmetrically-placed  maxillary  processes  (B), 
and  these  again  below  from  the  more  prominent  mandibular  processes  (C), 
which  early  unite  across  the  middle  line,  to  form  the  lower  jaw.  The  fronto- 
nasal process  soon,  however,  changes, 
developing  four  rounded  buds,  the 
relations  of  which  are  indicated  in 
Fig.  362.  On  either  side  of  a  slight  de- 
pression in  the  median  line  is  placed  the 
internal  nasal  process  (A),  from  which 
are  produced  superficially  the  central 
portion  of  the  upper  lip,  and  from  its 
deeper  aspect  the  inner  segment  of  the 
intermaxilla  (endognathion,  Fig.  363, 
EG),  carrying  the  central  incisor. 
Separated  from  this  by  a  hollow  (F), 
which  subsequently  forms  the  anterior 
nares,  is  the  rounded  external  nasal 
process  (B),  from  which  develop  the  side 
of  the  cheek,  the  ala  nasi,  and  from  its 
deep  side  the  outer  segment  of  the 
intermaxilla  (mesognathion,  MG)  and 
probably  the  lateral  incisor.  External 
to  this  a  fissure  (naso-orbital)  runs  up 
to,  and  even  beyond,  the  primitive  eye 
(C),  and  this  is  later  on  closed  by 
amalgamation  of  the  internal  and  ex- 
ternal nasal  processes  on  the  inner  side 
with  the  adjacent  maxillary  process  on 
the  outer  (D),  except  in  the  deepest  part, 
which  constitutes  the  nasal  duct 


^m^ 


,nv 


^ 


Fig.  363.  —  Diagram  to  Represent 
THE  Albrecht  Theory  of  Hare- 
lip, SHOWING  the  Situation  of  the 
Cleft  in  the  Alveolus  between 
the  Inner  and  Outer  Segments 
of  the  Intermaxilla. 

EG,     Endognathion  ;     MG,     mesogna- 
thion ;    XG,  exognathion  ;  fj,  central 
incisor;  i.2,  lateral  incisor;  4.  acces- 
sory incisor ;  c,  canine  ;  m-^,  m^,  first 
and  second  molars. 


The 

integrity  of  the  upper  lip  is  obtained  by  the  union  of  the  lower  parts  of  the  internal 
nasal  and  maxillary  processes,  which  thus  exclude  the  external  nasal  from  parti- 
cipation in  its  free  border.  It  is  doubtless  owing  to  this  arrangement  that  the 
sulcus  or  depression  around  the  ala  nasi  constitutes  such  a  distinct  and  characteristic 
feature  of  the  face.  At  the  same  time  the  deeper  parts  of  these  nasal  processes  are 
uniting  with  one  another  and  with  the  palatal  plates,  which  grow  horizontally 
inwards  from  the  under  side  of  the  maxillary  processes,  uniting  in  a  Y-shaped 
suture,  the  point  of  junction  of  the  limbs  being  situated  at  the  anterior  palatine 
canal.  The  union  of  all  these  elements  is  taking  place  from  the  sixth  to  the  tenth 
week,  and  by  that  date  even  the  uvula,  the  last  part  to  unite,  should  be  complete. 
Ordinary  hare-lip  is  due  to  a  failure  of  union  of  the  internal  nasal  process  with 
the  structures  in  external  relation  with  it ;  if  limited  to  the  soft  parts  (simple 
hare-lip),  the  cleft  runs  between  the  internal  nasal  and  maxillary  processes ;  if 
complete  or  alveolar,  between  the  same  two  below  and  superficially,  but  in 
addition  between  the  internal  and  external  nasal  processes  above  and  on  the  deep 
side.  The  cleft  in  the  alveolus  passes  between  the  inner  and  outer  segments  of 
the  intermaxilla  (Fig.  363),  and  is  thus  bounded  on  the  inner  side  by  the  central 
incisor,  on  the  outer  side  by  the  lateral  incisor.  Occasionally  two  teeth  are 
found  growing  from  the  endognathion,  the  outer  of  the  two  being  an  accessory 
tooth  [la),  whilst  the  lateral  incisor,  and  presumably  the  outer  segment  of  the  inter- 

*  For  fuller  details  of  the  development  and  treatment  of  ha-re-lip  and  cleft  palate, 
we  must  refer  readers  to  '  Hare-lip  and  Cleft  Palate,'  by  W.  Rose  ;  Lewis  and 
Co.,  1891.  It  is  but  fair  to  our  readers  to  point  out  that  the  Albrecht  theory  as 
outlined  above  is  not  accepted  by  all  authorities;  thus,  see  Keiih.,  B lit.  Med. 
7ci!»'«.,  August  7,  1909. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  797 

maxilla,  are  often  undeveloped,  or  exist  in  a  very  rudimentary  condition  attached 
to  the  maxilla. 

The  OS  incisivum,  or  projecting  portion  of  the  intermaxilla,  consists  of  two 
segments  of  bone,  the  two  endognathia,  united  in  the  median  line,  and  in  a  child 
contains  two  milk  central  incisors,  and  the  rudiments  of  the  two  permanent  ones  ; 
occasionally,  as  we  have  just  stated,  there  may  be  an  accessory  tooth  developed 
on  one  or  both  sides  of  the  process. 

A  simple  hare-lip  does  not  interfere  seriously  with  the  infant's 
nutrition,  but  when  double,  and  especially  if  associated  with  a  cleft 
palate,  considerable  trouble  may  arise,  thus  necessitating  surgical 
treatment  as  a  life-saving  measure  at  a  very  early  date.  It  must 
also  be  remembered  that  all  movements  of  the  face — e.g.,  in  crying 
or  laughing — exaggerate  the  deformity  from  the  unbalanced  action 
of  the  divided  orbicularis  oris  and  other  muscles. 

As  to  the  period  at  which  to  operate,  it  is  better  to  allow  the  infant 
to  get  over  the  shock  of  its  entrance  into  the  world  and  become 
acclimatized  to  an  independent  existence,  whilst  at  the  same  time 
the  operation  should  be  performed  before  the  troubles  of  dentition 
begin.  From  six  weeks  to  three  months  is  perhaps  the  best  age  for 
operation — in  well-nourished  and  healthy  children  at  the  earlier  date, 
in  poorly-fed  and  weakly  children  at  the  later,  unless  the  inanition 
is  due  to  the  difficulty  of  feeding  the  infant  owing  to  the  deformity. 
Under  such  circumstances  the  operation  may  have  to  be  undertaken  . 
within  the  first  three  weeks. 

Operation  for  Single  Hare-lip. — The  child  should  be  laid  on  an 
operating-table  with  its  arms  bound  to  the  body.  The  surgeon 
stands  behind  it,  the  anaesthetist  and  assistant  one  on  each  side. 
The  operation  may  be  described  in  three  stages : 

1.  The  lip  is  thoroughly  dissected  up  from  the  maxilliB  and  alveoli  by 
cutting  through  the  reflections  of  mucous  membrane  and  the  attach- 
ment of  the  muscles  and  other  soft  parts.  This  is  mainly  needed  on 
the  outer  side,  and  where  there  is  much  flattening  of  the  nose  the 
ala  nasi  will  also  require  to  be  separated.  This  may  cause  some 
amount  of  bleeding,  but  sponge  pressure  easily  controls  it. 

2,  The  edges  of  the  cleft  are  then  pared.  Many  different  methods 
have  been  employed  to  accomplish  this,  but  it  is  only  necessary  to 
mention  two.  The  object  to  be  attained  is  the  union  of  the  cleft  lip 
by  means  of  a  cicatrix,  which  shall  be  as  unobtrusive  as  possible, 
whilst  the  red  margin  must  be  continuous,  and  the  section  such  that 
the  raw  surfaces  are  larger  than  are  absolutely  necessary,  so  as  to 
allow  for  subsequent  cicatricial  contraction  without  the  development 
of  a  notch.     The  methods  recommended  are  as  follows  : 

[a)  The  incision  extends  from  the  apex  of  the  cleft,  or  from  within 
the  nostril,  in  a  crescentic  manner  (Fig.  364),  so  that  a  sHght  angular 
projection  is  formed  to  constitute  a  prolabium.  This  is  done  on  each 
side,  and  where  the  nose  is  much  flattened,  more  tissue  is  removed 
on  the  outer  than  on  the  inner  side,  so  that  when  the  parts  are  sutured 
together  the  nostrils  become  as  nearly  as  possible  symmetrical.  By 
this  means  the  depth  of  the  lip  is  increased  to  allow  of  subsequent 
contraction,  whilst  the  red  margin  can  be  made  continuous. 


798 


A  MANUAL  OF  SURGERY 


(b)  Miraulfs  Operation  (Fig.  365). — The  inner  margin  and  apex  of 
the  cleft  are  pared,  so  as  to  leave  a  raw  surface  ;  a  flap  of  red  marginal 
tissue,  as  thick  as  possible,  is  then  cut  from  the  outer  side,  and  im- 
planted on  the  bevelled  raw  surface  of  the  red  margin  on  the  inner 
side,  the  upper  portions  of  the  cleft  being  also  apposed. 


Fig.  364. — Rose's  Operation  for  Single  Hare-lip. 

On  the  left  side  the  semilunar  incisions  are  seen  extending  as  far  as  the  free 
borders  of  the  lip.  The  right-hand  figure  shows  the  parts  drawn  into 
position ;  the  wide  cross  lines  represent  the  wire  sutures,  the  narrow  ones 
the  catgut  or  horsehair  stitches. 

3.  Sutures  are  now  inserted  to  maintain  the  lip  in  the  position  into 
which  it  can  be  drawn  by  the  fingers  without  tension.  Two  deep 
silver-wire  sutures  should  be  introduced,  one  just  above  the  red 
margin,  and  one  close  to  the  nose,  to  draw  into  position  and  steady 
the  nostril,  which  should  be  left  smaller  than  that  on  the  other  side, 


Fig.  365. — Mirault's  Operation  for  Hare-lip. 

In  the  right-hand  figure  the  prolabial  flap  is  shown  ready  to  be  implanted 
on  the  prepared  inner  side. 

so  as  to  allow  for  subsequent  dilatation,  which  is  certain  to  occur. 
Horsehair  or  catgut  stitches  are  used  to  bring  the  exact  margins 
together,  the  continuity  of  the  muco-cutaneous  line  being  accurately 
p^reserved,  and  the  cut  edges  of  the  mucous  membrane  upon  the 
deeper  aspect  being  sutured,  each  stitch,  after  it  is  tightened,  being 


AFFECTIONS  OF  THE  LIPS  AND  yAWS 


799 


used  to  elevate  and  evert  the  lip,  and  thus  assist  the  insertion  of  the 
next.  The  wound  is  dressed  with  a  small  piece  of  gauze,  and  secured 
by  another  dry  piece  cut  in  the  shape  of  a  butterfly,  so  that  the 
narrow  body  shall  fit  over  the  lip,  and  the  wings  spread  over  the 
cheeks  ;  this  is  fixed  by  collodion,  and  maintained  for  some  days 
after  the  stitches  are  removed,  the  deep  ones  on  the  fourth  day,  and 
the  superficial  ones  about  the  eighth  or  tenth.  Careful  feeding  by 
spoon  is  necessary,  the  mother's  milk  being  drawn  off  and  given 
in  this  way  if  possible.  In  simple  cases  the  child  may  be  returned 
to  the  breast  about  the  fifth  day.  In  order  to  prevent  the  child  from 
picking  at  the  lip  or  disturbing  the  dressing,  it  is  well  to  put  a  splint 
on  the  flexor  side  of  each  arm  to  control  the  elbow-joint. 

The  Treatment  of  Double  Hare-lip  may  be  discussed  under  two  head- 
ings, viz.,  the  treatment  of  the  os  incisivum,  and  that  of  the  soft  parts. 

The  OS  incisivum  need  not  be  touched   if  it  retains   its   normal 


Fig.  366. — Rose's  Operation  for  Double  Hare-lip. 

The  central  tubercle  is  pared  in  a  V-shaped  manner,  and  the  lateral  segments  by 

curved  incisions,  extending  to  the  red  margin,  and  then  inwards.  Only  the 
apex  of  the  central  portion  is  included  in  the  completed  lip.  The  long  cross 
lines  represent  the  position  of  the  wire  stitches,  the  shorter  ones  of  the  catgut 
sutures. 

position,  and  the  labial  clefts  are  then  alone  dealt  with ;  but  if  it 
projects  forwards,  as  is  often  the  case,  it  must  be  either  removed, 
replaced,  or  reduced  in  size,  (a)  In  bad  cases  where  there  is  much 
projection  the  process  must  be  removed.  The  central  portion  of  the 
upper  lip  is  freed  from  it  by  dissection,  and  the  base  of  the  process 
divided  with  cutting-pliers  ;  a  small  artery  in  the  bone  will  spurt 
vigorously,  and  may  need  an  application  of  the  cautery  to  stop  it. 
The  operation  on  the  lip  is  deferred  till  ten  days  later.  A  certain 
amount  of  deformity  from  dropping  back  of  the  upper  lip  is  certain 
to  result,  but  can  be  in  measure  obviated  by  adding  a  projecting 
cheek-plate  to  that  which  carries  the  artificial  incisors,  (b)  Reposi- 
tion may  be  effected  by  several  methods,  the  best  of  which  is 
Bardeleben's,  who  incises  the  lower  border  of  the  septum,  strips  off 
the  muco-periosteum  from  either  side,  and  then  bends  or  breaks  the 
bone  back  into  position,  fixing  it  by  silver  wires,  and  uniting  the  lip 
at  once  to  form  a  splint  to  maintain  it  in  situ.  The  advantages 
claimed  for  reposition  are  that  the  patient  retains  his  own  central 


8oo 


A  MANUAL  OF  SURGERY 


incisor  teeth,  and  that  the  normal  contour  of  the  jaw  and  face  is  not 
interfered  with.  Against  this  plan,  however,  must  be  placed  the 
facts  that  the  bone  rarely  becomes  firmly  united,  that  the  teeth  are 
stunted  and  erupt  obliquely  backwards  from  rotation  of  the  process, 
and  that  its  presence  prevents  the  maxillae  from  falling  together  and 
increases  the  difficulties  of  subsequently  closing  the  palatal  cleft. 
{c)  Where,  however,  the  projection  is  not  great,  it  is  possible  to 
diminish  the  size  of  the  os  incisivum  by  gouging  away  the  teeth 
contained  within  it,  so  that  the  lip  can  be  closed  over  it. 

The  soft  parts  of  the  lip  are  dealt  with  in  much  the  same  way  as  in 
single  hare-lip.  They  are  freely  detached  from  the  maxillae,  and  the 
edges  pared,  as  shown  in  Fig.  366,  the  central  portion  being  cut  into 
a  V,  and  no  attempt  made  to  incorporate  it  into  the  free  margin  for 
fear  of  depressing  the  tip  of  the  nose,  whilst  the  lateral  segments  are 
pared  as  in  the  single  operation.  These  latter  are  now  drawn  together 
and  imited  in  the  middle  line  below  the  central  portion,  so  that  a 
Y-shaped  cicatrix  results.  One  of  the  deep  silver  stitches  should  fix 
the  apex  of  the  V;  the  other  should  be  inserted  just  above  the  red 
margin.  The  dressing  and  after-treatment  are  as  in  the  single  opera- 
tion. For  a  time  the  child  may  have  difficulty  in  breathing  owing  to 
the  diminution  in  the  size  of  the  oral  aperture,  but  this  is  obviated  by 

the  nurse  drawing  down  the  lower 
>,  lip  with  the  fingers,  or  by  painting 

it    in    a   vertical  direction   with 

collodion. 

Other  congenital  abnormalities  of  the 
lip  are  met  with,  which,  however,  can 
only  be  briefly  mentioned  here. 

Median  Hare-lip  may  occur  in  one  of 
two  forms  ;  either  a  simple  cleft  exists 
in  the  middle  line  (Fig.  367),  or  there 
may  be  an  absence  of  the  intermaxilla 
and  nasal  septum,  causing  flattening  of 
the  bridge  of  the  nose,  and  a  broad 
median  defect,  flanked  by  the  maxillary 
portions  of  the  lip. 

Oblique  Facial  Cleft  is  an  uncommon 
deformity,  characterized  by  a  cleft  or 
sulcus  in  the  face,  starting  from  the  usual  situation  of  a  hare-lip  below,  but 
running  up  outside  the  nostril  to  the  inner  side  of  the  lower  lid  (Fig.  568). 
Coloboma  of  the  iris  or  choroid  is  sometimes  associated  with  this  rare  defect. 
The  deformity  is  due  to  non-closure  of  the  naso-orbital  fissure,  and  runs  along , 
the  line  of  the  nasal  duct.  It  may  be  limited  to  the  soft  parts,  or  may  involve 
the  bones,  even  laying  open  the  antrum. 

Macrostoma  (Fig.  369)  is  characterized  by  an  abnormal  width  of  the  mouth, 
and  is  due  to  non-union  of  the  maxillary  and  mandibular  processes.  It  may  be  - 
uni-  or  bi-lateral,  and  is  usually  associated  with  anomalies  of  development  of  the 
ear,  accessory  auricles  being  often  present.  As  a  rule,  a  small  papilla  on  the 
upper  and  lower  margins  will  indicate  the  true  limits  of  the  mouth,  being  con-  • 
stituted  by  the  points  of  attachment  of  the  orbicularis.  The  existence  of  these 
is  of  great  importance  as  indicating  the  extent  to  which  the  cleft  must  be  pared 
in  order  to  restore  the  mouth  to  its  normal  size. 

Mandibular  Clefts  are  exceedingly  rare.     They  are  due  to  non-union  of  the 
mandibular  processes  in  the  middle  line,  and  involve  either  the  soft  tissues  of  the 


Fig.  367. — Median  Hare-lip. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


801 


lower  lip  alone,  or  may  extend  to  the  bone,  and  even  the  tongue.     Treatment  is 
as  for  ordinary  hare-lip. 

Microstoma  is  the  term  applied  to  a  condition  in  which  the  fusion  of  the  parts 
entering  into  the  formation  of  the  lips  progresses  to  a  greater  extent  than  usual, 
so  that  the  oral  orifice  is  contracted.  It  may  be  associated  with  defective 
development  of  the  lower  jaw.  In  the  more  severe  cases,  where  the  mouth  is 
extremely  narrowed,  a  transverse  cut  should  be  made  outwards  on  each  side,  and 
the  mucous  membrane  stitched  to  the  skin. 

Macrocheilia,  or  hypertrophy  of  the  lip,  occurs  in  three  forms: 
I.  The  congenital  variety,  a  condition  analogous  to  macroglossia, 
and  due  to  a  congenital  distension  of  the  lymphatic  spaces,  or  chronic 
lymphangiectasis,  accompanied  by  overgrowth  of  the  connective 
tissue.     The  lower  lip  is  most  often  involved,  and  is  firm,  thickened, 


-sr 


) 


Fig.  368. — Oblique  Facial  Cleft,  or, 
RATHER,  Cicatricial  Deformity 
ALONG  the  Line  usually  traversed 
BY  SUCH  A  Cleft.     (Kraske's  Case.) 


Fig.  369. — Macrostoma  with 
Auricular    Appendages, 
(Fergusson.) 


and  everted,  causing  considerable  deformity.  The  treatment  consists 
in  the  removal  of  a  V-shaped  portion  from  the  centre.  2.  An 
acquired  form  occurs  in  children  and  young  people  with  a  tuberculous 
inheritance,  constituting  the  so-called  '  strumous  lip.'  Either  lip 
may  be  affected,  but  perhaps  more  frequently  the  upper ;  the  thick- 
ening is  due  to  a  chronic  lymphangitis,  resulting  from  the  absorption 
of  septic  material  from  persistent  cracks  and  fissures.  If  these  can  be 
healed,  and  the  general  health  improved,  diminution  in  the  size  of  the 
lip  soon  follows.  3.  In  adults,  macrocheilia  is  in  almost  all  cases  due 
to  tertiary  syphilis.  The  lower  lip  is  most  often  enlarged,  and  be- 
comes thick  and  hard.  It  is  due  to  the  diffuse  sclerosis  characteristic 
of  tertiary  mischief.  General  treatment,  and  not  local,  is  needed. 
Syphilitic    Aflfections  of   the  lip  are  not  uncommon.     A  primary 

51 


802 


A   MANUAL  OF  SURGERY 


chancre  may  be  caused  by  kissing,  or  by  smoking  an  infected  pipe, 
or  drinking  from  a  glass  with  an  infected  rim.  It  usually  presents  a 
smooth  ulcerated  surface,  discharging  a  small  amount  of  sero-pus, 
resting  on  a  mass  of  infiltrated  tissue  which  may  extend  over  the 
whole  lip  (Fig.  370).  The  induration  is  not  so  great  as  in  chancres 
upon  the  genital  organs,  but  the  infiltration  is  much  more  extensive. 
Enlargement    of    the    submaxillary   lymphatic    glands    occurs  very 

early,  and  the  disease  usually  runs 
an  active  course.  Ordinary  specific 
treatment  is  all  that  is  needed.  A 
labial  chancre  may  closely  resemble 
epithelioma,  but  is  distinguished 
from  it  by  its  rapid  development 
up  to  a  certain  point,  by  the  early 
implication  of  the  glands,  which 
soon  become  very  large,  by  the 
absence  of  typical  cachexia,  by  the 
age  of  the  patient,  and  the  course 
taken  by  the  case,  as  well  as  by 
the  local  appearances.  The  surface 
is  usually  flattened,  and  less  warty 
and  irregular  than  in  epithelioma, 
whilst  the  skin  is  more  involved  than 
the  mucous  membrane.  Should  the 
chancre  have  existed  for  any  time, 
the  presence  of  a  rash  or  sore  throat 
may  materially  assist  in  forming  a 
diagnosis.  Moreover,  it  is  more 
common  on  the  upper  lip,  whilst 
epithelioma  is  usually  seen  on  the 
lower  (compare  Figs.  370  and  371). 
In  the  secondary  stage  mucous  tubercles  are  frequently  met  with, 
involving  the  inner  side  of  the  lip  and  the  angle  of  the  mouth.  In 
the  tertiary  period  serpiginous  ulceration  and  gummata  may  occur,  or 
the  diffuse  induration  described  above.  In  inherited  syphilis,  cracks 
and  mucous  tubercles  are  constantly  present,  and  may  be  so  ex- 
tensive as  to  leave  cicatrices  radiating  from  the  mouth,  which  are 
very  characteristic  (Fig.  34). 

Cracked  Lips  (or,  as  they  are  often  called,  chapped  lips)  are  usually 
the  result  of  cold  weather,  a  central  crack  or  fissure  forming  which 
is  extremely  painful,  and  liable  to  bleed  very  readily  on  everting  or 
stretching  the  part.  The  lower  lip  is  that  generally  affected.  In 
tuberculous  children  more  than  one  may  occur,  and  by  their  per- 
sistence they  give  rise  to  a  considerable  degree  of  induration  and 
infiltration,  and  perhaps  lead  to  glandular  trouble.  All  that  is  needed 
in  the  shape  of  treatment  is  the  application  of  a  little  lanoline  or  cold 
cream,  but  if  they  persist,  it  may  be  advisable  to  touch  them  with 
nitrate  of  silver. 

Herpes  Labialis  is  a  condition  usually  associated  with  catarrh,  and 


Fig.  370. — Chancre  of  Upper  Lip. 
(From  a  Photograph.) 

The  enlargement  of  the  submaxil- 
lary lymphatic  glands  is  very 
evident. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


803 


not  unfrequently  with  pneumonia  or  other  fevers.  Either  Up  may 
be  affected,  and  the  herpetic  eruption  is  quite  Hmited  in  extent.  It 
consists  of  a  number  of  httle  vesicles  situated  on  a  hypersemic  and 
painfiil  base ;  after  a  few  days  the  vesicles  become  transformed  into 
pustules,  and  these  in  turn  burst  and  dry  up,  the  whole  affection 
lasting  perhaps  a  week  or  ten  days.  No  special  treatment  is  required. 
If  the  inner  aspect  of  the  lip  is  affected,  the  epithelium  early  becomes 
sodden  and  is  shed,  so  that  the  vesicular  stage  is  much  shorter. 

Mucous  Cysts  occur  on 
the  inner  side  of  the  lip  in 
the  form  of  small  rounded 
swellings,  which  are  trans- 
lucent and  contain  a  glairy 
fluid.  They  are  often  due 
to  trauma,  whereby  the 
opening  of  a  mucous  gland 
is  blocked.  The  whole  cyst 
wall  should  be  dissected 
out,  and  the  wound  closed 
by  stitches. 

Nsevi  are  frequently  met 
with  in  the  lip.  If  confined 
to  the  inner  aspect  they 
may  be  dissected  out,  but 
when  large  and  involving 
the  whole  thickness,  they 
should  be  dealt  with  by 
electrolysis. 

Warty  Growths  are  often 
seen  on  the  lower  lip, 
especially  near  the  angle, 
and  may  then  simulate 
epithelioma.  They  are  dis- 
tinguished, however,  by  the 
fact  that  ulceration  is  not  often  present,  that  the  lymphatic  glands 
are  not  involved,  and  that  there  is  but  little  infiltration  of  the  base. 
They  should,  however,  be  removed  as  early  as  possible,  since 
malignant  disease  often  starts  from  them. 

Epithelioma  of  the  lip  usually  occurs  in  men  of  the  working  classes, 
and  is  commonly  stated  to  be  due  to  the  irritation  produced  by 
smoking  a  short  clay  pipe,  which  is  allowed  to  rest  on  one  or  the 
other  side  near  the  angle.  A  semicircular  notch  will  frequently  be 
noticed  in  the  teeth  of  the  upper  and  lower  jaw,  corresponding  to 
the  situation  of  the  growth  on  the  lip,  and  caused  by  the  constant 
friction  of  the  pipe-stem.  It  may  also  start  opposite  the  site  of  some 
projecting,  rough,  or  carious  tooth.  It  is  but  rarely  met  with  in 
women,  occurring  in  England  in  not  more  than  5  to  6  per  cent,  of 
the  cases,  and  of  these,  according  to  Hutchinson,  half  are  clay-pipe 
smokers.    It  is  also  more  common  amongst  country  folk,  who  use  the 


Fig.  371. — Chronic  Epithelioma  of  Lower 
Lip.     (From  a  Photograph.; 


<?04 


A  MANUAL  OF  SURGERY 


Fig.   372. — V-SHAPED  Incision  for  Re- 
moval OF  Epithelioma  of  Lip. 


short  clay  pipe,   than  amongst  the  cigarette   and  cigar  smokers  in 
towns. 

The  disease  may  start  as  an  induration  around  a  crack  or  fissure, 
which  gradually  extends,  forming  a  typical  malignant  ulcer ;  or  as  a 
wart-like  growth,  which  fungates  and  ulcerates  ;  or  as  a  chronic  in- 
filtration leading  to  an  irregular  nodulated  thickening  of  the  lip,  which 
sometimes  looks  shrunken  and  feels  sclerosed  (Fig.  371). 

If  allowed  to  run  its  course  unchecked  by  treatment,  the  disease 
steadily  progresses,  forming  an  ulcerated  mass  of  greater  or  less  size, 
and  even  involving  the  jaw.     The  submental  and  submaxillary  glands 

are  early  implicated,  and  secon- 
dary deposits  are  also  found  in 
the  glands  which  accompany 
the  carotid  vessels.  Beyond 
this,  however,  the  disease  rarely 
extends,  visceral  complications 
being  uncommon.  When  a 
fatal  issue  results,  it  is  gener- 
ally caused  by  the  secondary 
growths  in  the  neck,  which 
attain  considerable  dimensions 
and  then  ulcerate,  this  stage 
being  possibly  preceded  by  one 
of  cystic  degeneration.  From 
these  ulcerating  surfaces  a  quan- 
tity of  discharge  escapes,  the  amount  varying  with  the  septicity  or  not 
of  the  wounds.  Intense  pain  is  caused  by  implication  of  nerves,  and 
haemorrhage  is  also  likely  to  follow  from  erosion  of  some  of  the 
vessels  in  the  neck. 

The  Diagnosis  of  epithelioma  is  rarely  doubtful,  but  occasionally 
warty  growths,  or  even  a  primary  chancre  (p.  802),  may  be  mistaken 
for  it.  The  clinical  history  generally  suffices  to  determine  the  nature 
of  the  mass,  as  also  the  character  of  the  base  and  the  appearance  of 
the  parts  ;  but  in  uncertain  cases  the  removal  of  a  small  portion  of 
the  edge  under  cocaine,  and  its  microscopic  examination,  are  required 
to  set  doubts  at  rest. 

Treatment. — The  primary  growth  must  be  excised  completely,  if  such 
be  possible,  and  the  submental  and  submaxillary  region  thoroughly 
cleared  of  lymphatic  glands,  whether  they  can  be  felt  enlarged  or  not. 
When  the  deeper  glands  in  the  neck  have  been  attacked,  they  often 
contract  such  adhesions  as  to  render  their  extirpation  impracticable. 

If  the  growth  is  limited  to  one  part  of  the  lip,  a  V-shaped  wedge 
extending  half  an  inch  beyond  it  in  all  directions  may  be  taken  away 
(Fig.  372),  and  the  wound  closed,  as  in  a  case  of  hare-lip,  without 
much  deformity  resulting.  When  it  is  more  extensive,  considerable 
ingenuity  must  be  exercised  in  order  to  make  good  the  defect.  One 
plan  that  often  gives  good  results  is  to  excise  the  growth  by  a  some- 
what larger  V-shaped  incision,  and  then  to  extend  the  labial  fissure 
transversely  to  one  or  the  other  side,  or  to  both,  dissecting  up  these 


AFFECTIONS  OF  THE  LIPS  AXD  JAWS  Soj 

segments  from  the  bone  ;  the  flaps  can  then  usually  be  brought 
together,  whilst  the  mucous  membrane  is  united  to  the  skin  along  the 
margin  of  the  new  lip. 

When  the  whole  lower  lip  requires  removal,  Symes  opeyation  may 
be  performed  with  advantage.  It  consists  first  of  all  in  the  complete 
excision  of  the  diseased  lip.  Two  curved  incisions  are  then  made, 
starting  from  the  middle  line  of  the  wound,  and  extending  do"wnwards 
under  the  chin,  to  terminate  below  the  angles  of  the  jaw,  an  inverted 
V-shaped  portion  of  skin  between  them  remaining  fixed  to  the  sym- 
physis menti  to  form  a  base  of  support  for  the  new  lip.  The  lateral 
flaps  are  now  dissected  up,  raised,  and  united  one  to  the  other  in  the 
middle  line,  so  as  to  constitute  the  new  lip,  an  inverted  Y-shaped 
cicatrix  resulting.  The  elasticit}'  of  the  skin  in  this  region  allows 
this  to  be  accomplished,  and  the  whole  wound  closed,  without  leaving 
any  part  to  granulate.  The  mucous  membrane  should  be  finally 
stitched  to  the  skin  over  the  upper  free  margin.  Healing  by  first 
intention  usually  follows. 

If  the  whole  of  the  upper  lip  needs  to  be  removed,  it  may  be 
restored  in  a  variety  of  ways.  Perhaps  one  of  the  best  consists  in 
making  incisions  which  skirt  the  ate  nasi  on  each  side,  and  then 
extend  outwards  into  the  cheeks  sufficiently  to  allow  the  tissues,  when 
they  have  been  freed  from  the  maxilte  by  undercutting,  to  be  drawn 
together  in  the  middle  fine.  In  such  cases  care  must  be  taken  not  to 
encroach  on  Stenson's  duct. 

The  Extraction  of  Teeth. 

Although  this  operation  is  usually  undertaken  by  dentists,  yet 
surgeons  and  medical  practitioners  have  not  unfrequently  to  perform 
it,  and  not  a  little  skill  and  judgment  are  sometimes  needed  in  its 
execution.  An  anesthetic  may  or  may  not  be  employed.  If  merely 
one  or  two  teeth  are  to  be  dravi-n,  gas  or  chloride  of  ethyl  will  suffice  ; 
but  when  a  large  number  require  extraction  at  one  sitting,  it  is  better 
to  give  ether  or  the  A.C.E.  mixture ;  chloroform  should  never  be  ad- 
ministered when  the  patient  is  in  the  sitting  position.  The  posterior 
teeth  are,  of  course,  dealt  with  first,  and  subsequently  those  in  front. 
Suitable  forceps  are  required  for  the  various  teeth,  and  the  number  of 
fangs  belonging  to  each  must  be  kept  in  mind.  Incisor  and  canine 
teeth  are  removed  by  a  combination  of  traction  and  rotation ;  the 
bicuspids  and  molars  by  traction  combined  with  lateral  mo^•ement, 
especially  inwards.  The  forceps,  after  being  sterilized,  should  be 
pushed  well  up  under  the  gum,  and  no  traction  made  until  a  firm 
grasp  has  been  taken  of  the  neck  of  the  tooth,  and  the  tooth  itself 
loosened  by  lateral  swaying. 

Accidents  of  various  t\'pes  happen  from  time  to  time.  The  cro'\\-n 
may  break  away,  leaving  the  fangs  in  situ,  and  then  each  of  these 
must  be  sought  with  root  forceps  and  accounted  for.  In  dealing  with 
the  first  or  second  upper  molar,  it  is  quite  possible  to  drive  a  fang 
upwards  into  the  antral  cavity,  setting  up  thereby  acute  suppuration 
within  the  cavity.     Laceration  of  the  gum  is  often  unavoidable,  and 


8o6  A  MANUAL  OF  SURGERY 

injury  to  the  alveolar  margin  may  follow  ;  but  such  accidents  as  frac- 
ture of  the  lower  jaw  or  dislocation  of  the  temporo-maxillary  joint  are 
certainly  avoidable.  The  use  of  an  elevator  is  sometimes  desirable 
in  order  to  remove  old  roots,  but  it  is  an  instrument  that  must  be  used 
with  great  care. 

After  extraction  the  mouth  is  washed  out  with  sterilized  or  car- 
bolized  water,  and  the  bleeding  usually  ceases  without  delay.  If  the 
gum  has  been  much  torn,  it  should  be  pressed  back  into  position  by 
the  fingers,  and  when  the  mouth  is  septic,  it  may  be  desirable  to  touch 
the  socket  over  with  tincture  of  iodine.  A  mouth-wash  of  boric  acid 
or  sanitas  is  subsequently  employed. 

Should  the  hemorrhage  continue,  as  in  patients  suffering  from  pur- 
pura, scurvy,  and  haemophilia,  the  socket  must  be  carefully  plugged 
with  a  strip  of  gauze  soaked  in  a  styptic,  such  as  adrenalin  or  anti- 
pyrin  ;  the  use  of  perchloride  of  iron  in  this  connection  is  undesirable. 
Occasionally  the  bleeding  re-starts  after  two  or  three  days,  and  is 
then  due  to  septic  contamination  of  the  alveolus  ;  in  such  cases  it  is 
usually  necessary  to  open  up  the  socket  freely  from  the  outer  side, 
cutting  away  gum  and,  if  need  be,  bone,  so  as  to  allow  free  exit  to  dis- 
charges and  a  more  ready  access  for  strips  of  gauze  soaked  in  styptics 
or  antiseptics. 

Affections  of  the  Gums  and  Alveolar  Processes. 

Spongy  Gums  are  not  unf requently  met  with  as  a  result  of  a  dirty 
and  uncared-for  condition  of  the  teeth,  the  administration  of  mercury, 
or  scurvy.  They  are  characterized  by  being  soft  and  congested, 
bleeding  readily  on  pressure,  and  perhaps  showing  signs  of  ulceration. 
All  that  is  necessary  is  the  correction  of  the  determining  cause  and 
the  use  of  an  alum  mouth-wash. 

Alveolar  Abscess  (Fig.  373)  is  almost  always  associated  with  sup- 
puration around  the  fang  of  a  carious  tooth,  the  bacteria  findmg  their 
way  out  of  the  pulp  chamber  through  the  apical  foramen.  The 
alveolar  walls  become  expanded,  and  the  pus  either  finds  its  way  over 
the  edge  of  the  bone  (C,  D),  or  even  through  the  osseous  tissue  (A), 
under  the  external  periosteum.  If  limited  in  extent,  it  perforates  the 
gum  directly,  and  is  then  known  as  a  gum-boil ;  but  occasionally  it 
burrows  beneath  the  periosteum,  which  is  stripped  from  the  bone, 
and  may  thus  lead  to  an  abscess  of  larger  size,  possibly  resulting  in 
necrosis  of  the  jaw.  The  formation  of  an  alveolar  abscess  is  almost 
always  associated  with  considerable  oedema  of  the  face,  pain  of  a 
serious  character,  and  when  extensive  may  give  rise  to  marked 
constitutional  disturbance.  Sometimes  graver  complications  ensue; 
thus,  in  the  upper  jaw  the  antrum  may  be  opened,  and  suppuration  in 
this  cavity  follow,  whilst  in  the  lower  the  abscess  may  travel  down- 
wards and  burst  externally,  either  close  to  the  lower  margin  of  the 
bone  or  in  the  neck.  A  troublesome  sinus  results,  which  can  onl}^  be 
cured  by  the  removal  of  the  tooth,  and  even  then  a  depressed  and 
adherent  cicatrix  ensues,  which  is  very  unsightly.     The  most  essential 


AFFECTIONS  OF  THE  LIPS  AND  jfAWS 


807 


point  in  the  treatment  necessarily  consists  in  the  removal  of  the  offend- 
ing tooth.  Often  this  is  quite  sufficient,  and  possibly  the  tooth  may 
come  away  with  an  abscess  cavity  attached  to  one  of  the  fangs. 
When  suppuration  occurs  beneath  the  periosteum,  the  pain  can  at 
first  be  relieved  in  measure  by  fomentations,  but  as  soon  as  fiuctua' 
tion  is  detected  a  free  incision  should  be  made,  if  possible,  through  the 
gum,  and  the  cavity  emptied.  Possibly  it  may  be  wise  to  keep  a 
small  piece  of  stuffing  in  for  a  few  hours,  but  if  a  large  enough  open- 
ing has  been  made,  all  that  is  subsequently  needed  is  repeated  and 
frequent  irrigation,  preferably  with  peroxide  of  hydrogen.  When  the 
skin  is  thinned  and  the  cheek  red,  an  external  incision  is  usually 
required,  and  sometimes  this  may  have  to  be  undertaken  as  a  pre- 


FiG.  373.— Diagram  of  Alveolar  Abscess,  resulting  from  Disease  of 
Molar  Tooth  (After  the  American  System  of  Dentistry.) 
A.  Abscess  arising  from  escape  of  septic  material  from  B,  the  pulp  chamber 
through  the  foramen  at  apex  of  the  fang  ;  it  has  burrowed  directly  through 
the  alveolar  process  and  burst  through  the  gum ;  C,  similar  abscess,  which 
has  tracked  down  between  the  tooth  and  the  alveolus,  and  spread  out 
beneath  the  alveolar  periosteum  at  D,  constituting  the  typical  alveolar 
abscess ;  E,  cheek  ;  F,  antrum  ;  G,  nasal  cavity. 

liminary,  the  extraction  of  the  tooth  being  left  until  the  swelling  has 
somewhat  subsided.  If  a  small  sinus  persists  after  removal  of  the 
tooth,  it  must  be  opened  up,  and  any  carious  or  necrosed  bone 
taken  away.  Not  unfrequently  the  masseter  becomes  infiltrated  and 
sclerosed  when  the  lower  jaw  is  affected,  and  this  may  result  in  fixed 
closure  of  the  mouth,  demanding  operative  treatment  for  its  cure. 

Pyorrhoea  Alveolaris  (or  Riggs'  Disease)  consists  in  an  inflammatory 
condition  of  the  margins  of  the  gums,  accompanied  by  a  purulent 
discharge,  which  arises  from  pockets  or  pouches  which  may  extend  a 
greater  or  less  distance  along  the  roots  of  the  teeth.  In  the  early 
stages  the  gums  are  swollen  and  oedematous  to  such  an  extent  that 
they  often  hide  or  partially  cover  the  stumps  of  decayed  teeth,  and 


So8  A   MANUAL  OF  SURGERY 

they  bleed  readily.  The  tongue  is  coated,  and  the  breath  exceedingly 
offensive.  In  less  severe  cases  and  in  the  later  stages  the  tissues  of 
the  gums  shrink,  and,  together  with  the  alveolar  border,  become 
atrophic  ;  the  fangs  are  thereby  uncovered  and  the  teeth  loosened,  so 
that  after  a  vi^hile  a  natural  cure  may  be  established  by  the  patient 
becoming  edentulous.  The  process  is  limited  to  a  few  teeth,  or  may 
involve  many.  It  is  generally  preceded  by  an  excessive  deposit  of 
tartar,  beneath  which  bacterial  infection  occurs,  the  inflammation 
spreading  down  along  the  periodontal  membrane,  and  perhaps  extend- 
ing to  surrounding  parts — e.g.,  the  maxillary  antrum.  In  most  cases, 
on  making  pressure  along  the  alveolar  margins,  a  greater  or  less 
quantity  of  pus  can  be  squeezed  out.  For  the  constitutional  results 
of  this  oral  sepsis,  see  p.  76. 

Treatment  must,  in  the  first  place,  be  directed  to  the  teeth,  and  con- 
sists in  the  removal  of  tartar  and  the  application  of  astringents  and 
antiseptics,  preferably  peroxide  of  hydrogen,  not  only  to  the  exposed 
mucous  membrane,  but  also  into  the  pouches  and  pockets  where  pus 
collects.  In  some  cases  it  is  wise  to  destroy  the  granulation  tissue 
forming  the  outer  wall  of  these  pouches  by  means  of  the  electric 
cautery,  or  even  to  remove  the  teeth.  Too  much  must  not  be  done  at 
a  time,  as  the  general  symptoms  may  be  aggravated  by  an  increased 
absorption  of  toxins,  and  the  reparative  activities  of  the  patient  may 
be  very  deficient.  Goadby*  has  pointed  out  that  in  many  of  the 
worst  cases  the  resisting  power  of  the  individual,  as  estimated  by  the 
opsonic  index,  is  very  low  to  particular  organisms  isolated  from 
the  mouth,  and  recommends  the  employment  of  a  suitable  vaccine 
prepared  from  these  particular  bacteria. 

Hypertropliy  of  the  Gums  is  met  with  in  the  form  of  a  sessile  over- 
growth, sometimes  almost  cauliflower-like,  around  and  between  the 
teeth,  which  are  usually  carious ;  it  occurs  most  frequently  in 
children.  In  slight  cases  the  overgrowth  may  be  destroyed  by 
the  application  of  a  crystal  of  trichloracetic  acid ;  but  in  the  more 
exaggerated  types  excision  is  required. 

Dental  Cysts  are  by  no  means  uncommon,  resulting  from  the 
irritative  effects  of  dental  caries ;  hence  they  follow  the  distribution 
of  that  aff'ection,  and  are  most  frequently  seen  in  connection  with 
the  upper  first  molars  and  bicuspids.  They  develop  at  the  roots  of 
the  teeth,  causing  a  painless  regular  expansion  of  the  bone,  free  from 
inflammator}^  phenomena,  unless  infected  secondarily  with  bacteria. 
After  a  time  the  centre  of  the  swelling  softens,  and,  as  the  bony  wall 
is  absorbed,  parchment-like  crackling  can  be  felt ;  finally,  the  condition 
presents  as  a  rounded  tense  elastic  swelling,  around  the  margins  of 
which  the  remains  of  the  expanded  bone  can  be  detected.  In  the 
upper  jaw  they  often  encroach  on  and  project  into  the  bony  antral 
cavity,  pushing  the  mucous  membrane  in  front  of  it.  The  tooth 
which  is  the  cause  of  the  trouble  is  always  dead,  and  frequently 
meiely  a  septic  root  is  present. 

*  Goadby :  Erasmus  Wilson  Lecture  on  '  Pyorrhcea  Alveolaris  '  {Lancet, 
March  9,  1907). 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


S09 


The  cause  of  these  cysts  is  probably  the  proliferation  of  certain 
embryonic  remains  of  the  enamel  organ,  brought  about  by  the 
irritation  of  septic  matter  which  has  escaped  from  the  pulp  cavity. 
These  foetal  residues  are  lighted  up  into  activity,  developing  into  masses 
or  columns  of  epithelial  tissue,  which  undergo  cystic  degeneration. 
Their  pathogenesis  is  practically  identical  with  that  of  the  epithelial 
odontome,  but  merely  one  cyst  develops  here  instead  of  many.  The 
fluid  contained  therein  is  thick  and  mucoid  in  character,  and  broken- 
down  epithelial  cells  and  cholesterine  are  seen  in  it  on  microscopical 
examination. 

Treatment. — The  cyst  must  be  laid  freely  open  into  the  mouth,  the 
septic  tooth  or  stump  removed,  and  the  anterior  wall  of  its  alveolus 
cut  away.  The  alveolus 
and  cyst  thus  laid  into 
one  cavity  are  scraped 
so  as  to  remove  all  the 
epithelial  lining,  and 
packed  with  gauze  so  as 
to  insure  healing  by 
gxanulation.  In  the  upper 
jaw  the  utmost  gentle- 
ness is  required  in  deal- 
ing with  the  deeper  Avail 
of  the  cyst,  as  the  septum 
between  it  and  the  antral 
cavity  may  be  extremely 
thin  and  entirely  devoid 
of  bony  tissue. 

Epulis. — By  this  term  is 
meant  a  tumour  growing 
from  the  alveolar  peri- 
osteum. Tw^o  varieties 
are  described,  viz.,  the 
simple  and  the  malig- 
nant. 

A  Simple  Epulis  is  usually  of  a  fibromatous  nature,  and  may  grow 
from  either  jaw,  though  more  commonly  from  the  lower.  It  is 
generally  due  to  the  irritation  of  diseased  teeth,  and  although  most 
marked  on  the  outer  aspect,  it  burrows  between  the  teeth,  and  is  also 
found  on  the  inner  side.  It  appears  as  a  red  fleshy  mass,  smooth,  or 
perhaps  lobulated  (Fig.  374),  of  an  elastic  consistency,  and  possibly 
associated  with  a  little  superficial  ulceration.  It  is  covered  with 
mucous  membrane,  and  may  contain  a  few  spicules  of  bone.  The 
treatment  consists  in  removing  the  growth  together  with  the  teeth  or 
stumps  with  which  it  is  connected.  If  small,  it  will  suffice  to  cut 
away  and  scrape  the  bone  from  which  it  arises  ;  but  if  large,  or  if  it 
recurs  after  such  treatment,  the  portion  of  the  alveolus  from  which  it 
springs  must  also  be  excised.  This  is  best  accomplished  by  extract- 
ing a  tooth  on  either  side  of  the  tumour,  and  cutting  vertically  through 


Fig.  374.  —Simple  Epulis. 


8io  A  MANUAL  OF  SURGERY 

each  socket  with  a  saw,  the  two  incisions  being  united  below  with 
a  chisel,  so  as  to  remove  a  quadrangular  portion  of  bone  without 
interfering  with  the  continuity  of  the  jaw. 

Malignant  Epulis. — This  title  is  applied  to  a  myeloid  sarcoma 
developing  from  the  alveolar  process,  and  probably  from  its  medullary 
contents.  It  forms  a  soft,  rapidly  increasing  mass  of  a  dusky  purple 
colour,  which  runs  on  to  ulceration  or  fungation  ;  the  deeper  portions 
may  contain  an  ossific  deposit.  As  with  all  forms  of  myeloid 
growth,  it  is  only  locally  malignant.  Treatment  consists  in  free 
removal  of  the  tumour  and  of  the  portion  of  alveolus  from  which  it 
arises.  In  the  upper  jaw  this  sometimes  necessitates  excision  of  the 
complete  palatal  segment  of  the  maxilla,  but  in  the  lower  jaw  it  is 
generally  possible  to  maintain  the  continuity  of  the  mandible  by 
removing  merely  a  quadrilateral  portion  in  the  same  way  as  for  a 
simple  epulis. 

Epithelioma  and  Sarcoma  (round  or  spindle -celled),  arising  from 
the  gum,  are  both  met  with.  Epithelioma  in  this  situation  occa- 
sionally fungates,  but  more  often  invades  the  bony  tissues,  and  in 
the  upper  jaw  extends  upwards  to  the  antrum ;  hence  it  is  sometimes 
termed  a  '  creeping  or  burrowing  epithelioma.'  The  ordinary  signs  of 
this  disease  become  evident,  lymphatic  glands  are  enlarged,  and  typical 
ulceration  of  the  gum  follows.  The  only  possible  treatment  consists  in 
free  excision  of  the  growth,  together  with  the  portion  of  bone  affected. 

Necrosis  of  the  Jaw. — Causes :  (i)  Subperiosteal  alveolar  abscess, 
connected  with  dental  caries.  (2)  Traumatism,  such  as  blows  on 
the  jaw,  with  or  without  fracture,  in  the  latter  instance  being  due  to 
septic  periostitis  or  osteo-myelitis,  owing  to  the  lesion  becoming  com- 
pound. The  use  of  dirty  forceps  or  elevators  in  extracting  a  tooth 
may  similarly  light  up  an  infective  inflammation,  resulting  in  necrosis. 
(3)  In  tertiary  syphilis  necrosis  also  occurs,  affecting  most  frequently 
the  palate  or  alveolar  borders.  (4)  It  results  from  mercurial  poison- 
ing, but  rarely  at  the  present  day.  (5)  Phosphorus  necrosis  is  met 
with  amongst  those  who  work  in  lucifer-match  factories,  but  only 
when  ordinary  phosphorus  is  used ;  the  amorphous  form  is  harmless. 
The  fumes  are  supposed  to  gain  access  to  the  jaws  through  carious 
teeth,  giving  rise  to  a  somewhat  acute  inflammation,  which  terminates 
in  necrosis.  A  considerable  amount  of  new  bone  forms  beneath  the 
periosteum,  and  the  sequestrum,  which  is  curiously  gray  and  porous, 
like  dirty  pumice-stone,  is  always  slow  in  separating.  Either  jaw 
may  be  affected,  but  perhaps  the  lower  a  little  more  commonly  than 
the  upper.  (6)  Necrosis  may  follow  one  of  the  exanthemata  or  any 
condition  of  malnutrition  or  anaemia,  arising  as  an  infective  idiopathic 
or  embolic  osteo-myelitis,  and  then  probably  affecting  a  considerable 
extent  of  bony  tissue,  possibly  the  whole  mandible.  (7)  Tubercle  is 
occasionally  responsible  for  this  condition. 

The  symphysis  menti  in  children  is  occasionally  the  seat  of  a 
pyogenic  or  tuberculous  infection,  previous  to  the  eruption  of  the 
permanent  incisors.  An  abscess  forms,  and  caries  or  a  limited 
necrosis  results.     In  a  case  of  this  type  an  opening  is  required  in 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  8ii 

the  submental  region,  through  which  the  diseased  tissue  can  be 
thoroughly  scraped  away.  The  teeth  are  of  course  lost,  but  a  good 
result,  and  with  but  little  scarring,  may  be  anticipated. 

The  Clinical  Phenomena  associated  with  necrosis  of  the  jaw  are 
necessarily  much  the  same  whatever  the  cause.  The  acute  form 
commences  with  severe  pain  in  and  around  the  jaw,  followed  by 
great  swelling  of  the  face  and  difficulty  in  opening  the  mouth  or 
taking  food.  The  temperature  is  raised,  and  even  rigors  may  be 
present ;  the  breath  is  usually  foul.  Sooner  or  later  an  abscess  forms, 
which  may  point  either  in  the  mouth  or  on  the  face,  or  the  pus  may 
burrow  dowmwards  for  some  distance  into  the  neck.  Sinuses  persist, 
discharging  the  most  offensive  pus  ;  a  new  covering  of  bone  some- 
times forms  in  the  lower  jaw,  enclosing  the  sequestrum,  but  in  the 
upper  this  is  rarely  noticed,  and  even  in  the  lower  it  is  not  unusual 
to  see  a  considerable  amount  of  bare  or  dead  bone  absorbed  without 
the  formation  of  an  involucrum. 

Treatment. — In  the  early  stage  the  cheek  should  be  fomented,  but 
as  soon  as  there  is  any  suspicion  of  pus  a  free  incision  is  made 
down  to  the  bone  inside  the  mouth  and  along  the  line  of  reflection 
of  the  mucous  membrane.  When  necrosis  is  present,  it  must  be 
treated  in  the  ordinary  way,  the  sinuses  being  flushed  out  with  an 
antiseptic  solution  three  or  four  times  a  day  until  the  sequestrum  is 
loose ;  it  is  then  removed,  if  possible,  from  within  the  mouth. 
Drainage  by  means  of  an  external  opening  is  often  absolutely 
necessary.  In  the  worst  cases  necrosis  may  extend  from  the  middle 
line  of  the  mandible  to  the  temporo-maxillary  articulation ;  it  is  then 
wise  to  make  an  external  incision,  and  remove  the  bone  in  toto  after 
detaching  it  by  saw  from  the  other  ramus. 

Affections  of  the  Antrum. 

Suppuration  within  the  Antrum  {empyema  of  maxillary  sinus)  fre- 
quently arises  from  disease  connected  with  the  fangs  of  the  first 
or  second  molar  or  bicuspid  teeth  ;  it  not  uncommonly  results  from 
an  acute  inflammation  of  the  nasal  cavities  as  in  influenza,  and  may 
then  be  associated  with  trouble  in  the  other  accessory  nasal  sinuses, 
such  as  the  frontal  and  ethmoidal  (p.  833) ;  it  is  occasionally  lighted 
up  by  injury.  In  chronic  cases  it  is  not  unusual  to  find  the  antrum 
filled  with  soft  polypoid  granulations. 

The  Symptoms  produced  are  often  extremely  equivocal,  and  the 
condition  may  be  present  for  some  time  without  being  recognised. 

In  the  chronic  forms  all  that  is  noticed  msry  be  an  intermittent  dis- 
charge of  pus  into  and  from  one  side  of  the  nose,  associated  perhaps 
with  some  pain  in  the  infra-orbital  region,  a  chronic  cough,  and 
an  irritable  throat.  The  pus  varies  considerably  in  amount  and 
character,  being  sometimes  extremely  offensive.  On  holding  the 
patient's  head  forwards,  it  can  be  demonstrated  that  there  is  an  over- 
flow of  pus  into  the  nostril,  and  sometimes  when  the  patient  reclines 
it  flows  back  into  the  pharynx.  Should  the  opening  into  the  nose 
become  blocked,  all  the  symptoms  are  aggravated,  the  pain  becoming 
more  marked  and  the  swelling  increasing.     Signs  of  distension  of  the 


Si2  A  MANUAL  OF  SURGERY 

cavity  may  also  be  produced  in  this  way ;  such  are  manifested  in 
four  directions :  (a)  Inwards,  causing  obstruction  to  nasal  respiration, 
and  possibly  epiphora,  from  compression  of  the  nasal  duct ;  (b)  up- 
wards, leading  to  protrusion  of  the  eyeball  or  exophthalmos ;  (c)  down- 
wards, resulting  in  depression  of  the  side  of  the  palate,  and  possibly 
irregularity  in  the  line  of  the  teeth  ;  and  (d)  outwards,  giving  rise  to 
a  somewhat  characteristic  projection  of  the  cheek  beneath  the  malar 
eminence.  Under  these  circumstances,  a  finger  inserted  into  the 
mouth,  between  the  cheek  and  the  bone,  will  detect  a  loss  of  resistance 
in  the  anterior  wall  of  the  antrum,  and  if  the  distension  has  lasted 
long,  eggshell-crackling  may  be  noticed,  or  the  whole  anterior  wall 
may  be  absorbed  and  an  elastic  swelhng  take  its  place.  Infra-orbital 
neuralgia  is  often  a  marked  feature  in  these  cases. 

In  acute  cases  all  the  above  phenomena  may  be  present  in  an 
accentuated  degree,  accompanied  by  severe  tensive  pain  and  some 
amount  of  febrile  disturbance.  Necrosis  of  the  lining  bony  walls 
may  also  be  induced,  owing  to  the  fact  that  the  mucous  membrane 
is  closely  adherent  to  the  periosteum. 

The  Diagnosis  of  suppuration  within  the  antrum  is  not  always  easy. 
The  periodic  discharge  of  pus  from  the  nose  is  suggestive,  as  also 
the  presence  of  a  dead  or  painful  molar  or  bicuspid  tooth.  If  a  flow 
of  pus  can  be  induced  by  change  of  position  of  the  head,  it  is  pathog- 
nomonic of  suppuration  within  one  of  the  accessory  sinuses  connected 
with  the  nose,  probably  of  the  antrum.  If,  after  the  nose  has  been 
cleared  and  the  head  hung  down,  pus  is  seen  welling  up  from  under 
the  middle  turbinal,  the  diagnosis  is  almost  certain.  Transillumination 
of  the  antrum  may  confirm  this  opinion.  A  small  electric  lamp  is 
placed  within  the  mouth,  and  if  the  patient  is  in  a  dark  room,  or  if  be 
and  the  surgeon  are  under  a  photographer's  cloth,  and  his  antra  are 
normal,  the  cheeks,  lips,  and  lower  margins  of  the  orbits  become  of 
a  rosy-red  colour.  If,  however,  the  cavities  are  occupied  by  pus, 
blood,  or  a  growth,  the  parts  remain  dark.  Transillumination  does 
not  answer  in  every  individual,  and  hence  the  value  of  the  test  is 
much  diminished.  The  presence  of  illumination  excludes  intra-antral 
growths  or  abscess,  but  its  absence,  unless  unilateral,  is  not  of  much 
significance.  Finally,  the  antrum  may  be  punctured  with  trocar  and 
cannula  through  the  canine  fossa,  or  through  the  inferior  nasal 
meatus,  and  an  absolute  diagnosis  obtained. 

The  Treatment  necessarily  varies  with  the  type  of  the  disease.  It 
must  always  be  remembered  that  the  orifice  of  the  antrum  into  the 
middle  meatus  is  an  inch  above  the  antral  floor,  and  hence  the 
natural  drainage  is  very  defective  (Fig.  383). 

In  the  early  active  form  that  sometimes  follo^ys  the  extraction  of  a 
tooth,  and  may  even  be  associated  with  the  pushing  up  of  a  broken 
fang  into  the  cavity,  it  will  probably  suffice  to  enlarge  the  opening  in 
the  alveolus  with  a  suitable  antrum  drill.  A  solid  rubber  plug  is 
introduced,  and  the  cavity  washed  out  into  the  nose  with  sterile 
salt  solution  two  or  three  times  a  day,  until  the  purulent  discharge 
ceases,  when  the  opening  may  be  allowed  to  granulate.     The  solid 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  813 

plug  is -better  than  a  hollow  tube,  which  permits  discharge  to  get 
into  the  mouth,  and  food  or  septic  material  to  pass  up  into  the 
antrum. 

In  the  acute  post-infiuenzal  cases  the  cavity  may  be  washed 
out  from  the  nose,  the  inner  wall  being  punctured,  after  efficient  co- 
cainization,  through  the  inferior  meatus  ;  this  lavage  may  be  required 
at  first  daily,  but  subsequently  less  frequently,  and  in  the  intervals 
the  patients  must  be  guarded  from  cold.  Sometimes  a  change  of  air 
will  clear  up  the  trouble. 

In  the  more  chronic  cases,  intranasal  drainage  may  still  be  effi- 
cacious, but  the  inner  wall,  together  with  the  anterior  end  of  the 
inferior  turbinal,  will  have  to  be  removed.  If,  however,  the 
mucous  membrane  is  thickened  and  infiltrated,  and  possibly  polypi 
are  present,  a  more  extensive  procedure  is  required.  The  antrum  is 
opened  by  gouging  through  its  anterior  wall  above  the  first  molar 
after  dividing  the  mucous  membrane.  If  this  tooth  is  present,  it  may 
advisably  be  drawn,  and  the  anterior  v/all  of  its  socket  cut  or  gouged 
away.  A  sufficient  opening  must  be  made  for  the  admission  of  the 
finger,  so  as  to  allow  the  interior  of  the  cavity  to  be  thoroughly 
explored  and  curetted.  It  is  also  important  to  deal  with  any 
intranasal  mischief  that  is  present ;  polypi  and  diseased  bone  should 
be  removed,  and  if  need  be  the  opening  into  the  nose  enlarged,  so  as 
to  give  a  free  exit  for  discharge,  and  admit  of  thorough  irrigation. 
It  is  sometimes  possible  to  close  the  incision  in  the  mouth,  the 
antrum  being  washed  out  from  the  nose ;  but  in  old-standing  cases 
it  is  often  necessary  to  pack  the  cavity  with  gauze  from  the  mouth, 
and  make  it  heal  by  granulation.  After  a  while  the  opening  into  the 
mouth  contracts  so  as  to  allow  of  the  introduction  of  a  solid  metal  or 
rubber  plug  fitted  to  a  tooth-plate,  which  can  be  gradually  reduced 
in  size  so  as  to  allow  the  sinus  to  heal. 

Hydrops  Anti  is  the  term  applied  to  a  chronic  distension  of  the 
antrum  with  a  glairy  mucoid  fluid,  somewhat  similar  in  character  to 
that  contained  in  a  ranula.  The  condition  is  painless,  and  free  from 
inflammatory  phenomena,  and  as  the  expansion  increases,  eggshell 
crackling  of  the  anterior  wall,  or  even  distinct  fluctuation,  may  be 
observed.  It  was  formerly  supposed  to  arise  from  obstruction  to  the 
aperture  into  the  nose  and  retention  of  secretion,  but  is  in  reality 
due  to  a  cystic  tumour  forming  from  the  glands  of  the  mucous 
membrane,  or  more  often  to  a  dental  cyst  (p.  808)  which  has  en- 
croached on  the  antral  cavity ;  rarely  is  it  due  to  the  presence 
of  a  dentigerous  cyst  (p.  819).  The  treatment  required  is  to  open 
thoroughly  the  cyst  from  the  mouth  after  dividing  the  mucous  mem- 
brane, subsequently  removing  a  sufficient  portion  of  the  anterior  wall 
to  enable  it  to  be  washed  out  and  drained.  It  is  sometimes  possible 
to  remove  the  whole  lining  membrane  without  wounding  the  mucous 
membrane  of  the  antrum. 

Various  Tumours  may  originate  in  the  antrum — e.g.,  mucous  polypi, 
fibromata,  odontomata,  osteomata,  sarcomata,  and  cancers.  If 
limited  to  the  cavity,   they  produce  no  definite  symptoms,  except 


8i4  A  MANUAL  OF  SURGERY 

when  large  enough  to  cause  expansion  of  its  walls.  Malignant 
growths,  however,  usually  pass  beyond  the  limits  of  the  antrum, 
and  lead  to  the  usual  signs  of  malignant  disease  of  the  upper  jaw. 
Treatment  consists  in  removing  simple  growths,  if  possible,  without 
interfering  with  the  integrity  of  the  maxilla.  This  may  be  accom- 
plished by  reflecting  the  overlying  cheek,  as  in  excision  of  the  uppei 
jaw.  For  malignant  tumours,  removal  of  the  complete  upper  jaw 
on  the  affected  side  is  probably  the  only  remedy. 

Tumours  of  the  Upper  Jaw. 

Many  of  the  Simple  Tumours  springing  from  the  upper  jaw  have 
been  already  described  amongst  those  involving  the  alveolar  border 
and  antrum.     Only  a  few  remain  to  be  dealt  with. 

Osteoma  occurs  either  in  the  form  of  a  tumour  composed  of 
compact  tissue,  then  usually  growing  within  the  antrum  ;  or  occa- 
sionally as  a  diffuse  symmetrical  overgrowth,  constituting  the  con- 
dition known  as  leontiasis  ossea.  A  few  cases  of  Chondroma  have  also 
been  reported. 

By  Leontiasis  Ossea  is  meant  a  disease,  fortunately  very  rare, 
characterized  by  the  formation  of  diffuse  hyperostoses  from  either 
the  cranial  or  facial  bones,  or  from  both.  It  usually  commences  in 
young  adult  life,  and  both  rickets  and  syphilis  have  been  suggested 
as  playing  some  part  in  its  causation,  although  nothing  definite  as 
to  its  origin  is  known.  Nodular  outgrowths  of  soft  spongy  bone 
gradually  develop,  increasing  slowly  in  size,  and  giving  rise  to 
irregular  bony  protuberances  projecting  beneath  the  skin,  and  when 
affecting  the  maxillae  and  mandibles  leading  to  an  extremely  repul- 
sive appearance  of  the  individual.  Sometimes  merely  the  cranial 
bones  are  affected,  at  other  times  only  the  jaws,  whilst  occasionally 
the  whole  skull  participates  in  the  change,  which  is  almost  always 
symmetrical.  As  growth  progresses,  the  new  bone  encroaches  on 
the  cavities  of  the  skull,  so  that  the  antrum  may  be  obliterated,  the 
eyes  may  protrude  owing  to  the  contraction  of  the  intra-orbital 
space,  and  even  coma  and  death  may  supervene  from  cerebral  com- 
pression. Prior  to  this,  however,  a  variety  of  symptoms,  especially 
neuralgia,  may  be  induced  by  pressure  on  the  cranial  nerves.  Treat- 
ment is  only  occasionally  possible,  and  consists  in  the  removal  of  the 
projecting  masses  of  bone  by  the  chisel. 

Malignant  Disease  of  the  Upper  Jaw  occurs  in  the  form  of  sarcoma 
or  cancer.  Sarcoma  is  perhaps  the  more  common,  and  originates 
either  fi'om  the  anterior  wall,  from  the  cavity  of  the  antrum,  from 
the  spheno-maxillary  fossa  behind  the  bone,  or  may  extend  into  the 
maxilla  from  the  naso-pharynx.  Not  unfrequently  these  growths 
have  a  considerable  ossific  basis,  and  this  is  sometimes  so  extensive 
as  to  obliterate  the  antral  cavity,  and  convert  the  bone  into  a  solid 
mass.  Cancer  develops  in  the  form  of  a  squamous  burrowing  epithe- 
lioma, springing  from  the  gums ;  or  as  a  columnar  or  acinous  cancer 
starting  in  the  glandular  tissue,  found  both  in  the  nasal  and  antral 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  815 

cavities.  It  is  probable  that  not  a  few  of  these  growths,  both  sarcoma 
and  carcinoma,  are  derived  from  embryonic  rests,  associated  with  the 
enamel  organs  and  teeth,  and,  as  Sir  F.  S.  Eve*  points  out,  are  in 
reality  malignant  odontomata. 

The  Clinical  Features  of  both  forms  of  malignant  disease  are 
practically  identical. 

If  arising  from  the  anterior  aspect  of  the  bone,  a  tumour  is  produced 
which  projects  under  the  cheek,  the  tissues  of  which  are  invaded  by 
it  ;  it  extends  down  towards  the  mouth,  and  is  readily  detected 
through  the  mucous  membrane.  It  may,  however,  spread  deeply, 
and  involve  the  cavity  of  the  antrum.  It  causes  no  obstruction  to 
nasal  respiration,  and  no  epiphora  except  in  the  later  stages. 

If  it  originates  within  the  antrum,  the  usual  signs  of  distension  of 


Fig.  375. — Osteo-Sarcoma  of  the  Upper  Jaw. 

that  cavity  are  produced,  associated  with  a  foul,  and  often  blood- 
stained, discharge  from  the  nose,  within  which  the  ulcerated  surface 
of  the  growth  may  be  seen.  Epiphora  is  caused  by  pressure  on  the 
nasal  duct,  whilst  the  growth  has  been  known  to  burrow  upwards 
along  this  passage  and  project  near  the  inner  canthus.  The  passage 
of  air  through  the  nose  on  that  side  is  also  impeded,  and  the  palate 
may  be  depressed. 

If  the  growth  commences  behind  the  maxilla,  it  usually  springs 
from  one  of  the  walls  of  the  spheno-maxillary  fossa,  or  from  the 
base  of  the  skull,  and  is  then  characterized  by  a  great  tendency  to 
spread  in  all  directions.  It  may  push  the  whole  bone  bodily  forwards 
without  encroaching  upon  the  antrum  ;  sometimes  it  finds  its  way 
outwards   to   the    pterygoid   fossa    through    the   pterygo-maxillary 

*  Sir  F.  S.  Eve,  Brit.  Med.  Journ.,  June  29,  1907. 


8i6 


A  MANUAL  OF  SURGERY 


fissure,  or  inwards  to  the  nose  through  the  palatine  foramen,  or 
even  up  into  the  orbit ;  whilst  more  rarely  it  spreads  down  along 
the  posterior  palatine  canal,  so  as  to  appear  at  the  postero-external 
corner  of  the  palate ;  in  the  later  stages  the  antral  cavity  is  also 
involved,  and  even  the  base  of  the  skull  eroded. 

The  General  Signs  of  a  malignant  growth  of  the  superior  maxilla 
consist  in  the  appearance  of  a  tumour  which,  in  its  earlier  stages,  may 
produce  various  effects,  but  finally  tends  to  destroy  the  bone  and 
occupy  the  whole  of  the  maxillary  region  (Fig.  375).  It  is  usually 
accompanied  by  nasal  obstruction,  epiphora,  and  frequently  by  a 
discharge  of  blood  or  pus  from  the  nares.  Severe  pain  sometimes 
accompanies  the  process,  especially  affecting  the  second  division  of 

the  trigeminal.    Neighbouring  lymphatic 
glands  become  enlarged,  more  especially 
in  the  carcinomata  ;  those  in  the  sub- 
maxillary region  are  first  involved,  and 
afterwards  those  in  the  anterior  triangle  ; 
secondary  deposits  in  the  viscera  may 
also  occur  somewhat  later.     The  tumour 
follows  a  typical  malignant  course,  and, 
owing  to  the  great  vascularity  of   the 
parts,  its  onward  progress  is  very  rapid. 
The  Diagnosis  of  malignant  disease  of 
the    upper  jaw  from  a  simple  tumour 
or   cyst   should   be   readily    made ;  the 
rapidity  of  its  growth,  the  greater  pain 
and  more  abundant  discharge  from  the 
nose,  the  associated  enlargement  of  the 
lymphatic  glands,  and  the  tendency  to 
Fig.  376. — A,  Incision  FOR  Re-  spread  to  and  encroach  upon  surrounding 
MovAL  OF  Superior  Maxilla  ;  structures,  all  point  to  malignant  disease. 
uJ°^  ^^''°^^''  °^  ^^^^"^  In  some  cases,  however,  an  exploratory 
■'      '  incision  is  required  to  make  certain  of 

the  diagnosis.  More  frequently  the 
existence  of  a  tumour  at  all  is  for  some  time  entirely  overlooked, 
some  one  prominent  symptom,  such  as  neuralgia  or  epiphora,  being 
treated  without  ascertaining  the  cause.  Transillumination  (p.  812) 
may  assist  in  clearing  up  the  diagnosis,  as  also  radiography,  which 
would  indicate  the  presence  of  an  unerupted  tooth  in  a  dentigerouscyst. 
Treatment  consists  in  free  removal  of  the  growth,  if  such  be 
practicable,  together  with  total  or  partial  ablation  of  the  superior 
maxilla.  Where,  however,  the  tissues  of  the  cheek  have  been 
invaded,  or  where  the  growth  has  spread  beyond  the  limits  of  the 
antrum,  the  surgeon  may  well  hesitate  before  recommending  an 
operation,  since  complete  eradication  is  always  a  matter  of  un- 
certainty and  difficulty,  and  often  secured  only  at  the  expense  of 
terrible  mutilation  and  considerable  risk  to  the  patient's  life.  Of 
course,  in  those  cases  which  are  recognised  as  springing  from  behind 
the  maxilla,  operative  treatment  should  never  be  undertaken. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS 


817 


Excision  of  Superior  Maxilla  varies  somewhat  in  different  cases 
according  to  the  character  and  extent  of  the  disease. 

The  patient's  head  and  shoulders  are  well  raised,  and  anaesthesia 
is  maintained  by  means  of  chloroform  given  by  Junker's  apparatus. 
Preliminary  tracheotomy  is  scarcely  necessary  or  desirable  if  good 
assistance  is  to  hand.  The  proceeding  may  be  described  in  stages 
as  follows  : 

Stage  J. :  Incision  and  Reflection  of  the  Soft  Structures  of  the  Cheek. — 
The  central  incisor  tooth  of  the  affected  side  having  been  extracted, 
the  upper  lip  is  divided  in  the 
middle  line  ;  the  incision  is  carried 
round  the  ala  and  along  the  side 
of  the  nose,  to  a  point  half  an  inch 
below  the  inner  canthus  ;  it  thence 
extends  along  the  lower  orbital 
margin  to  a  point  below  its  outer 
border,  or  even  to  the  zygoma 
(Fig.  376,  A).  The  flap  thus 
marked  out  is  raised  from  the 
bone,  and  reflected  outwards  so  as 
to  clear  the  zygomatic  eminence, 
and  the  more  important  vessels 
secured,  as  they  are  divided,  by 
Spencer  Wells'  forceps. 

Stage  II.  :  Division  of  the  Bony 
Attachments.  —  A  keyhole  saw  is 
passed  into  the  nose,  and  the  Fip.  377. 
alveolus  and  hard  palate  divided 
from  before  backwards  through  the 
empty  socket  of  the  central  incisor 
tooth.  The  side  of  the  nose  is 
then  freed  from  its  bony  attach- 
ments, and'the  periosteum  stripped 
up  from  the  floor  of  the  orbit.  The 
nasal  process  of  the  superior  max- 
illa is  now  cut  through  with  a  saw 
(Fig.  377),  and  also  the  malar 
bone  divided  so  as  to  open  into 

the  spheno-maxillary  fissure.  The  surgeon  then  takes  a  pair  of 
long-handled  cutting-pliers,  and  completes  the  division  of  each  of 
these  bony  attachments,  but  reversing  the  order,  dealing  with  the 
malar  bone  first,  next  with  the  nasal  attachments,  and  finally  with 
the  palate.  The  cutting-pliers  must  always  be  applied  with  the 
smooth  surface  towards  the  tissues  which  are  to  be  left,  and  the 
bevelled  surface  towards  the  part  which  is  to  be  removed.  When 
the  section  of  the  palate  is  completed,  the  cutting-pliers  are  used  as 
a  lever  to  prise  the  bone  out  of  its  bed,  the  sound  bone  acting  as  a 
fulcrum,  the  posterior  attachments  being  thus  fractured.  The 
pterygoid  processes  are  broken  through  close  to  their  origin  from 

§2 


Skull  showing  Lines  of 
Section  of  the  Bone  in  Excision 
OF  THE  Superior  Maxilla. 

On  the  right  side  of  the  skull  the  malar 
bone  is  divided  into  the  spheno-maxil- 
lary fissure,  as  would  be  required  for 
disease  limited  to  the  body  of  the 
bone.  If  the  tumour  invades  the 
malar  bone,  incisions  as  on  the  left 
side  must  be  made — viz.,  horizontally 
through  the  upper  part  of  the  malar 
bone  into  the  fissure,  and  behind 
through  the  zygoma. 


8i8  A  MANUAL  OF  SURGERY 

the  sphenoid,  and  the  lateral  mass  of  the  ethmoid  yields  along  the 
inner  orbital  margin. 

Stage  III.  :  Removal  of  the  Bone  and  Tumour. — The  bone  is  now 
seized  by  lion  forceps,  one  blade  holding  the  alveolus,  and  the  other 
the  infra-orbital  border ;  the  mouth  is  gagged  open,  and  the  soft 
palate,  if  free  from  disease,  is  divided  from  its  attachment  to  the 
hard  by  a  transverse  incision,  and  when  all  other  connections  to  the 
soft  tissues  have  been  severed,  the  bone  is  removed.  Considerable 
haemorrhage  may  occur  at  this  stage  from  the  infra-orbital  and 
posterior  palatine  vessels  ;  it  is  checked  temporarily  by  plugging 
the  w^ound  firmly  with  a  sponge,  and  subsequently  the  chief  vessels 
are  secured  by  ligature.  Any  outlying  portions  of  the  tumour  are 
now  dealt  with,  and  the  cavity,  after  being  dabbed  over  with  a 
solution  of  chloride  of  zinc  (40  grains  to  the  ounce),  is  packed 
with  strips  of  sterile  gauze.  The  wound  in  the  cheek  is  closed,  the 
greatest  care  being  taken  to  obtain  accurate  apposition  of  the  flap, 
especially  at  the  lip  margin,  and  dressed  "wdth  gauze  secured  with 
collodion. 

In  the  majority  of  cases  there  is  comparatively  little  shock,  and 
the  patients  do  remarkably  well — at  any  rate,  for  a  time — although, 
unfortunately,  recurrence  is  only  too  likely  to  follow.  The  plug  in 
the  nose  is  left  in  situ  for  twent3'-four  hours  and  then  removed 
through  the  mouth,  and  the  wound  irrigated  with  some  antiseptic 
solution.  The  plug  may  be  replaced,  but  can  usually  be  dispensed 
with  if  the  cavity  is  washed  out  several  times  a  day.  Heahng  is 
effected  by  granulation,  and  of  course  a  large  gap  communicating 
vinth  the  mouth  remains.  This  can  be  subsequently  remedied  by 
an  obturator,  to  the  upper  surface  of  which  is  attached  a  plug  or 
cheek-plate  to  prevent  falling  in  of  the  cheek,  and  to  diminish  the 
cavity  of  the  nose.  The  patient  is  fed  for  the  first  few  days  by  the 
rectum,  or  by  a  tube  passed  into  the  pharynx,  but  soon  acquires 
the  knack  of  swallowing  fluids,  especially  when  the  soft  palate  has 
been  left  intact. 

Although  malignant  disease  must  always  be  removed  with  a  free 
hand,  yet  the  amount  of  deformity  caused  by  a  complete  extirpation 
of  the  maxilla  is  not  inconsiderable,  and  whenever  it  is  justifiable, 
the  operation  should  be  limited,  and  no  more  bone  removed  than  is 
absolutely  essential.  In  particular,  the  floor  of  the  orbit  should  not 
be  needlessly  sacrificed,  as  its  removal  always  involves  displacement 
downwards  of  the  eye,  and  possibly  diplopia.  To  efi"ect  this,  the 
nasal  portion  of  the  incision  is  alone  required  ;  the  alveolus  and  hard 
palate  are  divided,  and  then  a  saw  is  carried  horizontally  outwards 
from  the  nares  across  the  bone — i.e.,  through  the  antrum — ^just 
below  the  orbital  plate.  The  posterior  connections  are  dealt  with  as 
before.  Occasionally  a  still  more  limited  proceeding  may  suffice  for 
the  removal  of  an  alveolar  growth,  whilst  the  upper  part  of  the  bone 
can  be  taken  away  without  the  lower.  For  these  proceedings  text- 
books of  operative  surgery  must  be  consulted. 

\"arious  forms  of  osteoplastic  resection  of  the   superior  maxilla 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  S19 

required  for   the   treatment   of  tumours  of  the  naso-pharynx  are 
mentioned  later  (p.  839) 


/ 


Tumours  of  the  Lower  Jaw. 

These  are  similar  in  character  to  those  met  with  in  the  upper  jaw. 
Thus,  Chondroma,  Osteoma,  Fibroma,  and  the  simple  and  malignant 
forms  of  Epulis,  have  been  already  described. 

Dentigerous  Cysts  form  around  teeth  which  are  misplaced  so  that 
they  cannot  erupt ;  though  occa-  ^ 

sionally  seen  in  the  upper  jaw, 
they  are  much  more  common  in 
the  lower.  Their  characters  and 
nature  have  been  already  de- 
scribed under  the  title  oi  folliciilav 
odontonies  at  p.  207.  They  are  met 
with  in  young  people,  and  give 
rise  to  expansion  of  the  jaw 
(Fig.  378) ;  the  tumour  thus  formed 
is  at  first  hard  and  solid  to  the 
touch,  but  later  on  eggshell 
crackling  and  even  true  fluctua- 
tion are  observed  when  the  en- 
casing wall  has  become  thin  or 
absorbed.  Absence  of  one  of  the 
permanent  teeth  may  sometimes 
be  noted,  but  not  necessarily, 
since  the  corresponding  milk 
tooth  is  not  always  shed,  owing 
to  the  want  of  pressure  from 
below.  Occasionally  suppuration 
within  the  cavity  may  be  caused 
by  an  extension  of  inflammation 
from  the  fang  of  a  neighbouring 
tooth,  or  by  the  cyst  being  opened 
during  its  extraction,  and  a  sinus 
discharging  ofiensive  pus  will  then 
form.  The  diagnosis  from  a  myeloid 
tumour  or  from  a  dental  cyst  is 
not  always  easy.  The  long  history  and  the  dental  irregularity 
would  point  to  a  dentigerous  cyst ;  whilst  dental  caries  would  suggest 
a  dental  cyst ;  but  the  actual  diagnosis  is  perhaps  best  made  by 
radiography,  when  the  misplaced  tooth  can  be  seen.  Treatment 
consists  in  freely  opening  the  cyst  through  the  mucous  membrane, 
and  removing  a  sufficient  portion  of  the  bony  wall  to  allow  of  the 
removal  of  the  misplaced  tooth.  The  cavity  is  left  open  and  allowed 
to  heal  by  granulation,  during  which  process  strict  attention  to 
cleanliness  must  be  observed. 

Fibro-cyEl;ic  Disease  of  the  Jaw  {epithelial  odontome,  p.  207)  has  been 


Fig.  378. — Dentigerous  Cyst,  show- 
ing Expanded  Condition  of  the 
Lower  J  AW,  and  Unerupted  Tooth 
LYING  Horizontally  within  it. 
(College  of  Surgeons'  Museum.) 


820 


A  MANUAL  OF  SURGERY 


already  mentioned  as  characterized  by  the  formation  of  a  tumour, 
often  of  great  size,  which  consists  of  spaces  lined  with  cuboidal 
epithelium,  and  supposed  to  originate  from  the  enamel  organ 
(Fig.  379).  It  occurs  most  frequently  in  young  people,  and,  as  a 
rule,  runs  a  perfectly  benign  course,  although  when  of  large  size  it 
may  encroach  on  surrounding  parts  and  even  destroy  life.  The  only 
Treatment  consists  in  complete  removal  of  the  affected  portion  of 
the  jaw. 

Actinomycosis  sometimes  develops  in  connection  with  the  jaws, 
but  more  frequently  in  the  lower.  It  produces  a  large  swelling 
due  to  its  growth  within  the  bone,  which  may  closely  simulate  a 
sarcoma  ;  the  constant  tendency  of  this  disease  to  suppurate  and 
discharge  the  mycelial  elements  is  a  characteristic  feature.  For  the 
general  clinical  signs  and  treatment,  see  p.  182. 

Myeloid -Sarcoma  is  met  with  in  the  lower  jaw,  not  only  in  the  form 
of  an  epulis,  but  also,  occasionally  as  an  endosteal  growth,  usually 


Fig.  379. — FiBRO-CYSTic  Disease  of  the  Lower  Jaw. 
(By  kind  permission  of  the  Council  of  the  Royal  College  of  Surgeons.) 

attacking  the  central  portion  of  the  bone,  which  becomes  expanded 
by  it.  It  presents  but  slight  evidences  of  malignancy,  and  may  be 
treated  in  the  first  place  by  opening  the  outer  shell  of  bone  through 
the  mouth  and  scraping  away  the  soft  contents,  the  cavity  thus 
formed  being  swabbed  out  with  pure  carbolic  acid,  and  plugged  with 
gauze.  Should  it  recur,  the  affected  portion  of  the  bone  must  be 
removed,  although,  whenever  possible,  a  bridge  of  osseous  tissue  is 
left  so  as  to  connect  the  two  segments  of  the  jaw ;  if  this  is  not 
attended  to,  they  are  likely  to  fall  together,  and  lead  to  considerable 
deformity  and  discomfort.  If  the  whole  thickness  of  the  bone  is 
excised,  a  wire  frame  or  splint  should  at  once  be  introduced  between 
the  fragments  with  the  same  object.  It  is  replaced  later  on  by  a 
suitable  plate  carrying  artificial  teeth. 

Round  or  Spindle -Celled  Sarcoma  also  occurs,  usually  springing  from 
the  periosteum,  the  deeper  parts  undergoing  ossification  (Fig.  380). 
The  course  is  typically  malignant,  and  free  removal  of  the  affected 
Dortion  of  the  bone  must  be  undertaken. 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  821 

Epithelioma  invades  the  lower  jaw  as  an  extension  of  a  similar 
affection  arising  either  from  the  gum,  lips,  or  tongue.  Excision 
of  a  portion  of  the  bone  together  with  the  primary  disease  is  always 
required,  unless  it  has  extended  so  far  as  to  render  extirpation 
impracticable. 

Excision  of  the  Lower  Jaw  is  employed  in  the  treatment  of  various 
tumours  arising  from  that  bone,  as  also  sometimes  for  extensive 
necrosis.  In  the  latter  case  it  may  be  possible  to  deal  with  it  from 
the  mouth,  but  when  required  for  the  treatment  of  malignant  disease 
an  external  incision  is  absolutely  essential. 

If  the  whole  of  one  side  is  to  be  removed,  an  incision  is  made, 
reaching  from  just  below  the  red  margin  of  the  lip  downwards  to  a 
point  immediately  below  the  symphysis,  and  thence  along  the  under 


Fig.  3S0.  — Osteo-Sarcoma  of  the  Lower  Jaw. 

surface  of  the  body  of  the  jaw  as  far  as  the  angle  ;  it  is  then  prolonged 
upwards  along  the  posterior  border  of  the  vertical  ramus,  not  extend- 
ing further  than  the  attachment  of  the  lobule  of  the  ear,  so  as  to 
avoid  the  facial  nerve  (Fig.  376,  B).  When  a  large  tumour  is  being 
dealt  with,  the  whole  thickness  of  the  lip  should  be  divided,  and  the 
flap  thus  marked  out  dissected  off  the  bone,  and  turned  outwards. 
Where,  however,  the  upper  portion  of  the  lip  is  left,  the  incisions  are 
carried  down  to  the  bone,  the  facial  vessels  being  secured  above  and 
below  before  division.  The  soft  parts  are  then  freed  from  the  outer 
aspect  of  the  bone,  and  the  cavity  of  the  mouth  opened.  The  central 
incisor  tooth  is  drawn,  and  the  jaw  divided  through  the  empty  socket 
with  a  saw  and  cutting-pliers  a  little  to  the  side  of  the  middle  line. 
By  this  means  the  genial  tubercles  and  their  attached  muscles  are 


522  A  MANUAL  OF  SURGERY 

not  encroached  on,  or  the  movements  of  the  tongue  impaired.  The 
bone  is  seized  and  drawn  outwards,  and  its  internal  connections  as 
far  as  the  angle  divided.  It  is  then  firmly  depressed,  and  the 
muscular  attachments  of  the  masseter  on  the  outer  side,  and  of  the 
internal  pterygoid  on  the  inner,  cut  through,  as  also  the  inferior 
dental  nerve  and  artery.  By  still  further  depressing  the  bone,  the 
temporal  tendon  is  exposed,  and  should  be  divided  by  successive 
touches  of  the  knife,  which  is  kept  close  to  the  bone.  Finally,  the 
condyle  is  freed  after  division  of  the  external  pterygoid  muscle  and 
of  the  ligaments  of  the  temporo-maxillary  articulation.  The  proximity 
of  the  internal  maxillary  artery  to  the  inner  aspect  of  the  neck  of  the 
bone  must  be  remembered.  After  haemorrhage  has  been  arrested,  the 
wound  is  stitched  together  and  dressed  with  collodion  and  gauze  ; 
possibly  a  drainage-tube  may  be  inserted  with  advantage  for  a  few 
days  through  the  floor  of  the  mouth.  Considerable  deformity  usually 
results  from  this  operation,  owing  to  the  remaining  half  of  the  bone 
being  drawn  across  the  mi<^dle  line. 

Diseases  of  the  Temporo -Maxillary  Articulation. 

Acute  Synovitis  may  supervene  in  the  course  of  an  attack  of 
rheumatic  fever,  and  is  evidenced  by  pain  on  movement  of  the  jaw, 
and  by  tenderness  and  swelling  immediately  beneath  the  root  of  the 
zygoma,  due  to  effusion  into  and  around  the  joint.  Resolution  generally 
follows,  but  fibroid  thickening  of  the  ligaments  and  impairment  of 
movement  may  result. 

Acute  Arthritis  arises  from  pyaemic  infection  after  the  exanthemata, 
or  from  gonorrhoea,  but  may  be  caused  by  direct  extension  of  inflamma- 
tion from  the  middle  ear,  as  in  scarlatina.  It  occurs  in  children,  and 
is  due  '  to  the  persistence  of  a  hiatus  in  that  part  of  the  tympanic 
plate  which  forms  the  floor  of  the  meatus  and  the  roof  of  the  articula- 
tion '  (Barker).  It  is  characterized  by  the  usual  signs  of  a  severe 
localized  inflammation,  with  the  formation  of  abscesses,  and  results 
commonly  in  ankylosis.  Fomentations  and  the  antiseptic  opening  of 
abscesses  constitute  the  only  early  treatment,  whilst  excision  of  the 
condyle  is  sometimes  required  at  a  later  date. 

Osteo-Arthritis  is  by  no  means  a  rare  affection  of  this  joint.  It  is 
often  symmetrical,  and  characterized  by  an  enlargement  of  the 
condyle,  which  can  be  felt  distinctly  in  front  of  the  tragus,  especially 
on  opening  the  mouth,  when  crepitus  is  also  noticed.  The  pain  is 
worse  at  night"  and  in  wet  weather,  and  the  jaw  becomes  deflected 
to  the  sound  side  if  the  disease  is  unilateral ;  when  both  sides  are 
affected,  the  jaw  is  pushed  forwards,  and  the  chin  projects.  The 
articular  cartilage  undergoes  the  usual  changes,  the  inter-articular 
cartilage  disappears,  and  the  glenoid  cavity  becomes  enlarged  and 
flattened,  so  that  the  eminentia  articularis  is  relatively  less  marked, 
thus  permitting  the  external  pterygoid  muscle  to  draw  the  condyle 
forwards.  After  a  time,  considerable  difficulty  is  experienced  in 
opening  the  mouth,  even  amounting  to  ankylosis.     Ordinary  medical 


AFFECTIONS  OF  THE  LIPS  AND  JAWS  823 

treatment  may  be  used  in  the  early  stages,  but  in  the  latter  the  condyle 
of  the  jaw  should  be  excised,  a  proceeding  followed  by  excellent 
results. 

Tuberculous  Disease  may  arise  either  in  the  bone  or  synovial 
membrane,  perhaps  spreading  to  it  from  neighbouring  lymphatic 
glands.  It  runs  the  usual  course  of  the  disease,  terminating  in  caries 
of  the  condyle,  and  ankylosis  after  protracted  suppuration  ;  to  pre- 
vent this,  excision  of  the  condyle  is  indicated. 

Immobility  or  Closure  of  the  Jaw  may  be  caused  by  a  variety  of 
conditions  : 

1.  True  ankylosis  of  the  temporo-maxillary  joint,  fibrous  or 
osseous,  as  the  result  of  any  of  the  diseases  mentioned  above. 

2.  Cicatricial  contraction  of  the  soft  structures  either  within  or 
without  the  mouth,  as  from  burns,  lupus,  or  extensive  operations  in 
the  pterygoid  region  upon  the  roots  of  the  fifth  nerve,  from  cancrum 
oris,  or  very  rarely  from  myositis  ossificans.  * 

3.  Spasm  of  the  muscles  of  the  jaw  (trismus),  due  to  reflex  irrita- 
tion, as  from  carious  teeth  or  an  unerupted  wisdom-tooth,  or  some 
other  local  lesion.  It  is  occasionally  hysterical,  and  is  one  of  the  early 
symptoms  of  tetanus. 

4.  Local  inflammatory  conditions  often  render  opening  of  the 
mouth  impossible,  both  from  the  pain  and  swelling — e.g.,  in  mumps, 
parotid  abscess,  acute  alveolar  periostitis — whilst  in  epithelioma  of 
the  jaw,  tongue  or  fauces,  and  various  forms  of  tumour,  the  size 
and  position  of  the  growth  may  seriously  impair  the  mobility  of  the 
jaw. 

The  term  ankylosis  can  only  be  applied  to  the  conditions  mentioned 
in  the  first  two  groups.  In  the  others  appropriate  treatment  must 
be  instituted  according  to  the  character  of  the  affection.  Where  the 
closure  of  the  jaw  is  permanent,  it  may  be  due  to  osseous  ankylosis, 
the  bony  masses  extending  not  only  between  the  articular  surfaces, 
but  also  between  the  alveoli ;  or  to  fibrous  adhesions  within  the 
joint ;  or  to  extra-articular  contraction  of  the  soft  parts,  not  only  the 
skin  and  mucous  membrane  being  involved,  but  also  frequently  the 
muscles  and  deeper  structures. 

Division  of  the  neck  of  the  bone  or  excision  of  the  head  may  thus 
be  impracticable,  or,  even  if  possible,  is  useless,  since  the  muscles  of 
the  jaw  hold  the  surfaces  in  such  good  apposition  as  to  bring  about 
a  recurrence  of  bony  union,  unless  obviated  by  implanting  a  flap  of 
the  temporal  muscle  or  a  vulcanite  plate  between  the  bony  surfaces. 
Division  of  the  intra-  or  extra-buccal  cicatrices  is  usually  unsatisfac- 
tory, owing  to  their  rapid  re-formation.  The  best  treatment  in  most 
cases  is  either  removal  of  the  vertical  ramus  of  the  jaw  down  to  the 
level  of  the  alveolus,  or  the  plan  suggested  by  Esmarch,  viz.,  excision 
of  a  wedge  of  bone,  with  its  apex  towards  the  alveolar  border,  from 
the  neighbourhood  of  the  angle,  and  the  establishment  of  an  artificial 
joint  at  that  spot.  The  incision  should  be  made  below  and  behind 
the  angle  down  to  the  bone,  from  which  the  periosteum  is  stripped  up, 
and  division  is  accomplished  by  means  of  the  saw. 


S24  A  MANUAL  OF  SURGERY 

Excision  of  the  Condyle  of  the  Jaw  is  not  always  a  simple  opera- 
tion, since  the  space  at  the  surgeon's  disposal  is  limited  by  the 
zygoma  above,  the  facial  nerve  below,  the  parotid  gland  in  front, 
and  the  external  ear  behind.  The  best  incision  is  a  curvilinear  one, 
commencing  over  the  middle  of  the  zygoma,  and  passing  downwards 
in  front  of  the  tragus.  It  should  merely  divide  the  skin  and  sub- 
cutaneous tissue,  and  the  flap  thus  marked  out  is  turned  forwards. 
A  transverse  incision  is  now  made  through  the  deep  fascia  im- 
mediately below  the  posterior  extremity  of  the  zygoma,  extending 
down  to  the  neck  of  the  bone,  which  is  cleared  by  a  raspatory  and 
divided  by  cutting-pliers  ;  the  condyle  is  then  grasped  by  necrosis 
forceps,  and  twisted  out.  But  little  bleeding  occurs,  and  the  wound 
heals  by  first  intention,  except  along  the  track  of  the  drainage-tube, 
which  should  always  be  employed. 


CHAPTER  XXVIII. 

AFFECTIONS  OF  THE  NOSE  AND  NASOPHARYNX. 

Affections  of  the  Outer  Nose. — Several  forms  of  Injury,  including 
fracture  of  the  nasal  bones  and  separation  of  the  cartilages,  have 
been  already  noticed  (p.  486). 

Depression  or  Flattening  of  the  Bridge  of  the  Nose  is  either  a  result 
of  traumatism,  such  as  a  fracture  of  the  nasal  bones,  or  may  follow 
defective  growth  of  the  ethmo-vomerine  septum,  due  to  disease 
either  of  syphilitic  or  tuberculous  origin  early  in  life,  whilst  it  may 
also  be  due  to  tertiary  syphilis.  If  caused  by  injury,  and  dealt 
with  promptly,  it  may  be  remedied  ;  but  when  once  acquired,  and 
especially  if  the  consequence  of  disease,  treatment  is  much  less 
satisfactory.  Several  cases  have  been  recorded,  however,  in  which 
bone-grafting  has  been  successful.  An  incision  is  made  down  the 
middle  line  of  the  nose,  the  soft  parts  are  reflected  on  either  side, 
and,  after  making  a  comfortable  bed  for  it,  the  bone-graft  is  in- 
troduced, and  kept  in  position  partly  by  sutures,  but  mainly  by 
closing  up  the  wound  in  the  soft  tissues.  In  one  case  the 
patient's  own  fourth  metatarsal  bone  was  utilized  with  success, 
whilst  platinum,  gold,  or  celluloid  frames  have  also  been  employed 
in  the  same  way. 

The  subcutaneous  injection  of  paraffin  has  been  utilized  in  many  of 
the  worst  cases  with  advantage.  At  first  a  paraffin  was  employed 
which  melts  at  1 10°  F.  ;  this,  however,  caused  a  good  deal  of  irrita- 
tion, and  its  exact  limitation  to  the  desired  area  was  difficult.  At  the 
present  time  a  cold  paraffin  is  utilized,  being  expressed  little  by  little 
from  a  powerful  syringe  (Mahu's),  and  the  tissues  are  built  up  into 
shape  exactly  as  is  desired.  The  paraffin  is  supposed  to  remain 
permanently  as  an  infiltration  of  the  tissues,  but  further  experience 
is  required  to  make  sure  that  this  is  the  case. 

Expansion  of  the  Bridge  of  the  Nose  is  always  the  outcome  of  some 
long-continued  intranasal  pressure,  especially  from  the  growth  of 
polypi.  It  rarely  follows  the  development  of  mucous  polypi,  except 
when  they  are  very  large  and  chronic,  but  it  is  not  an  uncommon 
accompaniment  of  the  fibrous  or  fibro-sarcomatous  variety.  The 
bridge  is  flattened  and  bulged  out  on  either  side,  giving  the  face  an 

825 


826 


A  MANUAL  OF  SURGERY 


appearance  justifying  the  name  '  frog-nose  '  which  has  been  appHed 
to  it. 

Congenital  swelHngs  at  the  root  of  the  nose  are  not  very  un- 
common, and  may  be  either  a  meningocele  (p.  738),  or  a  dermoid 
cyst  which  may  have  a  deep  connection  between  the  nasal  bones  with 
the  cerebral  membranes.  It  is  often  advisable  to  leave  them  alone 
until  adult  life,  since  their  intracranial  connections  may  be  shut  off 
as  the  child  grows  up. 

It  is  impossible  to  discuss  all  the  different  affections  of  the  skin  of 
tlie  nose.  Many  of  them  are  associated  with  the  sebaceous  glands, 
which  in  this  region  are  very  large  and  abundant.  Thus,  acne  is 
commonly  met  with,  arising   from   an   inflammation  of   the  glands 

after  obstruction  to  their  ducts.  It  is 
especially  frequent  in  drinkers  and  dys- 
peptics, women  addicted  to  tea-drinking 
often  suffering  severely.  When  the 
superficial  capillaries  become  markedly 
dilated  and  the  face  readily  flushes  on 
the  imbibition  of  hot  or  stimulating 
fluids,  the  term  rosacea  is  attached  to  it, 
whilst  if  acne  pustules  are  also  present, 
it  is  known  as  acne  rosacea.  Sometimes 
the  spots  become  much  enlarged,  and 
there  is  a  considerable  amount  of  infil- 
tration of  the  base,  a  condition  described 
as  acne  hypertvophicum.  In  the  most  ex- 
aggerated stage  the  sebaceous  glands 
become  overgrown  and  form  large  pro- 
tuberant nodular  masses  projecting  from 
the  end  of  the  nose,  and  covered  with  red  greasy  skin,  in  which  the 
dilated  orifices  of  the  glands  are  very  evident,  and  with  dilated 
capillaries  coursing  freely  over  them.  This  condition  is  generally 
known  as  lipoma  nasi,  rhinophyma,  or  hammer -nose  (Fig.  381)-  The 
Treatment  of  simple  acne  consists  in  correcting  the  dyspepsia,  and 
limiting  the  amount  of,  or  interdicting  entirely,  alcohol  or  tea. 
Capsules  of  ichthyol  (3  to  10  minims)  may  also  be  administered 
thrice  daily,  and  soothing  applications  should  be  used  locally,  such 
as  a  lotion  consisting  of  calamine,  oxide  of  zinc,  and  precipitated 
sulphur,  held  in  suspension  with  glycerine  and  lime  water.  Dilated 
and  unsightly  capillaries  may  be  dealt  with  by  puncturing  them  with 
the  gal vano- cautery  or  an  electrolytic  needle.  Rhinophyma  requires 
operative  proceedings ;  the  protuberant  mass  should  be  freely  dis- 
sected away  from  the  cartilages,  and  the  raw  surface  covered  by 
Thiersch  grafts. 

Partial  or  Total  Destruction  of  the  Nose  may  result  from  traumatism, 
but  usually  from  some  chronic  inflammatory  or  malignant  growth, 
such  as  lupus,  tertiary  syphilis,  or  rodent  ulcer.  Epithelioma  some- 
times attacks  it,  and  requires  total  removal  of  the  nose  for  its  cure. 
In  any  of  these  conditions  the  resulting  deformity  is  so  repulsive 


Fig.  381.  —  Rhinophyma,    of 
Hammer-nose.  (Tillmanns.) 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


827 


that  the  surgeon  is  certain  to  be  asked  to  undertake  some  proceeding 
to  remedy  it.  Indian  surgeons  have  had  a  good  deal  of  experience 
in  this  direction,  since  in  that  country  cutting  off  the  nose  is  often 
resorted  to  as  a  means  of  avenging  some  real  or  fancied  wrong. 
Various  plastic  operations  have  been  devised,  which,  however,  we 
can  only  indicate  briefly  here,  referring  students  to  larger  works  of 
operative  surgery  for  fuller  details. 

The  chief  methods  of  Rhinoplasty  are  as  follows  : 

1.  The  so-called  Indian  method*  consists  in  the  formation  of  a  ncse  from  a  flap 
of  skin  obtained  from  the  forehead.  The  flap  (Fig.  382)  is  more  or  less  pyriform, 
with  the  pedicle  so  placed  as  to  contain  one  of  the  frontal  arteries  and  the  supra- 
trochlear nerve.  Necessarily  its  exact  shape  and  __ 
size  vary  with  the  character  of  the  defect  and 
with  the  type  of  nose  desired.  Keegan,  who 
has  done  some  excellent  work  in  this  direction, 
advises  that  the  skin  covering  the  nasal  bones, 
as  high  as  the  level  where  the  bridge  of  spectacles 
would  rest,  should  first  be  turned  down  in  two 
flaps,  using  their  attachment  to  the  nasal  mucosa 
as  a  hinge,  so  that  the  cutaneous  surface  shall 
look  inwards  and  the  raw  surface  outwards.  Over 
these  the  forehead  flap  is  placed,  and  there 
should  be  sufficient  tissue  in  the  nasal  flaps  to 
enable  their  free  ends  to  be  stitched  below  to  the 
forehead  flap  on  either  side  of  the  columna,  thus 
completing  the  anterior  nares.  The  columna 
itself  is  formed  by  the  free  end  of  the  forehead 
flap.  Drainage-tubes  are  inserted  through  the 
anterior  nares  and  kept  in  position  for  ten  to 
fourteen  days.  The  lateral  margins  of  the  flap 
are  carefully  sutured  to  the  freshened  edges  of 
the  defect.  When  the  union  of  the  lower  portion 
is  sufficiently  firm,  the  nose  is  made  more  shapely 
by  partially  dividing  the  twisted  pedicle,  but  if 
possible  the  integrity  of  the  frontal  artery  should 
still  be  retained.  The  wound  in  the  forehead  is 
drawn  together  as  far  as  possible  by  sutures,  and 
healing  promoted  later  by  skin-grafting. 

2.  In  the  Taf^liacozzian  or  Italian  operation  (so 

called  from  Tagliacozzi,  the  surgeon  who  first  proposed  it)  a  flap  of  skin  is  taken 
from  the  arm.  The  pedicle  must  always  be  broad,  and  is  left  attached  to  the 
upper  part  of  the  inner  aspect  of  the  arm  ;  it  must  be  so  placed  that  it  can  be 
brought  into  apposition  with  the  nasal  defect  without  tension,  the  fore-arm  and 
hand  being  fixed  by  a  suitable  apparatus  above  the  head,  and  retained  there 
until  good  union  has  been  accomplished,  when  the  pedicle  is  gradually  divided. 
Absolute  fixation  of  the  arm  is  an  essential,  and  as  this  may  need  to  be  main- 
tained for  two  or  three  weeks,  the  patient  needs  a  considerable  amount  of  pluck 
and  perseverance.  When  the  pedicle  has  been  detached,  subsequent  plastic 
measures  are  required  to  mould  the  new  tissue  to  the  shape  of  the  nose. 

3.  The  cheeks  have  also  been  made  use  of  in  what  is  known  as  the  French 
method  to  supply  material  for  the  nose,  flaps  being  dissected  up  from  either  side, 
and  united  in  the  middle  line. 

4.  The  above  operations  have  the  great  objection  that  the  new  nose  only 
consists  of  soft  tissues,  and  hence  it  is  very  likely  to  shrivel  up  and  contract,  so 


Fig.  382. — Indian  Method 
OF  Rhinoplasty,  showing 
THE  Shape  and  Position 
OF  the  Forehead  Flap. 

The  points  A  and  B  are 
brought  down  to  A^  and 
B^  when  the  flap  is  twisted 
into  position. 


*  For  full   details  of  this    plan   we  would   refer  to    Keegan's    '  Rhinoplastic 
Operations.'     Bailliere,  Tindall,  and  Cox,  igoo. 


828  A  MANUAL  OF  SURGERY 

that  all  that  is  finally  obtained  is  a  covering  for  the  defect,  which  is  often  quite 
flush  with  the  surface.  To  obviate  this,  and  to  secure  a  bony  basis  for  the  nose, 
attempts  have  been  made  to  utilize  a  finger  for  the  purpose,  and  Mr.  Astley 
Bloxam  has  had  one  or  more  successful  cases.  The  terminal  phalanx  is  removed, 
the  soft  parts  split  down  the  middle  line  on  the  palmar  aspect,  and  the  divided 
segments  united  by  suture  to  the  margins  of  the  nasal  defect.  When  union  is 
secured,  the  amputation  of  the  finger  is  completed. 

Naturally,  where  only  a  portion  of  the  nose  is  destroyed,  partial  operations  can 
be  devised  to  meet  the  requirements  of  the  case. 

It  must  be  admitted,  however,  that  the  nose  produced  artificially 
by  any  of  these  methods  is  rarely  satisfactory,  and  has  a  considerable 
tendency  to  shrink.  Indeed,  it  is  probable  that  in  the  majority  of 
cases  patients  are  better  off  with  an  artificial  nose  made  of  vulcanite 
or  some  such  material  and  suitably  coloured,  and  held  on  by  a 
spectacle  frame  or  some  adhesive  substance. 

Examination  of  tlie  Nasal  Fossas  and  Naso-Pharynx. — In  order  to 
understand  fully  the  diseases  of  the  nose,  it  is  essential  that  the 
interior  of  the  organ  be  efficiently  examined,  and  to  do  this  three 
chief  methods  are  employed. 

1.  Anterior  rhinoscopy  consists  in  the  illumination  of  the  front  of  the 
nasal  cavity  through  "the  anterior  nares.  A  good  light  is  required, 
such  as  that  derived  from  an  electric  head-lamp,  and  some  form  of 
nasal  speculum.  Perhaps  Thudichum's  speculum  is  one  of  the  best ; 
it  consists  of  two  unfenestrated  blades,  connected  by  a  U-shaped 
spring,  which  is  held  in  the  hand,  whilst  the  blades  are  inserted  into 
the  nostril,  the  nasal  vibrissae  being  thus  held  aside ;  the  ring  and 
index  fingers  are  placed  one  on  each  limb,  so  as  to  regulate  the 
amount  of  tension,  and  prevent  painful  overstretching.  By  this  or 
similar  means  one  is  enabled  to  see  the  anterior  part  of  the  nasal 
fossae,  including  the  inferior  turbinal  and  the  erectile  tissue  at  its 
anterior  extremity.  The  amount  of  distension  of  the  latter  limits  the 
view  of  other  structures;  if  greatly  swollen,  it  feels  soft  and  even 
fluctuating,  but  collapses  entirely  on  the  application  of  a  5  per  cent, 
solution  of  cocaine,  allowing  the  free  convex  border  of  the  middle 
turbinal  to  come  into  view,  as  also  the  cleft  or  olfactory  fissure 
between  it  and  the  septum.  The  septum  can  also  be  examined, 
frequently  showing  deviations  from  the  middle  line,  and  thickenings 
or  spurs  of  bone  or  cartilage,  which  run  in  an  antero-posterior  or 
vertical  direction.  A  certain  amount  of  erectile  tissue  is  also  present 
on  the  septum. 

The  introduction  of  a  sterilized  probe  under  the  guidance  of  the 
eye  is  of  the  greatest  value  in  examining  the  nose.  It  not  only 
'serves  to  distinguish  the  different  qualities  of  growth  that  can  be 
seen,  but  will  also  give  information  concerning  regions  beyond  the 
surgeon's  eye. 

2.  'By  posterior  rhinoscopy  is  meant  an  examination  of  the  posterior 
nares  by  a  mirror  placed  behind  the  uvula  and  soft  palate.  It  is  by 
no  means  easy  to  accomplish,  and  requires  some  dexterity  and 
practice.  The  tongue  should  be  depressed,  and  a  small  mirror, 
previously   warmed  to   prevent  condensation   of   moisture,  is   then 


AFFECTIONS  OF  THE  MOSE  AND  NASO-PHARYNX  829 

passed  behind  the  uvula,  without  touching  it  or  the  posterior  wall  of 
the  pharynx,  and  by  shifting  its  angle  and  position  a  view  should  be 
obtained  of  the  structures  exposed  posteriorly.  If  not  successful,  and 
it  is  absolutely  necessary  to  obtain  a  view,  the  fauces  should  be 
cocainized  and  the  velum  held  up  by  some  form  of  palate  retractor, 
such  as  White's.  The  posterior  nares  (or  choanae)  are  seen,  separated 
by  the  vertical  posterior  free  margin  of  the  septum,  and  within  each 
cavity  the  rounded  ends  of  the  turbinals  with  the  meatuses  inter- 
vening. The  inferior  meatus  often  looks  very  small  owing  to  the 
prominence  of  the  velum  palati,  whilst  the  middle  meatus  may  be 
encroached  on  by  tumefaction  of  the  erectile  tissue  at  the  back  of  the 
inferior  spongy  bone.  Outside  the  choanae  are  seen  the  yellowish 
openings  of  the  Eustachian  tubes,  whilst  above  and  between  them 
Luschka's  tonsil,  a  raised  collection  of  lymphoid  tissue  in  the  roof  of 
the  pharynx  is  occasionally  observed. 

3.  Palpation  of  the  Posterior  Nares  with  the  index  finger,  previously 
disinfected,  will,  however,  give  better  results  in  the  majority  of  cases 
to  those  who  are  not  specially  practised  in  the  above  method.  The 
index  finger  is  passed  behind  the  uvula  and  velum,  and  the  nares  can 
then  be  well  explored,  and  the  existence  of  adenoids  or  other  growths 
determined. 

Spurs  and  Deviations  of  the  Nasal  Septum.— By  the  term  spur  is 
meant  a  cartilaginous  or  bony  ridge  or  thickening  of  the  septum, 
which  runs  in  a  more  or  less  transverse  direction,  and  is  of  congenital 
origin.  A  deviation  is  a  bending  of  the  septum  from  the  middle  line, 
leading  to  inequality  of  the  nasal  fossae  ;  the  cartilaginous  septum  is 
.mainly  involved,  and  the  condition  is  sometimes  of  traumatic  origin. 
The  two  conditions  are  not  unfrequently  combined,  and  when  they  are 
not  associated  with  injury,  a  high-arched  palate  is  usually  present. 
They  give  rise  to  unilateral  nasal  obstruction,  associated  with  a 
chronic  rhinitis  on  the  patulous  side.  Attacks  of  paroxysmal 
sneezing  of  the  hay-fever  type,  and  possibly  asthma,  may  result  from 
these  defects.  External  deformity  in  the  shape  of  nasal  asymmetry 
is  visible  in  most  of  the  cases  of  deviated  septum.  Spurs  may  be 
removed  by  a  special  knife  or  spokeshave,  if  cartilaginous,  and  by  a 
suitable  saw — e.g.,  Bosworth's — if  bony.  Many  operations  have  been 
devised  for  the  rectification  of  deviations,  but  that  chiefly  employed 
at  present  is  the  submucous  resection  of  the  septum.  It  is  performed 
under  a  local  or  general  anaesthetic,  and  the  results  are  excellent. 
The  mucous  membrane  is  stripped  up  on  the  convex  side,  and  the 
whole  thickness  of  the  cartilage  removed  ;  the  two  layers  of  mucous 
membrane  are  placed  in  contact,  and  by  their  union  constitute  a 
median  septum. 

Foreign  Bodies  are  rarely  impacted  in  the  nasal  passages  except  in 
children,  in  whom  the  condition  is  not  imcommon.  Any  unilateral 
purulent  discharge  from  a  child's  nose  should  suggest  the  likelihood 
of  such  an  occurrence,  peas,  beads,  or  buttons  being  the  substances 
usually  introduced.  A  certain  amount  of  unilateral  obstruction  to 
nasal  respiration  is  caused  thereby,  followed  by  a  catarrhal  or  even 


830  A  MANUAL  OF  SURGERY 

suppurative  rhinitis,  and  in  old-standing  cases  a  rhinolith  or  nasal 
calculus  may  be  caused  by  the  deposit  of  inspissated  mucus  upon 
the  outer  surface  of  a  foreign  body.  Removal  is  often  effected  by 
syringing  out  through  the  unaffected  nostril,  the  lotion  rushing  back 
through  the  other  side,  and  carrying  the  intruding  body  before  it. 
Failing  this,  the  child  should  be  anaesthetized  and  a  forceps  or  scoop 
employed,  the  surgeon's  manipulations  being  guided  by  a  rhinoscope 
and  frontal  illumination.  Necessarily,  all  instruments  used  for  this 
purpose  should  be  thoroughly  sterilized.  After  the  removal,  the 
nostrils  are  carefully  washed  out  for  a  few  days  with  a  weak  alkaline 
antiseptic  lotion,  such  as  salt  and  water  to  which  a  little  sanitas  has 
been  added. 

Acute  Rhinitis. — Several  distinct  varieties  of  this  affection  are 
described. 

1.  The  Catarrhal  form  is  extremely  common,  constituting  what  is 
popularly  known  as  a  '  cold  in  the  head.'  Not  only  is  the  nasal 
mucosa  involved,  but  the  inflammation  often  extends  to  the  frontal 
or  maxillary  sinuses,  causing  brow-ache  and  face-ache,  whilst  if  it 
spreads  to  the  mucous  lining  of  the  Eustachian  tube,  temporary 
deafness  may  ensue.  In  infants  great  dyspnoea  often  results  owing 
to  the  extreme  narrowness  of  the  nasal  passages,  and  this  may  be  so 
marked  as  to  interfere  for  a  time  with  breast-feeding.  Apart  from 
the  usual  domestic  remedies  directed  to  increasing  the  action  of  the 
bowels,  kidneys,  and  skin,  considerable  relief  can  often  be  obtained 
by  washing  out  the  nasal  cavities  three  or  four  times  a  day  with  a 
weak  warm  alkaline  lotion  containing  borax  and  possibly  a  little 
menthol. 

2.  A  Suppurative  form  arises  not  unfrequently  as  a  result  of  acute 
suppuration  in  one  of  the  accessory  sinuses  (acute  empyema),  and 
then  treatment  must  be  directed  mainly  to  the  sinus.  Occasionally 
it  is  due  to  gonorrhceal  infection  either  in  adults  or  infants,  but 
perhaps  more  commonly  in  the  latter.  The  discharge  is  abundant, 
and  causes  much  obstruction  to  nasal  respiration,  whilst  ulceration  is 
likely  to  occur.  The  passages  must  be  well  cleansed  with  a  solution 
of  boric  acid  several  times  daily,  and  the  interior  sprayed  or  painted 
with  a  weak  solution  of  nitrate  of  silver  (gr.  5  to  i  ounce)  once  every 
day  as  long  as  the  suppuration  continues. 

3.  True  diphtheria  also  occurs  in  the  nasal  fossse,  usually  as  a  com- 
plication of  the  same  disease  elsewhere,  and  requiring  a  similar  form 
of  treatment. 

Chronic  Rhinitis  occurs  in  many  distinct  types,  of  which  we  can 
merely  give  a  bare  outline.*  One  of  the  most  common  forms  is 
characterized  by  engorgement  of  the  erectile  tissue  covering  the 
inferior  turbinated  bone,  causing  obstruction  to  nasal  respiration  and 
an  abundant  discharge  of  muco-pus.  It  usually  occurs  in  patients 
with  prominent  noses,  where  the  passages  are  narrow,  and  in  conse- 
quence the  air  pressure  is  diminished  ;  it  may  be  lighted  up  by  some 

*  For  further  details,  consult  Greville  Macdonald's  '  Diseases  of  the  Nose.' 
A-lex.  P.  Watt  and  Son.     Second  edition,  1892. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  831 

slight  local  irritant,  such  as  a  sudden  change  of  temperature.  The 
anterior  end  of  the  inferior  turbinal  is  swollen,  red,  and  rounded,  the 
mucous  covering  being  oedematous,  and  the  mass  feeling,  on  touching 
it  with  a  probe,  like  a  sac  full  of  fluid.  The  local  application  of  a 
5  per  cent,  solution  of  cocaine  causes  its  complete,  though  temporary, 
collapse  in  a  few  moments.  If  it  is  allowed  to  persist,  hypertrophy 
of  the  mucous  membrane  follows,  and  in  the  most  marked  types  a 
projecting  papillomatous-like  mass,  almost  resembling  a  polypus, 
results.  It  is,  however,  merely  an  inflammatory  hyperplasia,  and 
not  a  new  growth  ;  true  papillomata  are  extremely  rare  in  this  situa- 
tion. The  posterior  end  of  the  bone  may  be  similarly  affected,  and 
the  mucous  covering  of  the  middle  turbinal  may  participate  in  the 
same  process.  A  certain  amount  of  pharyngitis  or  laryngo-tracheitis 
may  also  be  present.  Treatment. — In  the  early  stages  all  that  is 
required  is  to  wash  out  the  nasal  cavity  night  and  morning  with 
some  simple  nose  lotion,  such  as  borax  or  bicarbonate  of  soda 
(5  grains  to  i  ounce).  This  may  be  accomplished  either  by  sniffing 
the  solution  from  the  palm  of  the  hand,  or  by  using  some  form  of 
nasal  irrigator  or  douche  ;  Basdon's  douche  is  perhaps  the  best  for 
this  purpose.  If  such  is  insufficient  to  give  relief,  or  if  collapse  is 
not  produced  by  cocaine,  the  surface  may  be  swabbed  over  with  some 
diluted  caustic  {e.g.,  chromic  acid,  5  grains  to  i  ounce),  or,  better  still,  a 
point  of  galvano-cautery  at  a  red  heat  may  be  run  along  the  length 
of  the  bone.  In  the  later  stages  removal  of  the  hypertrophied 
excrescences  by  the  cold-wire  snare,  or  by  the  galvano-ecraseur,  is 
required. 

Another  group  of  cases  of  chronic  rhinitis  is  associated  with 
collapse  of  the  erectile  tissue,  and  then  there  is  but  little  discharge, 
since  the  exudation  dries  within  the  nasal  cavities  and  forms  inspis- 
sated crusts  or  scabs  which  are  often  difficult  to  remove  [rhinitis  sicca) . 
The  nasal  fossae  are  in  this  case  more  patulous  than  usual,  and  a  dry 
pharyngitis  and  chronic  laryngitis  are  often  present.  Both  nostrils 
may  be  involved,  but  occasionally  the  affection  results  from  devia- 
tions of,  or  spurs  on,  the  septum,  and  then  is  unilateral,  the 
discharge  coming  from  that  side  which  is  most  patulous,  whilst 
the  narrowed  side  remains  healthy.  When  symmetrical,  the  disease 
is  rather  due  to  constitutional  than  to  local  causes,  occurring  in 
weakly,  anaemic  women,  and  is  to  be  treated  by  general  rather  than 
local  measures.  In  the  unilateral  form,  the  deviation  or  spur  must 
be  remedied  (p.  829).  In  this  way  the  inspired  air  is  made  to  pass 
more  freely  along  the  narrowed  healthy  side,  and  the  other  nostril  is 
dealt  with  by  the  use  of  weak  alkaline  lotions.  It  may  also_  be 
advisable  to  plug  the  dilated  side  with  cotton-wool  for  some  time 
daily,  so  as  to  enforce  respiration  through  the  other  nostril.  Treat- 
ment is  always  likely  to  be  prolonged,  and  it  is  possible  that  a 
daily  alkaline  nose  lotion  may  be  needed  permanently.  Stimulating 
applications  are  never  borne  well,  and  hence  should  rarely  be 
ordered. 

Ozsena. — This  term  was  formerly  applied  to  any  offensive  muco- 


g32  A  MANUAL  OF  SURGERY 

purulent  discharge  from  the  nostrils,  whatever  the  cause,  and  thus 
was  made  to  include  such  conditions  as  tuberculous  or  syphilitic 
disease  of  the  turbinated  bones  or  of  the  septum,  suppuration  in  the 
accessory  sinuses,  the  impaction  of  foreign  bodies,  or  the  ulceration 
of  malignant  growths.  Improvements  in  differential  diagnosis  have 
reduced  the  cases  of  ozaena  to  a  very  small  number,  and  the  term  is 
now  limited  to  one  particular  affection,  and  that  a  special  atrophic 
form  of  rhinitis  sicca. 

The  disease  is  usually  met  with  in  young  females,  and  may  some- 
times originate  from  traumatism,  or  after  one  of  the  exanthemata, 
or  is  associated  with  inherited  tuberculosis  or  syphilis.  The  nose 
is  almost  always  wide  and  roomy ;  the  lips  are  often  thick  and 
everted,  and  the  mouth  is  usually  held  open  owing  to  the  im- 
pediment to  nasal  respiration  caused  by  inspissated  mucus.  The 
foetor  of  the  breath  due  to  the  decomposition  of  this  discharge 
is  the  special  feature  that  calls  attention  to  the  complaint :  it 
is  peculiarly  searching  and  objectionable,  but  the  patient  fortu- 
nately is  not  cognizant  of  it.  There  is  not  much  discharge,  but 
at  varying  periods  large  crusts  come  away,  giving  relief  both  to 
the  nasal  respiration  and  to  the  foetor.  Both  nostrils  are  usually 
involved. 

On  examination,  the  nares  are  found  to  be  unusually  patulous, 
and  the  vibrissae  are  scanty.  The  mucous  membrane  over  the 
turbinated  bones  is  dry,  collapsed,  and  pale,  so  that  after  clearing 
away  all  the  dried  mucus  and  scabs,  it  is  often  possible  to  see  the 
posterior  pharyngeal  wall,  and  even  the  orifices  of  the  Eustachian 
tubes.  The  pharyngeal  wall  is  also  dry,  and  may  be  coated  with  a 
film  of  inspissated  mucus.  No  ulceration  is  present,  although  the 
removal  of  the  crusts  may  be  associated  with  a  slight  amount  of 
bleeding  owing  to  their  close  attachment  to  the  mucous  membrane. 
The  examination  of  a  case  of  suspected  ozaena  should  also  include 
the  accessory  cavities  of  the  nose,  since  many  cases  in  which  crust- 
formation  is  a  prominent  symptom  are  really  due  to  an  empyema  of 
one  or  more  of  the  sinuses. 

The  chief  etiological  factor  is  the  wide,  roomy  nose,  from  which  it 
is  difficult  to  expel  the  exudation  arising  from  any  ordinary  rhinitis, 
and  hence  the  discharge  tends  to  collect  and  necessarily  to  putrefy. 
For  the  same  cause  the  mucous  membrane  becomes  dry  and  the 
erectile  tissue  collapses,  so  that  an  atrophic  form  of  rhinitis  sicca 
results^  followed  in  time  by  sclerosis  and  shrinking  of  the  turbinated 
bones.  It  is  always  a  prolonged  process,  although  in  the  course  of 
years  it  improves  and  gradually  disappears. 

Treatment. — The  first  essential  is  to  keep  the  nose  clean  and  free 
from  putrefying,  masses  of  dried  secretion.  This  must  be  accom- 
plished by  irrigating  the  cavity  once  or  twice  daily  with  a  warm 
weak  solution  of  common  salt  to  which  a  little  sanitas  has  been 
added.  At  first  it  is  well  for  the  surgeon  to  see  to  this  himself,  but 
after  a  while  the  patient  or  her  friends  can  be  entrusted  with  the 
task.     Every  portion  of  scab  ought  to  be  removed  daily,  and  the 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


«33 


surface  lubricated  with  some  such  appHcation  as  a  spray  of  menthol 
and  paroleine  (lo  grains  to  i  ounce).  The  nose  should  then  be 
partially  plugged  with  a  tampon  of  cotton-wool,  especially  along 
the  lower  meatus,  and  if  thought  desirable  the  wool  may  be  medi- 
cated with  some  antiseptic.  By  this  means  a  flow  of  mucus  from 
the  membrane  is  determined,  and  the  discharge  is  thus  rendered 
more  fluid,  and  inspissation  prevented.  A  similar  end  may  also  be 
obtained  by  plugging  the  nostril  partially  with  an  indiarubber  tube, 
so  as  to  diminish  its  size.  The  general  health  must  be  attended  to, 
and  patience  and  perseverance  will  generally  be  crowned  with  success. 
Operative  measures  are  scarcely  ever  required  in  this  disease,  although 
they  have  frequently  been  resorted  to  most  unnecessarily. 


MA,--/ 


NB- 


Fig.  383. — Outer  Wall  of  Nasal  Fossa,  indicating  the  Position  of  the 
Accessory  Sinuses  and  of  their  Orifices. 

F,  Probe  passed  from  frontal  sinus  down  the  infundibulum  to  middle  meatus  ; 
AE,  anterior  ethmoidal  cells  ;  PE,  orifices  of  posterior  ethmoidal  in  superior 
meatus,  shown  by  removal  of  a  portion  of  the  superior  turbinal  ;  S,  sphe- 
noidal sinus  with  probe  in  its  orifice;  MA,  orifice  of  maxillary  antrum  shown 
by  cutting  away  part  of  the  middle  turbinal  ;  ND,  orifice  of  nasal  duct  under 
cover  of  the  inferior  turbinal  ;  ET,  pharyngeal  opening  of  Eustachian  tube. 

Disease  of  the  Accessory  Sinuses  of  the  Nose  is  a  frequent  ac- 
companiment of  either  the  acute  or  chronic  nasal  affections  just 
passed  under  review,  or  it  may  arise  from  more  localized  Jesions — 
e.g.,  antral  trouble  from  affections  of  the  teeth,  or  frontal  sinus 
mischief  from  traumatism.  Perhaps  the  most  common  cause  is  a 
sharp  influenzal  attack,  which  may  lead  to  an  involvement  of  the 
nasal  fossae  and  all  the  sinuses  (the  so-called  pan  sinusitis) ;  this  is 
tolerably  amenable  to  treatment  in  the  early  stages,  but  if  neglected, 

53 


834  A  MANUAL  OF  SURGERY 

may  become  chronic,  and  then  serious  trouble  may  result.  Pyogenic 
infection  of  the  nasal  fossae  from  the  introduction  of  dirty  instruments 
by  careless  or  meddlesome  surgeons  may  also  be  responsible  for  this 
condition.  The  obvious  outcome  is  the  persistent  discharge  of 
offensive  purulent  material  from  the  nose,  which  is  often  wrongly 
termed  ozaena ;  to  this  may  be  added  special  features  according  to 
the  particular  sinuses  which  are  mainly  affected. 

It  must  be  remembered  that  the  outlet  of  most  of  the  sinuses 
(Fig.  383)  is  badly  placed  for  drainage  purposes,  especially  the 
maxillary  antrum,  the  opening  to  which  is  near  the  roof  rather  than 
the  floor.  Even  in  the  case  of  the  frontal  sinus,  the  outlet,  which  is 
well  situated  for  drainage,  is  a  long  narrow  passage  easily  blocked 
by  cedematous  swelling  of  the  mucous  lining.  When  once  suppura- 
tion has  commenced  among  the  sinuses,  it  is  likely  to  spread  from 
one  to  another  owing  to  the  close  proximity  of  the  various  orifices  ; 
thus  pus  escaping  from  the  infundibulum  is  almost  certain  to  find  its 
way  into  the  antrum  or  ethmoidal  sinuses,  especially  if  the  escape  of 
the  discharge  is  hindered  by  the  presence  of  masses  of  granulation 
tissue. 

In  the  more  acute  cases  which  follow  influenza  or  cold,  the  antrum 
and  frontal  sinus  are  most  frequently  involved.  Readers  are  referred 
back  to  what  has  already  been  written  on  these  subjects  (pp.  754 
and  811),  with  the  emphatic  reminder  that  careful  treatment  during 
the  early  stages  may  prevent  the  affection  becoming  chronic  and  save 
the  patient  from  much  suffering  and  danger.  The  nose  should  be 
carefully  irrigated  with  warm  saline  solution  night  and  morning  ;  the 
antrum  itself  should  be  washed  out  after  puncturing  its  internal  wall; 
the  frontal  sinus  should  also  be  cleansed  in  a  similar  fashion. 

In  chronic  cases  the  discharge  will  be  found  to  come  from  one  or 
both  sides  of  the  nose,  and  the  patient  will  complain  of  feeling  stuffed 
up ;  breathing  will  be  mainly  oral,  and  the  breath  is  likely  to  become 
very  offensive.  On  examining  the  interior  of  the  nose,  even  after 
cleansing  it,  the  cavity  is  not  found  to  be  patent  as  in  ozaena,  but  is 
blocked  up  with  polypoid  masses  of  granulation  tissue,  which  project 
mainly  from  the  middle  meatus  ;  they  are  often  covered  with  a  half- 
dried  scab,  and  pus  can  be  seen  to  exude  from  it  when  pressed  upon  ; 
this  usually  comes  from  the  antrum  or  frontal  sinus,  a  mass  of 
granulation  tissue  developing  both  above  and  below  the  entrance. 
A  probe  passed  into  the  mass  always  impinges  on  dead  or  carious 
bone,  which  is  probably  a  part  of  the  middle  turbinal. 

The  special  features  of  diseases  of  the  frontal  sinus  and  antrum  of 
Highmore  have  been  already  indicated,  and  their  peculiar  dangers 
and  methods  of  treatment  discussed. 

The  ethmoidal  cells  lie  along  the  inner  wall  of  the  orbit,  and 
should  they  become  distended  with  mucus  or  pus,  may  bulge  into 
the  orbital  cavity  on  the  inner  side  and  even  displace  the  eyeball 
outwards.  The  sphenoidal  sinus  lies  at  the  back  of  the  nose 
(Fig.  383,  S),  and  the  discharge  escapes  downwards  into  the  naso- 
pharynx.    Suppuration  therein  causes  deep-seated  pain  in  the  back 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  835 

of  the  orbit  and  nose,  and,  unless  relieved,  may  determine  infective 
complications  about  the  base  of  the  skull — e.g.,  basal  meningitis, 
thrombosis  of  the  cavernous  sinus,  or  affections  of  the  nerves  to  the 
eye  and  orbit  in  the  neighbourhood  of  the  sphenoidal  fissure. 

The  Diagnosis  from  ozaena  is  made  by  the  fact  that  in  the  latter 
the  characteristic  features  are  the  abnormal  width  of  the  nasal  fossse, 
the  symmetry,  the  collapse  of  the  erectile  tissue,  the  more  complete 
inspissation  of  the  secretion,  and  the  pathognomonic  stench. 

Treatment,  except  in  the  simpler  cases,  should  always  be  handed 
over  to  a  rhinological  expert,  as  operative  measures  of  a  serious 
character  may  have  to  be  undertaken.  The  essential  element  is 
drainage  of  the  affected  cavities,  together  with  removal  of  the  pro- 
tuberant granulation  tissue  and  diseased  bone  which  hinder  the 
exit  of  the  discharge.  It  may  be  desirable  for  a  few  days  to  treat 
the  patient  merely  by  irrigation  of  the  nasal  fossae,  and  of  such 
sinuses  as  are  readily  accessible,  e.g.,  the  antrum  and  frontal  sinus; 
but  further  and  more  effective  treatment  must  not  be  long  delayed. 
In  many  of  these  cases  the  lining  membranes  of  these  cavities  will  be 
thickened  and  transformed  into  polypoid  masses,  and  hence  the  more 
extensive  of  the  procedures  mentioned  at  pp.  755  and  813  are  likely  to 
be  required  for  the  frontal  sinus  and  antrum.  For  suppuration  of  the 
ethmoidal  sinuses  it  may  suffice  to  remove  the  anterior  portion  of  the 
middle  turbinal  and  to  break  down  the  inner  wall  of  the  cells,  so  as 
to  lay  the  cavities  into  the  nose  ;  but  when  the  surrounding  bone  has 
become  diseased,  it  may  be  desirable  to  open  into  them  from  the 
orbit  by  prolonging  backwards  the  incision  for  exposing  the  frontal 
sinus.  The  sphenoidal  sinus  can,  of  course,  only  be  dealt  with  from 
its  nasal  aspect,  and  an  opening  has  to  be  carefully  made  into  its 
anterior  wall,  which  is  picked  away  by  punch  forceps. 

Syphilitic  Disease  of  the  nasal  fossae  is  generally  tertiary  in  type,  and 
consists  in  a  diffuse  gummatous  affection  of  the  septum  and  turbinals, 
with  resultant  suppuration,  and  either  caries  or  necrosis.  The  con- 
dition is  usually  a  very  offensive  one,  but  the  accessory  sinuses  are 
not  specially  liable  to  involvement.  Treatment  is  of  the  usual  anti- 
syphilitic  type,  including  the  injection  of  salvarsan,  and  perhaps  the  use 
of  iodides  and  mercury.  Locally,  the  nose  must  be  kept  clean  by 
irrigation,  and  diseased  bone  removed.  It  is  probable  that  if  the 
septum  is  seriously  affected,  the  bridge  of  the  nose  will  become 
depressed. 

Nasal  Polypi. — Two  forms  of  nasal  polypus  are  described,  viz., 
the  simple  or  mucous  polyp,  and  the  fibrous  or  fibro-sarcomatous. 
Other  malignant  tumours  occur  in  the  nasal  fossae,  to  which,  how- 
ever, the  term  polypus  can  scarcely  be  extended  ;  they  mainly 
originate  from  the  superior  maxilla. 

The  Mucous  Polypus  consists  of  a  soft  gelatinous  mass,  which 
on  microscopic  examination  much  resembles  myxomatous  tissue, 
covered  by  ciliated  columnar  epithelium,  and  supplied  freely  with 
bloodvessels.  Polypi  are  now  considered  to  be  inflammatory  in 
origin,  consisting  merely  of  oedematous  hypertrophic  tissue,  some- 


836 


A  MANUAL  OF  SURGERY 


times  dependent  on,  and  kept  up  by,  suppuration  in  one  of  the  ad- 
jacent sinuses,  especially  the  ethmoidal,  sometimes  due  to  disease  of 
the  underlying  turbinal,  out  not  unfrequently  occurring  apart  from  any 
obvious  lesion.  They  are  usually  situated  on  the  middle  and  superior 
turbinals ;  they  rarely  start  from  the  roof  of  the  nasal  fossae,  occasion- 
ally in  the  sinuses,  or  at  the  orifices  leading  into  them  ;  they  hardly 
ever  involve  the  septum  or  inferior  turbinal.  Polypi  are  generally 
multiple  (Fig.  384),  a  large  one  projecting  downwards  and  forwards 
towards  the  anterior  nares,  and  covering  or  hiding  a  series  of  smaller 
ones,  which  readily  spring  into  prominence  when  that  in  front  is 
removed.  They  are  usually  attached  by  a  small  pedicle,  and  when 
developing  in  the  nasal  fossa  are  pyriform  and  laterally  compressed. 
When  of  large  size,  they  may  protrude  through  the  nostrils,  and  then 
the  epithelium  covering  the  anterior  portion  becomes  squamous,  and 

the  mass  firmer  in  texture  and 
papillomatous  in  appearance. 
Sometimes  they  project  back- 
wards into  the  pharynx,  and 
are  then  more  distinctly  globu- 
lar and  usually  single.  Occa- 
sionally they  are  the  starting- 
point  of  a  myxo-sarcomatous 
growth,  which  develops 
rapidly,  and  early  tends  to  in- 
vade the  surrounding  bones. 

The  main  Symptom  arising 
from  nasal  polypi  is  obstruc- 
tion to  the  passage  of  air  along 
one  or  both  sides  of  the  nose. 
This  is  always  of  gradual  onset, 
and  invariably  worse  in  wet 
weather,  on  account  of  the 
hygroscopic  property  of  mu- 
coid tissue.  There  is  often  a 
thin,  watery  discharge  from  the  nose,  which  may  perhaps  be  blood- 
stained. The  patient  is  unable  to  blow  the  nose,  and  his  articulation 
becomes  nasal  in  quality.  On  rhinoscopic  examination  one  finds  a 
grayish  semi-translucent  glistening  mass  occupying  the  nostril,  and 
attempts  to  blow  the  nose  render  this  more  obvious.  Its  peduncu- 
lated nature  can  be  easily  demonstrated  by  passing  a  probe  around 
it.  When  of  large  size,  some  flattening  or  expansion  of  the  bridge 
of  the  nose  may  be  caused  thereby,  and  possibly  epiphora  from 
pressure  on  the  opening  of  the  nasal  duct. 

The  Diagnosis  should  present  no  difficulty  to  one  who  knows  how 
to  employ  the  nasal  speculum.  Abscess,  a  spur,  or  a  deviation  of  the 
septum,  though  causing  unilateral  obstruction,  can  be  recognised  by 
the  exercise  of  a  very  small  amount  of  intelligence.  (Edematous 
masses  of  granulation  tissue,  associated  with  tuberculous  or  syphi- 
litic disease  of  the  bones,  are  recognised  by  involving  usually  the 


Fig.     384.— Mucous    Polypi    of    Nose, 

SPRINGING    FROM    THE    BaCK    AND    FrONT 

OF  THE  Middle  Turbinated  Bone. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  837 

septum  as  well  as  the  turbinals,  by  the  absence  of  superficial 
epithelium,  and  by  not  being  distinctly  pedunculated;  carious 
bone  can  often  be  felt  by  a  probe  through  the  granulation  tissue. 
From  hypertrophy  of  the  mucous  membrane  over  the  inferior  tur- 
binated bone,  a  polypus  is  known  by  the  fact  that  it  scarcely  ever 
springs  froni  this  region,  whilst  the  former  condition  is  sessile  and 
red,  and  diminishes  considerably  in  size  by  the  application  of 
cocaine. 

The  Treatment  of  mucous  polypi  consists  in  their  removal  either 
by  forceps  or  the  snare.  The  former  plan  is  usually  condemned  by 
rhmologists  as  unscientific  and  barbarous,  and  as  utilized  by  manj, 
of  the  old  class  of  surgeons,  such  it  certainly  was  ;  but  if  employed 
in  the  way  described  below,  it  is  just  as  efficient  as  the  snare,  and 
gives  the  patient  very  httle,  if  any,  more  pain. 

In  undertaking  avulsion  by  forceps,  the  patient  is  seated  in  a  chair, 
and  the  surgeon  sits  or  stands  in  front  of  him.  The  nasal  cavities 
are  well  sprayed  with  a  solution  of  eucaine  or  cocaine  (5  per  cent.)  and 
adrenalin  (5  per  cent.),  and  the  situation  of  the  pedicle  ascertained  by 
inspection  and  by  the  use  of  a  probe.  The  forceps  employed  should 
be  long,  with  delicate,  though  strong,  blades,  which  are  deeply  serrated 
on  either  side  of  a  median  groove.  They  are  introduced  open,  with  a 
blade  placed  horizontally  on  either  side  of  the  growth,  and  are  gently 
pressed  upwards  until  the  pedicle  is  grasped  as  close  to  the  turbinated 
bone  as  possible.  The  blades  are  then  closed  firmly,  and  the  polyp 
twisted  off  and  removed,  a  certain  amount  of  haemorrhage  resulting. 
The  same  process  is  repeated  to  the  smaller  tumours  until  the  nostril 
is  clear.  It  may  be  plugged  with  a  strip  of  sterilized  gauze  if  there  is 
much  bleeding,  but  such  should  never  be  left  unchanged  longer  than 
twenty-four  hours.  The  plug  is  then  removed,  and  the  base  of  the 
growth  carefully  examined  and  cauterized  with  the  galvano-cautery 
by  the  aid  of  a  nasal  speculum.  This  cannot  be  so  accurately 
accomplished  immediately  after  removal,  as  the  bleeding  interferes 
with  clear  vision.  The  cauterization  of  the  base  is  a  most  important 
item  in  the  treatment,  as  without  it  the  growths  are  sure  to  recur. 
The  patient  should  be  again  examined  after  a  short  interval,  so  that 
any  smaller  polypi  which  have  commenced  to  develop  may  be  suit- 
ably dealt  with. 

To  remove  polypi  with  the  ecraseur  or  wire  snare,  a  speculum 
is  inserted,  and  the  loop  passed  round  the  growth  so  as  to  encircle 
its  base,  and  gradually  tightened  until  it  has  cut  through.  This  plan 
is  specially  adapted  to  large  masses  which  project  downwards  behind 
the  palate.  Precautions  as  to  bleeding  and  cauterization  of  the  base 
are  needed  as  indicated  above. 

Whichever  method  is  employed,  recurrences  are  not  uncommon, 
and  the  condition  of  the  surrounding  sinuses  must  be  carefully 
investigated,  and  if  need  be  suitable  treatment  must  be  adopted. 
Occasionally  the  middle  turbinal  needs  to  be  removed. 

A  Fibrous  Polypus  is  the  term  applied  to  a  fibroma,  which  sooner 
or  later  becomes  sarcomatous,  springing  from  the  base  of  the  skull, 


838  A  MANUAL  OF  SURGERY 

especially  from  the  basi-sphenoid  or  basi-occipital.  It  is  at  first 
distinctly  pedunculated,  and  is  usually  firm,  smooth,  and  fleshy  in 
character  ;  when  of  large  size,  it  may  be  lobulated.  The  early 
symptoms  are-  almost  limited  to  those  of  obstruction  to  nasal  respira- 
tion, but  to  this  is  not  unfrequently  added  severe  epistaxis,  owing  to 
the  vascularity  of  the  capsule  and  of  the  overlying  mucous  membrane. 
As  it  increases  in  size,  ulceration  occurs,  leading  to  a  fcetid  sanious 
discharge,  and  the  growth  rarely  remains  limited  to  the  nasal  fossae. 
If  pushing  forwards,  it  may  lead  to  expansion  of  the  bridge  of  the 
nose  and  separation  of  the  eyes,  which  may  even  be  made  to  diverge  ; 
but  if  backwards,  it  may  depress  the  velum,  and  hang  downwards  as 
a  naso-pharyngeal  tumour.  In  other  cases  it  may  force  its  way  into 
the  orbit  or  any  of  the  other  surrounding  cavities,  or  may  even  erode 
the  base  of  the  skull,  or  encroach  upon  the  cranium.  It  is  rare  for 
any  of  these  latter  manifestations  to  occur  until  after  the  tumour  has 
taken  on  a  distinct  sarcomatous  type. 

The  disease  usually  attacks  young  people,  and  mainly  those  in  the 
second  decade  of  life.  It  progresses  with  considerable  rapidity,  and 
the  fatal  issue  may  be  due  to  haemorrhage,  asphyxia,  or  cerebral 
complications. 

Treatment. — Unfortunately,  this  condition  is  but  rarely  recognised 
in  the  early  stages,  owing  to  the  fact  that  the  majority  of  practitioners 
are  quite  unable  to  use  the  rhinoscope.  Every  case  of  nasal  obstruc- 
tion or  of  chronic  discharge  from  the  nose  should  be  carefully  in- 
vestigated both  by  the  mirror  and  by  a  finger  passed  behind  the 
velum.  When  the  growth  is  small  and  polypoid,  it  can  often  be 
dealt  with  from  the  anterior  nares  by  means  of  a  galvano-ecraseur. 
The  wire  loop  is  inserted  from  the  front,  and  hitched  over  the  tumour, 
so  as  to  encircle  its  base,  by  the  assistance  of  the  right  index  finger 
passed  behind  the  velum.  The  pedicle  must  be  divided  as  near  the 
skull  as  possible,  as  otherwise  recurrence  is  almost  certain  to  follow. 
Nelaton's  operation,  described  below  (p.  839),  will  in  some  instances 
assist  the  surgeon  to  reach  the  base  of  the  skull  and  deal  with  the 
tumour. 

In  the  more  severe  cases,  where  the  growth  has  become  diffuse,  it 
is  very  doubtful  whether  much  good  can  be  done  by  operation,  since 
the  base  of  the  skull  is  sure  to  be  gravely  affected.  If  treatment  is 
attempted,  one  or  other  of  the  many  plans  for  exploring  the  nose  or 
naso-pharynx  must  be  resorted  to,  and  the  operative  measures  must 
be  modified  according  to  the  peculiar  requirements  of  the  case. 
Probably  total  ablation  of  the  superior  maxilla  will  give  the  best 
approach  to  the  mass. 

Other  forms  of  Malignant  Disease  of  the  Nose  are  met  with,  and 
may  originate  in  any  part  of  the  nasal  fossae.  Squamous  epithelioma 
is  that  which  occurs  most  frequently  ;  the  symptoms  consist  in  the 
presence  of  a  blood-stained  discharge,  and  a  certain  amount  of 
respiratory  obstruction,  together  with  pain  and  cachexia.  The 
lymphatic  glands  at  the  angle  of  the  jaw  are  early  enlarged,  and  the 
course  of  the  disease  is  usually  rapid,  owing  to  the  great  vascularity 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  S39 

of  the  part.  It  is  sometimes  possible  to  deal  with  these  patientsby 
operative  measures,  which  must  be  varied  according  to  the  require- 
ments of  the  case.     Radium  may  perhaps  be  of  service. 

Sarcoma  may  also  commence  in  the  nose  itself,  quite  apart  from 
that  which  originates  in  the  superior  maxilla.  It  gives  rise  to  the 
usual  signs  of  an  intranasal  growth,  and  may  occasionally  be  dealt 
with  in  a  satisfactory  manner  by  local  means,  such  as  curetting  and 
the  application  of  caustics.  Not  a  few  cases  are  on  record  in  which 
such  treatment  has  proved  efficacious  in  curing  the  disease,  although 
one  would  now  raise  the  question  as  to  whether  these  tumours  were 
sarcomatous  at  all,  and  not  endotheHomata. 

The  operations  which  have  been  devised  for  dealing  with  disease  of  the  nose  and 
naso-pharynx  are  so  numerous  and  complicated  that  it  is  impossible  for  us  to 
mention  more  than  a  few  of  the  most  useful  and  important. 

(a)  In  many  cases  of  intranasal  disease  considerable  assistance  can  be  derived 
by  opening  up  the  anterior  naves,  especially  when  one  is  operating  for  caries  or 
necrosis  of  the  turbinated  bones.  It  may  suffice  merely  to  divide  one  ala  nasi 
and  the  attachments  of  the  cartilages  to  the  maxilla  ;  but  where  both  sides  are 
involved  Rouge's  operation  is  advisable.  This  consists  in  the  detachment  of  the 
mask  of  the  face  from  the  maxilla  by  everting  the  upper  lip  and  incising  the 
mucous  membrane  and  subjacent  tissues  until  the  nasal  cavities  are  opened.  The 
septum  nasi  is  divided  by  cutting-pliers,  and  the  nasal  cartilages  are  completely 
separated.  The  soft  tissues  of  the  face  can  then  be  retracted  upwards,  and  the 
nasal  fossae  fully  exposed.  The  bleeding  is  always  considerable,  and  the  space 
gained  in  children  is  but  slight.  When  the  operation  is  completed,  the  mask  of 
the  face  is  allowed  to  fall  back  again  into  position,  union  occurring  without 
difficulty,  although  no  sutures  are  employed. 

When  the  upper  and  anterior  portion  of  the  nasal  cavity  is  to  be  dealt  with, 
Langenbeck's  plan  can  sometimes  be  utilized  with  advantage.  An  incision  down 
to  the  bones  is  made  along  the  outer  border  of  the  nose  from  the  root  downwards 
and  outwards  towards  the  ala.  The  soft  parts  are  retracted  on  either  side  so  as 
to  expose  the  nasal  bone  and  the  nasal  process  of  the  superior  maxilla,  a  wedge- 
shaped  portion  of  which  can  be  divided  by  cutting-pliers  and  prised  upwards, 
but  left  with  their  superior  connections  untouched,  so  that  after  the  operation 
they  can  be  replaced. 

When  the  septum  alone  is  involved  in  malignant  disease,  it  is  possible  to  deal 
with  it  by  an  operation,  which  consists  in  splitting  the  upper  lip  in  the  middle 
line,  and  carrying  the  incision  round  the  ala  nasi  on  each  side  so  that  the  lower 
portion  of  the  nose  can  be  turned  upwards  after  dividing  the  septum.  A  wedge- 
shaped  portion  is  then  removed  from  the  front  of  the  palate  after  detaching  the 
muco-periosteum  from  its  buccal  aspect.  An  excellent  approach  is  thus  obtained 
into  the  nasal  cavity,  and  the  entire  septum  can  in  this  way  be  removed  without 
difficulty.  The  parts  can  be  afterwards  brought  together  quite  naturally,  and  the 
deformity  is  very  slight.  A  patient  on  whom  this  operation  was  performed  for 
undoubted  epithelioma  of  the  septum  reported  himself  at  hospital  eight  years 
later ;  he  was  quite  free  from  recurrence,  and  apart  from  a  sunken  bridge  to  his 
nose,  there  was  no  defo  mity. 

(i)  When  the  disease  is  located  further  back,  originating  rather  in  the  naso- 
pharynx than  in  the  nose  itself,  the  palatine  route  may  be  used  with  advantage. 
Perhaps  the  best  of  the  several  suggested  operations  is  that  of  Nelaton.  This 
consists  in  a  median  section  of  the  velum  and  of  the  mucous  membrane  covering 
the  posterior  half  of  the  hard  palate.  A  transverse  incision  is  then  made  on 
either  side  of  the  anterior  extremity  of  this,  and  two  muco-periosteal  flaps  are 
reflected,  exposing  a  quadrilateral  area  of  bone  which  is  removed  by  chisel  and 
mallet.  If  need  l3e,  part  of  the  vomer  is  also  taken  away,  and  thus  thenasc-. 
pharynx  is  opened  sufficiently  to  allow  of  the  removal  of  the  polypus  or  growth. 
The  reflected  segments  of  the  palate  are  subsequently  sutured  together. 

{c)  Various   methods    of  osteoplastic  section   of  the   superior  maxilla   have   been 


^40  A  MAMUAL  OF  SURGERY 

practised,  and  Langenbeck's  name  has  been  associated  with  one  or  two  different 
plans,  which  are,  however,  only  suited  to  particular  cases  of  disease,  and  at  best 
give  but  poor  access  to  the  parts  behind  or  above  the  superior  maxilla,  whilst 
they  usually  leave  extremely  ugly  cicatrices.  Perhaps  the  best  plan  to  adopt  is 
to  detach  the  superior  maxilla  temporarily  from  its  bed,  turning  it  outwards 
together  with  the  cutaneous  and  subcutaneous  tissues  overlying  it,  and  then, 
after  completing  the  operation,  replacing  the  bone  and  suturing  the  soft  parts 
into  position.     The  results  of  such  practice  have  been  encouraging. 


Adenoids. — It  has  been  already  mentioned  that  the  naso-pharynx 
is  the  seat  of  a  large  amount  of  lymphoid  tissue,  similar  to  that  met 
with  in  the  tonsil,  which  may  either  be  distributed  widely  over  the 
whole  mucous  membrane,  or  be  gathered  into  a  special  mass  on  the 

roof,  known  as  the  pharyn- 
geal or  Luschka's  tonsil. 
Adenoids  consist  in  a  hyper- 
plasia of  this  tissue,  exactly 
analogous  to  the  chronic 
hypertrophic  form  of  tonsil- 
litis, with  which,  indeed,  it 
is  often  associated.  They 
usually  occur  in  the  form  of 
broad,  cushion-like  masses 
springing  mainly  from  the 
roof  or  posterior  walls,  or 
occasionally  as  pedunculated 
tumours  hanging  down  into 
the  posterior  nares.  The 
tumours  are  extremely  soft 
and  vascular,  bleeding  very 
readily.  The  surface  is 
often  plicated,  and  in  the 
recesses  or  folds  between 
the  different  portions  of  the 
mass  bacteria  lodge  and 
give  rise  to  various  inflam- 
matory troubles,  both  locally 
and  in  neighbouring  lym- 
phatic glands.  Not  uncom- 
monly isolated  masses  simi- 
lar in  structure  to  the  above 
are  also  to  be  seen  on  the 
posterior  wall  of  the  pharynx,  and  a  certain  amount  of  chronic 
rhinitis  and  laryngitis  may  be  associated.  The  condition  is  rarely 
seen  in  others  than  children,  and  especially  those  living  in  the  smoky 
atmosphere  of  large  towns.  If  untreated,  they  usually  atrophy  in 
time,  but  not  before  much  harm  may  have  been  done  to  the  individual. 
The  Symptoms  are  mainly  due  to  obstruction  to  nasal  respiration. 
The  mouth  is  generally  held  half  open,  so  as  to  allow  the  child  to 
breathe  through  it,  thereby  exposing  the  upper  central  incisors 
(Fig.  385) ;  from  a  similar  cause  he  snores  during  sleep,  and  usually 
wakes  with  the  mouth  and  tongue  dry.     The  nostrils  are  drawn  in, 


Fig.  585.  —  Adenoid  Facies.  (From  a 
Photograph  kindly  lent  by  Dr.  St. 
Clair  Thomson.) 

This  illustration  shows  well  the  sleepy  look, 
the  pinched  nostrils,  the  open  mouth  and 
projecting  upper  central  incisors,  so  char- 
acteristic of  this  condition. 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX 


84.1 


and  the  nose  is  thin  and  pinched,  the  whole  facies  being  very  charac- 
teristic ;  the  children  often  look  sleepy  and  half  silly,  and  indeed  may 
be  very  backward  in  their  studies.  Not  uncommonly  there  is  a  cer- 
tain amount  of  semi-purulent  discharge  from  the  nose,  or  it  may  be 
hawked  up  from  the  pharynx,  perhaps  mixed  with  blood.  Acute  or 
chronic  otitis  media  often  results  from  extension  of  the  catarrhal 
condition  to  the  mucous  lining  of  the  Eustachian  tubes,  and  deafness 
may  be  thereby  induced  ;  both  taste  and 
smell  are  sometimes  impaired.  The 
palate  becomes  high  and  arched,  owing 
to  the  defective  intranasal  air  pressure, 
and  as  the  patient  grows  up,  the  incisor 
teeth  may  project  forwards,  giving  a 
curious  rabbit-like  expression  to  the  face. 
The  cervical  glands  are  sympathetically 
enlarged,  and  often  the  seat  of  tubercu- 
lous disease.  In  bad  cases  which  have 
been  allowed  to  persist  throughout  adol- 
escence the  thorax  becomes  flattened 
owing  to  the  inability  of  the  child  to  take 
a  really  deep  inspiration,  the  ribs  are 
drawn  in,  and  the  spine  is  kyphotic 
(Fig.  386). 

Physical  Examination  consists  in  pos- 
terior rhinoscopy,  by  means  of  which 
the  growths  can  be  seen,  or  in  palpation 
of  the  posterior  nares,  a  process  more 
suitable  to  children,  who  rarely  have 
sufficient  control  to  permit  of  the  former. 
On  passing  the  finger  behind  the  velum, 
the  naso-pharynx  is  found  to  be  occupied 
by  a  soft  mass  of  tissue  which  readily 
bleeds,  and  more  or  less  obstructs  the 
openings  of  the  posterior  nares. 

Treatment  consists  in  the  great 
majority  of  cases  in  removal  of  the  ade- 
noids by  operation.  In  mild  cases,  how- 
ever, much  may  be  done  by  enforcing 
respiratory  exercises  with  the  mouth 
shut ;  and  in  young  adults  attention  to 
the  general  health,  combined  with  irriga- 
tion of  the  nose  with  salt  and  water,  and  perhaps  the  local  application 
of  a  weak  solution  of  nitrate  of  silver  (5  grains  to  i  ounce)  to  the 
naso-pharynx,  may  suffice  to  bring  about  improvement. 

Operation. — As  a  general  rule,  the  child  should  be  anaesthetized 
with  gas,  chloroform,  or  chloride  of  ethyl,  and  the  head  may  be 
allowed  to  hang  backwards  over  the  end  of  the  table.  If  enlarged 
tonsils  co-exist,  these  should  be  dealt  with  in  the.  first  place. 
Gottstein's  curette,  or  some  modification  of  it,  is  then  introduced 


Fig.  386. — Lateral  View  of 
A  Child  with  Neglected 
Adenoids.  (From  a  Photo- 
graph LENT  BY  Dr.  St. 
Clair  Thomson.) 

This  is  the  same  child  whose 
face  appears  in  Fig.  385 .  It 
will  be  seen  that  the  chest 
is  shallow  and  retracted,  and 
the  spine  kyphotic.  The 
arms  are  small,  but  the  legs 
are  well  developed. 


842  A   MANUAL  OF  SURGERY 

behind  the  soft  palate,  the  velum  being  drawn  forwards  by  the  left 
index  finger.  It  is  pressed  upwards  so  that  its  free  convex  edge 
impinges  on  the  upper  part  of  the  posterior  border  of  the  nasal  septum. 
It  is  then  swept  backwards  and  downwards  over  the  pharyngeal  wall, 
so  as  to  shave  away  the  chief  portion  of  the  projecting  mass  of 
adenoids.  Possibly  the  application  of  a  second  smaller  curette  may  be 
required  to  deal  with  outlying  lateral  portions  of  the  mass ;  and 
finally  the  adenoid  tissue  about  the  orifices  of  the  Eustachian  tubes 
and  any  remaining  tags  are  removed  by  the  use  of  Lowenberg's 
forceps  or  the  finger-nail.  Of  course,  there  is  considerable  bleeding, 
but  this  quickly  stops  of  itself  ;  as  soon  as  the  operation  is  over,  the 
child  should  be  turned  over  and  held  face  downwards,  so  as  to  allow 
the  blood  to  run  out  of  the  mouth  and  nose,  whilst  the  face  and  fore- 
head are  sponged  with  ice-cold  water  to  check  the  haemorrhage. 
The  patient  is  kept  indoors  for  a  few  days,  and  only  fluid  food 
allowed.  No  local  after-treatment  is  required  as  a  rule,  but  the 
throat  may  be  gargled  or  the  nose  washed  out  with  weak  salt  and 
water.     Nose-breathing  exercises  should  be  subsequently  instituted. 

Epistaxis,  or  bleeding  from  the  nose,  may  arise  from  a  variety  of 
causes,  including  traumatism,  directed  either  to  the  mucous  mem- 
branes or  the  bones,  or  from  the  presence  of  ulceration  or  tumours. 
Some  of  these  local  causes  are  very  evident,  if  only  they  are  carefully 
looked  for  with  a  rhinoscope  and  frontal  mirror.  One  of  the  com- 
monest lesions  is  a  small  abrasion  or  ulcer  of  the  septum,  due  to 
detaching  by  the  finger  a  scab  or  dried  crust  of  mucus  which  causes 
irritation  within  the  nostril ;  each  time  the  nose  is  '  picked '  in  this 
way,  bleeding  recurs.  Another  frequent  source  of  epistaxis  is  the 
rupture  of  a  varicose  vein  in  the  mucous  membrane  of  the  septum ; 
varix  occurs  not  unusually  in  plethoric  individuals,  and  sneezing  or 
blowing  the  nose  violently  may  lead  to  an  attack.  Foreign  bodies 
may  also  cause  haemorrhage,  as  also  ulceration  of  an  angioma  on 
the  septum.  It  frequently  occurs  in  young  people  about  puberty  in 
consequence  of  local  disturbance  in  the  vascular  arrangement  of 
the  parts;  again,  cerebral  congestion  may  induce  it,  owing  to  the 
communication  by  means  of  emissary  veins  between  the  interior  of 
the  skull  and  the  venous  plexuses  in  the  nose  ;  excessive  changes  in 
the  atmospheric  pressure,  as  in  mountaineering,  may  lead  to  epistaxis, 
whilst  in  abnormal  states  of  the  blood  it  may  be  associated  with 
haemorrhage  elsewhere,  as  in  haemophilia,  purpura,  and  scurvy.  It 
is  sometimes  an  evidence  of  chronic  Bright's  disease,  and  may  be 
one  of  the  first  symptoms  to  call  attention  to  its  existence,  and  may 
follow  cardiac  or  pulmonary  disease,  resulting  in  cerebral  congestion. 
One  or  both  nostrils  may  be  the  seat  of  the  bleeding,  and  it  may  be 
so  excessive  as  even  to  threaten  life. 

Treatment. — It  must  not  be  forgotten  that,  in  the  majority  of  cases, 
there  is  some  local  cause  of  epistaxis  which  can  be  found  and  treated 
directly — a  fact  which  once  more  emphasizes  the  necessity  for  gaining 
a  mastery  over  the  use  of  the  rhinoscope.  The  bleeding  is  generally 
unilateral,  and  in  nine  out  of  ten   cases  the  source  is  within  easy 


AFFECTIONS  OF  THE  NOSE  AND  NASO-PHARYNX  S43 

reach  of  the  anterior  nares,  and  hence  in  many  instances  all  that  is 
required  is  to  grasp  the  nostrils  firmly,  and  thus  allow  the  blood  to 
collect  within,  and  give  it  an  opportunity  of  clotting.  At  the  same 
time,  the  patient  should  sit  up,  and  cold  be  applied  to  the  root  of  the 
nose,  or  to  the  nape  of  the  neck.  If  on  examination  the  bleeding- 
point  is  detected,  whether  it  be  a  varicose  vein  or  an  ulcerated 
surface,  the  haemorrhage  can  almost  at  once  be  stayed  by  applying 
a  pointed  galvano-cautery,  or  by  sealing  the  spot  with  a  swab  soaked 
in  a  solution  of  chromic  acid  (5  per  cent.)  or  adrenalin.  Failing 
these  measures,  the  nostrils  may  need  to  be  plugged,  but  such  a  pro- 
ceeding ought  to  be  seldom  required.  It  may  suffice  merely  to  pack 
the  anterior  nares  with  long  strips  of  sterile  lint  or  gauze  soaked  in 
adrenalin,  or  a  sterilized  rubber  finger-stall  may  be  introduced  and 
filled  with  wool.  If  this  does  not  suffice  the  posterior  nares  must 
also  be  plugged.  For  this  purpose  Bellocq's  sound  is  usually 
employed  in  order  to  pass  a  thread  round  the  base  of  the  palate,  and 
out  of  both  nose  and  mouth ;  but  where  it  is  not  obtainable,  a 
suitably  curved  pair  of  laryngeal  forceps  or  a  rubber  catheter  may  be 
used  instead.  To  the  lower  end  of  this  thread  a  pledget  of  sterilized 
lint  or  gauze  about  i|-  inches  by  i  inch  in  size  is  attached,  and  this, 
guided  by  the  finger  round  the  soft  palate,  is  drawn  tightly  forwards 
into  the  posterior  nares.  It  is  a  good  plan  to  have  two  threads 
coming  forwards  out  of  the  nose,  and  these  may  be  tied  firmly 
around  a  pad  of  lint  placed  over  the  side  of  the  nostril,  thereby 
occluding  the  anterior  nares  and  completely  blocking  the  nasal 
cavity,  back  and  front.  The  loose  end  of  the  thread  emerging  from 
the  mouth  is  fixed  to  the  cheek  by  a  strip  of  adhesive  plaster.  The 
plug  is  retained  for  twelve  hours,  and  then  removed,  and  the  nasal 
fossae  irrigated  with  a  weak  warm  alkaline  antiseptic  lotion  in  order 
to  prevent  sepsis. 

Another  method  of  arresting  epistaxis  is  by  Cooper  Rose's  inflating 
plug  ;  it  consists  of  a  piece  of  gum-elastic  catheter,  surrounded  by  a 
thin  indiarubber  bag,  which  can  be  inflated  through  the  hollow  stem. 
It  is  oiled  and  passed  well  into  the  nose  from  the  front ;  the  india- 
rubber  bag  is  then  inflated  to  the  required  extent,  the  air  being 
retained  by  a  stop-cock.  This  generally  acts  most  efficiently,  and  can 
be  introduced  and  removed  with  scarcely  any  pain  to  the  patient. 


CHAPTER  XXIX. 

AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS. 

Stomatitis,  or  inflammation  of  the  mucous  membrane  of  the  mouth, 
is  by  no  means  uncommon,  especially  in  children. 

1.  Catarrlial  Stomatitis  results  from  mechanical  irritants,  such  as 
roughened  teeth,  from  irritating  chemicals,  or  from  septic  inflamma- 
tion following  operations  which  involve  the  mouth.  It  also  arises  in  the 
course  of  fevers,  and  in  conditions  of  debility  such  as  follow  measles 
and  other  exanthemata  in  children  ;  or  is  associated  with  disturbances 
in  the  alimentary  canal,  as  from  improper  feeding,  dyspepsia,  etc. 
The  mucous  membrane  becomes  hypersemic  and  swollen,  usually  in 
small  localized  patches,  which  may  gradually  spread  and  become 
confluent,  involving  nearly  the  whole  of  the  oral  cavity.  The  exuda- 
tion of  mucus  is  increased,  and  becomes  viscid  and  turbid,  whilst  the 
epithelium,  at  first  white  and  sodden,  is  after  a  while  rubbed  off, 
leaving  superficial  erosions  or  distinct  ulcers,  which  are  very  painful. 
The  treatment  consists  in  the  removal  of  all  sources  of  irritation,  and 
the  administration  of  drugs  to  correct  intestinal  derangements. 
Chlorate  of  potash,  possibly  combined  with  dilute  hydrochloric  acid, 
is  very  useful,  both  locally  and  internally.  In  the  more  severe  cases 
antiseptic  mouth-washes  should  be  employed,  such  as  the  liquor  sodge 
chlorinatae  (i  ounce  to  i  pint  of  water),  sanitas  (i  in  20),  boro- 
glyceride  (i  in  20),  etc. 

2.  Aphthous  Stomatitis  occurs  in  badly-fed  children  in  the  form 
of  small  whitish  spots  on  a  hypersemic  base,  which  run  together  and 
produce  ulceration.  Attention  must  be  directed  to  the  general  con- 
dition, and  a  little  borax  and  honey  or  a  solution  of  boro-glyceride 
(i  in  20)  applied  locally. 

3.  Thxush  is  due  to  the  presence  of  a  parasitic  fungus,  the  Oidiiim 
albicans,  and  occurs  in  patches  somewhat  resembling  curdled  milk  in 
appearance.  In  history  and  treatment  it  resembles  the  aphthous 
variety.  In  both  these  types  there  is  often  considerable  enlargement 
of  the  lymphatic  glands,  which,  however,  frequently  subside  without 
suppuration  w^hen  the  cause  is  cured. 

4.  Gangrenous  Stomatitis  is  much  the  same  in  origin  as  the  pre- 
ceding, but  more  acute  in  its  course.     It  occurs  in  debilitated  children 

84^* 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    845 

or  elderly  people,  the  subjects  of  albuminuria  or  diabetes,  and  is 
usually  due  to  foul  and  dirty  teeth.  The  gums  and  adjacent  tissues 
become  gangrenous,  and  severe  toxic  symptoms  result.  Active 
treatment  by  scraping  and  the  use  of  antiseptics,  such  a?  peroxide 
of  hydrogen,  is  urgently  necessary. 

In  children  this  condition  is  known  as  Cancrum  oris  (p.  114). 

5.  Mercurial  Stomatitis  may  arise  during  the  administration  of  a 
course  of  mercury,  or  occasionally  from  a  single  dose  in  persons  who 
are  sensitive  to  its  action.  It  is  increased  in  severity  if  the  mouth 
and  teeth  are  dirty,  or  if  the  patient  smokes  to  excess.  The  gums 
are  swollen  and  tender,  bleed  on  pressure,  and  are  very  painful, 
especially  when  biting,  or  drinking  hot  fluids.  The  teeth  may 
become  loose  and  fall  out,  whilst  the  alveolar  borders  may  be  laid 
bare  and  necrose.  The  tongue  is  sometimes  swollen  and  inflamed ; 
salivation  is  a  marked  symptom,  and  the  breath  becomes  very 
offensive.  Treatment. — Either  leave  off  the  mercury,  or  at  any  rate 
reduce  the  dose  considerably,  and  administer  saline  purgatives. 
Chlorate  of  potash,  combined  with  alum,  dilute  hydrochloric  acid, 
or  tincture  of  myrrh,  may  be  useful  locally. 

6.  For  Syphilitic  Stomatitis,  see  p.  150. 

The  buccal  mucous  membrane  is  also  involved  in  the  course  of 
other  diseases,  e.g.,  diphtheria,  scarlet  fever,  and  erysipelas,  but 
special  descriptions  are  not  needed  here. 

Affections  of  the  Tongue. 

Congenital  Abnormalities. — {a)  The  tongue  has  been  entirely 
absent.  (&)  One  half  of  the  tongue  is  defective  in  size  (hemiatrophy). 
(c)  Tongue-tie  is  said  to  be  present  when  the  fr^num  is  shorter  than 
usual,  causing  the  tip  to  be  depressed  and  fixed  in  the  floor  of  the 
mouth  so  that  it  cannot  be  protruded.  Sucking  becomes  difficult  in 
such  a  condition,  and  when  it  is  allowed  to  persist,  there  is  often  a 
lisp  in  the  speech.  Treatment  is  only  needed  in  the  severer  forms, 
and  consists  in  raising  the  tongue  with  the  index  and  middle  fingers 
placed  one  on  either  side,  and  snipping  the  frsenum,  thus  put  on  the 
stretch,  across  its  centre  with  a  pair  of  blunt-pointed  scissors  directed 
downwards,  [d)  The  tongue  may  be  adherent  to  the  floor  of  the 
mouth,  being  bound  down  by  folds  of  mucous  membrane  (ankyltglossia). 
This  may  also  exist  as  an  acquired  condition  due  to  cicatricial  con- 
traction after  ulceration.  In  congenital  cases  the  adhesions  are  but 
slight,  and  the  organ  can  be  readily  freed  ;  in  the  acquired  condition 
this  cannot  always  be  accomplished,  [e)  The  fraenum  and  tongue 
are  occasionally  too  long,  allowing  of  increased  mobility,  and  even 
fatal  results  have  occurred  from  the  organ  rolling  backwards  and 
impeding  respiration.  (/)  The  tongue  may  be  cleft,  presenting  a 
bifid  appearance ;  this  may  be  complete  or  partial,  and  is  usually 
associated  with  a  congenital  fissure  through  the  lower  lip  and 
mandible,  [g)  Macvoglossia  (or  large  tongue),  although  sometimes 
acquired,  is  usually  a  congenital  deformity.     The  organ  is  enlarged 


846  A  MANUAL  OF  SURGERY 

in  all  directions,  and  protrudes  from  the  mouth,  so  that  the  teeth 
indent  it,  and  cause  ulceration  and  considerable  interference  with  the 
venous  return.  It  thus  becomes  purpUsh  and  dry  from  exposure, 
the  mucous  membrane  looking  almost  like  skin,  although  saliva 
dribbles  freely  from  beneath  it.  In  old-standing  cases  the  teeth  are 
displaced  outwards  and  the  jaws  deformed,  so  that,  even  if  the  tongue 
is  reduced  to  its  normal  size  by  treatment,  it  may  be  impossible  to 
close  the  mouth.  Pathologically,  it  is  due  to  diffuse  overgrowth  of 
the  connective  tissue,  secondary  to  lymphatic  obstruction  and  dilata- 
tion. Recurrent  attacks  of  lymphangitis  add  to  the  trouble,  the 
tongue  gradually  increasing  in  size,  and  the  disease  has  been  known 
to  terminate  in  the  development  of  a  lympho-sarcoma.  The  treatment 
consists  in  excision  of  a  V-shaped  portion,  suturing  the  raw  surfaces 
subsequently  with  catgut. 

Wounds  of  the  tongue  are  usually  caused  by  the  teeth,  especially 
during  an  epileptic  seizure,  or  in  children  as  a  result  of  falls  with  the 
tongue  out.  There  is  often  brisk  haemorrhage  for  a  few  moments, 
which  soon  ceases,  though  blood  may  be  extravasated  into  its  sub- 
stance, and  cause  considerable  swelling.  In  simple  cases  the  wound 
should  be  examined  and  purified,  and  the  mouth  constantly  cleansed 
with  mild  antiseptic  lotions  ;  a  few  points  of  suture  may  also  be 
inserted  if  necessary,  but  the  wound  must  not  be  entirely  closed,  or 
tension  from  sepsis  will  result.  When  smart  arterial  bleeding  is 
present,  the  mouth  must  be  opened,  the  tongue  pulled  forwards,  and 
the  wounded  vessel  sought  for  and  tied.  Failmg  this,  the  lingual 
artery  may  be  tied  in  the  neck,  or  even  the  external  carotid. 

Acute  Superficial  Glossitis  occurs  as  part  of  a  general  stomatitis, 
and  needs  no  special  notice. 

Acute  Parenchymatous  Glossitis,  or  acute  inflammation  of  the 
tongue,  may  arise  from  penetrating  and,  of  necessity,  septic  wounds, 
or  from  the  bites  or  stings  of  insects,  or  may  be  associated  with 
acute  stomatitis  in  the  course  of  fevers,  but  is  most  commonly  due 
to  the  injudicious  administration  of  mercury.  The  condition  may 
be  limited  to  one  half  of  the  organ,  but  when  arising  from  general 
causes  is  bilateral.  The  tongue  becomes  painful,  swells  up  rapidly 
so  as  to  fill  the  mouth,  and  even  protrudes  beyond  the  teeth,  the 
pressure  of  which  leads  to  superficial  ulceration.  The  salivary  glands 
are  enlarged  and  painful,  and  salivation  is  a  marked  feature  in  the 
case.  Speech,  swallowing,  and  even  respiration  are  much  interfered 
with,  and  there  may  be  considerable  febrile  disturbance.  The  case, 
if  treated  with  care,  usually  ends  in  resolution  ;  but  diffuse  or  localized 
suppuration  may  ensue,  as  well  as  the  most  urgent  dyspnoea,  arising 
either  from  oedema  glottidis  or  from  the  pressure  of  the  enlarged 
organ.  Treatment  consists  in  stopping  the  mercury,  or  removing  any 
evident  cause,  and  in  the  administration  of  saline  purgatives  with 
chlorate  of  potash.  Leeches  may  be  applied  beneath  the  angles  of 
the  jaw,  but  in  bad  cases  a  free  incision  into  the  dorsum  should  be 
made  on  either  side  of  the  median  line  to  give  exit  to  the  effused  fluids 
and  blood.    The  most  rapid  relief  to  the  symptoms  is  thereby  obtained. 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    847 

although  the  organ  may  remain  enlarged  for  some  time.  If  asphyxia 
is  threatening,  high  tracheotomy  or  laryngotomy  is  required. 

Abscess  of  the  tongue  may  result  from  the  acute  process  described 
above,  but  is  more  usually  of  a  chronic  nature,  and  situated  at  the 
anterior  part  of  the  organ.  It  is  generally  due  to  the  admission  of 
micro-organisms  through  some  superficial  lesion  which  has  quickly 
healed.  It  presents  as  a  tense  swelling,  fluctuation  in  which  may  be 
masked  by  the  amount  of  inflammatory  thickening  which  surrounds 
it.     A  free  incision  both  settles  the  diagnosis  and  cures  the  case. 

Chronic  Superficial  Glossitis  is  an  interesting  and  important  disease, 
which  may  be  associated  with  a  similar  condition  of  the  mucous 
membrane  lining  the  interior  of  the  cheeks  and  lips.  It  is  most 
commonly  due  to  syphilis,  occurring  as  a  tertiary  phenomenon,  but 
may  arise  from  excessive  smoking,  ragged  and  rough  teeth,  or  spirit- 
drinking,  chronic  dyspepsia,  perhaps  of  a  gouty  nature,  being  also 
present  in  many  cases.  It  is  very  liable  to  be  followed  by  epithe- 
lioma, Barker  stating  that  out  of  no  cases  he  carefully  investigated 
cancer  occurred  in  43. 

For  purposes  of  description  it  is  useful  to  divide  the  disease  into 
the  following  five  stages,  although  it  must  be  clearly  understood  that 
they  are  artificial,  and  several  of  them  may  be  present  in  different 
parts  of  the  same  tongue,  (i.)  The  papillae  become  enlarged  and 
swollen,  leading  to  the  appearance  of  red  hyperaemic  patches,  which 
cannot  be  recognised  for  certain  unless  the  tongue  is  thoroughly 
dried  with  a  handkerchief,  towel,  or  piece  of  clean  blotting-paper, 
which  must  not  be  carelessly  dabbed  over  the  organ,  but  should 
be  firmly  pressed  down  upon  it  so  as  to  absorb  all  the  moisture, 
(ii.)  Overgrowth  of  epithelium  follows,  and  as  it  increases  in  thick- 
ness, it  becomes  opaqus  and  horny  (Plate  IV.),  so  that  the  red  patches 
are  replaced  by  white  ones,  leading  to  the  appearance  which  has  been 
designated  Leucoplakia.  Sometimes  the  papillae  become  much  en- 
larged, and  stand  out  definitely  and  separately  from  the  organ  ;  or 
the  whole  surface  may  be  covered  with  dense  white  patches.  To 
this  condition  the  term  Ichthyosis  has  been  applied,  (iii.)  Later  on, 
the  excess  of  epithelium  is  shed,  leaving  red  smooth  patches  in  which 
the  papillae  are  atrophied,  or  have  entirely  disappeared..  If  this 
occurs  over  the  greater  part  of  the  organ,  the  glazed  red  tongue  so 
characteristic  of  tertiary  syphilis  is  produced.  If,  however,  this 
process  only  occurs  in  smaller  areas  intermixed  with  portions 
covered  with  white  epithelium,  a  patchy  appearance  of  the  tongue 
results,  wrongly  termed  Psoriasis  Ungues,  (iv.)  At  varying  periods  of 
the  disease,  sometimes  earlier,  sometimes  later,  the  organ  becomes 
ulcerated,  cracked,  or  fissured  in  a  somewhat  characteristic  manner. 
A  median  fissure  is  usually  seen  running  down  the  middle,  and  from 
this  furrows  extend  transversely,  dividing  the  surface  into  rectangular 
compartments.  These  fissures  are  not  always  due  to  the  cicatrization 
of  cracks,  as  when  opened  out  healthy  papillae  are  seen  at  the  base, 
and  no  sign  of  superficial  scarring.  They  are,  then,  evidently  the 
result  of  the  contraction  of  deep  sclerosed  tissue  in  the  substance  of 


848  A  MANUAL  OF  SURGERY 

the  organ.  Superficial  ulceration  often  occurs,  apart  from  these 
fissures,  being  probably  due  to  some  local  irritation,  or  to  smoking ; 
the  atrophic  condition  of  the  mucous  membrane  explains  the  great 
liability  to  this  occurrence,  (v.)  Still  later,  epitheHoma  may  develop, 
and  usually  in  connection  with  one  of  the  cracks,  or  of  the  cicatrices 
arising  therefrom.  It  is  often  somewhat  slow  in  its  progress,  owing 
to  the  amount  of  sclerosis  induced  by  the  preceding  inflammation. 
The  typical  smoker's  patch  is  a  red  irritable  area  on  the  front  of  the 
tongue,  from  which  papillae  are  often  absent,  and  perhaps  covered 
with  a  yellowish-white  crust.  Sometimes  the  epithelium  is  heaped 
up  here  into  a  well-marked  leucoplakic  spot. 

All  these  stages  of  the  disease  are  accompanied  with  much  dis- 
comfort, the  tongue  being  sometimes  so  tender  that  the  patient  can- 
not drink  hot  fluids  or  take  condiments  or  stimulants  without  pain. 
The  speech,  too,  is  interfered  with,  [becoming  thick  and  indistinct. 
The  course  of  the  case  varies  considerably,  and  the  affection  may 
settle  down  after  a  time,  and  cause  but  little  discomfort,  so  long  as 
the  patient  conforms  to  the  restrictions  as  to  diet,  etc.,  which  are 
essential.  If,  however,  he  is  careless  or  refuses  to  obey  orders,  the 
trouble  may  progress,  and  epithelioma  develop. 

The  Treatment  of  the  case  is  usually  a  matter  of  some  difficulty. 
All  sources  of  irritation  are  excluded  from  the  mouth  as  a  first  pre- 
caution. Thus,  smoking  or  chewing  tobacco  must  be  rigidly  pro- 
hibited. Spirit-drinking  and  all  acid  wines  which  cause  pain  should 
be  forbidden,  dilute  whisky  and  water  being  perhaps  the  best 
stimulant.  The  teeth  must  be  well  brushed  night  and  morning,  and 
all  stumps  and  rough  excrescences  removed ;  definite  pyorrhcea 
must  be  carefully  treated.  Condiments,  such  as  mustard,  spices, 
curry,  and  cheese,  are  excluded  from  the  dietary,  and  only  simple  un- 
irritating  ingesta  allowed.  The  mouth  is  washed  out  frequently  with 
an  alkaline  lotion — e.g.,  bicarbonate  of  soda  (20  grains  to  i  ounce), 
or  borax  (10  grains  to  i  ounce) — especially  after  meals,  so  as  to 
exclude  all  risk  of  acid  fermentation  in  the  debris  of  food.  Cracks 
and  sores  are  treated  by  painting  the  surface  with  a  solution  of 
chromic  acid  (grs.  v.  ad  gi.)  or  of  perchloride  of  mercury 
(grs.  ii.  ad  gi.).  Solid  nitrate  of  silver  should  be  avoided,  as  its  use 
is  likely  to  predispose  to  epithelioma. 

General  antisyphilitic  remedies  are  employed  where  necessary, 
and  the  organic  preparations  of  iodine  are  specially  valuable  in  these 
conditions ;  the  digestion  is  attended  to,  and  if  the  new  formation  of 
epithelium  is  excessive,  arsenic  may  be  administered. 

On  the  appearance  of  definite  epithelioma  suitable  operative 
ineasures  must  be  instituted;  but  it  is  perfectly  justifiable  to  remove 
by  operation  irritable  and  infiltrated  fissures  and  cracks,  even  before 
true  cancer  has  appeared.  Any  wart-like  projections  should  also  be 
excised  early. 

Ulceration  of  the  tongue  arises  from  a  variety  of  causes,  and  occurs 
/n  many  different  forms.  Thus,  dental  or  traumatic  ulcers  are  due  to 
the  irritation  of  rough  and  carious  teeth.  Dyspeptic  ulcers  are  asso- 
ciated with  gastric  disturbances  ;   they  are  usually  located   on   the 


AFFECTIONS  OF  THE  MOVrti,  THROAT,  AND  (ESOPHAGUS     86 1 


are  dealt  with  by  turning  forwards  or  upwards  a  flap  of  skin  and 
subcutaneous  tissue,  so  as  to  expose  completely  the  capsule  and 
enable  the  dissection  of  the  growth  to  be  made  with  as  little  danger 
to  the  facial  nerve  as  possible.  It  is  generally  placed  beneath  the 
growth,  but  occasionally  runs  superficial  to  it,  or  in  its  substance. 
The  tumour  is  often  enucleated  without  much  difficulty,  but  the 
surgeon  must  make  certain  that  no  deeper  processes  are  left,  or  re- 
currence will  i-nevitably  follow.  The  hsemorrhage  from  the  trans- 
verse facial  and  other  arteries  is  free,  but  easily  restrained.  There 
is  no  need  to  remove  redundant  skin  in  these  cases,  as  it  quickly 
contracts. 

In  dealing  with  early  malignant  disease  excision  of  the  whole  payoiid 
gland  may  be  occasionally  required. 
It  is  accomplished  through  a  vertical 
incision,  or  if  the  skin  is  involved,  by 
two  crescentic  ones.  The  gland  is 
then  gradually  freed  from  its  con- 
nections, care  being  taken,  if  possible, 
to  keep  outside  its  capsule.  It  is 
best  to  deal  with  the  lower  part  first, 
securing  with  double  ligatures  the 
external  carotid  artery  and  temporo- 
facial  vein.  The  mass  is  then  drawn 
upwards  and  forwards,  and  its  deep 
connections  severed.  The  facial 
nerve  is,  of  course,  divided,  and  the 
patient  must  be  warned  before  the 
operation  of  the  necessarily  resulting 
facial  palsy.  Recurrence  is  almost 
certain  to  follow.  Removal  of  the 
angle  of  the  jaw  as  a  preliminary 
step  has  been  recommended,  since 
considerable  space  is  gained  thereby,  and  a  better  access  to  the  field 
of  operation. 

Tumours  of  tlie  Submaxillary  Gland  are  very  similar  in  nature  to 
those  of  the  parotid.  Simple  tumours  are  represented  by  endo- 
theliomata,  resembling  cartilaginous  or  myxomatous  growths, 
according  to  whether  they  are  hard  or  soft  (Fig.  390).  Sarcoma 
and  carcinoma  are  also  met  with ;  if  seen  in  the  early  stages  they 
are  easily  removed. 

Salivary  Fistula  occurs  almost  solely  in  connection  with  the  parotid 
gland.  It  arises  from  penetrating  wounds  of  the  cheek  dividing 
Stenson's  duct,  or  more  frequently  it  follows  operations  in  its  neigh- 
bourhood. It  is  a  very  troublesome  condition,  both  for  the  surgeon 
who  is  called  upon  to  treat  it,  and  for  the  patient  who  suffers  from 
the  inconvenience  of  saliva  flowing  down  the  cheek,  the  amount 
being,  of  course,  increased  at  meal-times.  Stenson's  duct  extends 
forwards  from  the  socia  parotidis  across  the  masseter  muscle  for  a 
distance  of  about  2  inches,  and  then  turns  abruptly  inw^ards  to  pierce 


Fig.  390. — Submaxillary  Tumour. 

(TiLLMAXNS.) 


862  A  MANUAL  OF  SURGERY 

the  buccinator,  and  enter  the  mouth  opposite  the  second  upper  molar 
tooth.  The  buccal  and  masseteric  portions  are  almost  at  right  angles, 
the  latter  being  represented  by  a  line  drawn  from  the  lobule  of  the 
ear  to  a  point  midway  between  the  ala  nasi  and  the  angle  of  Lhe 
mouth.  The  diameter  of  the  duct  is  about  ^  inch,  its  narrowest 
portion  being  at  the  orifice. 

Treatment. — If  the  buccal  portion  is  involved,  a  cure  is  often 
attained  by  slitting  up  the  duct  within  the  mouth;  but  when  the 
masseteric  portion  is  wounded,  and  especially  if  near  the  socia 
parotidis,  treatment  becomes  more  difficult.  The  following  plan 
is  often  successful  :  A  fine  probe  is  passed  along  the  duct  from  the 
mouth  as  far  as  the  lesion ;  it  is  then  grasped  by  forceps  inserted 
through  the  external  aperture,  and  drawn  out  on  to  the  cheek,  a  pro- 
ceeding sometimes  facilitated  by  slightly  enlarging  the  wound.  A 
double  thread  of  silk  is  now  tied  to  the  end  of  the  probe^  and  drawn 
through  the  thickness  of  the  cheek,  along  the  buccal  portion  of  the 
duct,  and  out  of  the  external  wound.  A  fine  drainage-tube  is  then 
carried  along  the  same  track,  and  left  so  as  to  project  both  externally 
and  internally.  A  silk  thread  is  attached  to  each  end  of  the  tube,  and 
these  are  knotted  together  round  the  angle  of  the  mouth.  By  this 
means  a  passage  is  re-established  into  the  mouth,  and  as  soon  as  it 
becomes  easier  for  the  saliva  to  travel  along  this  than  along  the 
external  wound,  the  fistula  will  close.  At  the  end  of  a  few  days  the 
outer  half  of  the  tube  is  removed,  and  only  a  silk  thread  allowed  to 
occupy  the  outer  portion  of  the  fistula,  which  gradually  contracts  so 
that  more  and  more  of  the  saliva  finds  its  way  into  the  mouth.  The 
silk  thread  and  tube  are  then  finally  removed,  and  if  the  opening  in 
the  mouth  is  kept  patent,  the  external  wound  soon  heals.  In  those 
cases  where  the  buccal  portion  of  the  duct  is  completely  obliterated 
or  obstructed  so  that  a  probe  cannot  be  passed,  a  trocar  and  cannula 
are  inserted  through  the  external  wound  and  cheek  into  the  mouth  ; 
a  silk  thread  is  insinuated  through  the  cannula,  and  a  tube  drawn  into 
position,  as  in  the  former  case.  The  subsequent  treatment  is  the 
same  as  that  indicated  above. 


Affections  of  the  Palate. 

Cleft  Palate. — By  cleft  palate  is  meant  a  congenital  defect  of  the 
roof  of  the  mouth,  whereby  the  structures  entering  into  its  formation 
do  not  unite  in  the  middle  line,  thus  allowing  an  abnormal  com- 
munication to  exist  between  the  nose  and  mouth.  The  term  does  not 
include  losses  of  substance,  resulting  from  injury,  syphilis,  or  lupus. 
The  cleft  usually  starts  posteriorly,  and  extends  forwards  for  a 
variable  distance,  although  it  has  been  known  to  be  limited  to  the 
anterior  portion  of  the  palate  and  bony  alveolus,  but  only  in  exceed- 
ingly rare  instances.  The  mildest  cases  consist  merely  of  a  bifid 
uvula,  perhaps  not  involving  the  palate  at  all  ;  the  next  degree  of 
severity  affects  the  velum  alone;  more  or  less  of  the  hard  palate 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    863 

may  also  be  implicated,  the  cleft  reaching  as  far  forwards  as  the  site 
of  the  anterior  palatine  canal  (Fig.  391,  B) ;  whilst  the  severest  type 
of  the  deformity  extends  in  addition  through  the  alveolus  and  upper 
lip  on  one  or  both  sides,  the  os  incisivum  being  in  the  latter  case 
displaced  forwards,  perhaps  on  the  tip  of  the  nose  (Fig.  391,  C). 

On  looking  carefully  at  a  cleft  palate,  the  defect  usually  appears  to 
be  mesial,  but  occasionally  it  seems  as  if  a  unilateral  or  bilateral 
fissure  existed.  To  understand  such  an  occurrence  it  must  be 
remembered  that  three  bony  processes  unite  in  the  middle  line  of 
the  roof  of  the  mouth,  viz.,  the  two  palatal  processes  growing  in 
horizontally  from  the  maxillae,  one  on  each  side,  and  the  ethmo- 
vomerine  septum  projecting  vertically  downwards  from  the  under 


a:  :b  c 

Fig.  391. — Various  Forms  of  Cleft  Palate:  A,  Involving  merely  the 
Velum  ;  B,  traversing  the  Hard  Palate  as  Far  Forwards  as  the 
Anterior  Palatine  Canal  ;  and  C,  being  complicated  with  a  Double 
Hare-lip. 

surface  of  the  fronto-nasal  process  and  base  of  the  skull.  All  these 
should  join  together  about  the  ninth  or  tenth  week  of  intra-uterine 
life.  If,  however,  the  palatal  processes  fail  to  reach  the  middle  line, 
a  median  defect  appears  (Fig.  392,  A),  unless  the  ethmo-vomerine 
septum  be  so  hypertrophied  as  to  project  between  them,  when  the 
appearance  of  a  double  cleft  is  produced  (Fig.  392,  B).  When  only 
one  division  of  the  palate  unites  with  the  mesial  septum,  an  appar- 
ently unilateral  cleft  results  ;  most  commonly  the  defect  is  on  the 
left  side,  the  vomer  being  attached  to  the  right  free  edge,  a  left- 
sided  alveolar  hare-lip  also  complicating  the  case  (Fig.  392,  C). 
The  reason  why  the  anterior  portion  of  the  palate  is  so  rarely 
affected  without  the  posterior  part  being  also  involved  is  that  the 
union  of  the  various  segments  progresses  fram  before  backwards. 

The  width  of  the  cleft  and  the  slope  of  the  segments  varies  greatly 
in  different  cases.  The  wider  the  cleft,  the  more  unfavourable  it  is 
for  treatment  by  operative  means ;  and  this  is  one  of  the  arguments 


g64 


A  Manual  of  surgeHV 


used  in  favour  of  the  removal  of  the  intermaxilla  in  cases  of  double 
hare-lip,  so  as  to  allow  of  the  approximation  of  the  two  maxillae. 
Remove  it,  and  they  fall  naturally  together ;  leave  it,  and  they  are 
wedged  permanently  apart.  As  to  the  slope  of  the  segments,  the 
more  vertical  they  are,  the  more  favourable  for  operation,  since  the 
flaps  of  muco-periosteum  easily  meet  in  the  middle  line.  When  the 
palate  is  more  horizontal,  and  like  a  Norman  rather  than  a  Gothic 
arch,  the  flaps  are  shorter,  and  greater  lateral  displacement  is  neces- 
sary to  bring  their  edges  into  apposition  ;  this  involves  much  more 
traction  on  the  stitches,  and  hence  less  satisfactory  results. 

The  effect  of  such  a  deformity  upon  the  infant,  from  a  physiological 
point  of  view,  is  very  serious.  The  process  of  nutrition  is  consider- 
ably impaired,  owing  to  the  fact  that  the  power  of  suction  is  lost, 


r 


ABC 

Fig.  392. — Diagram  to  Snow  the  Modifications  of  Cleft  Palate. 

a,   Ethmo- vomerine  septum;  b,  palatal  segments;    c,  tongue;    d,  cavity  of  the 
nose  ;  e,  buccal  cavity. 


and  fluids  taken  into  the  mouth  are  apt  to  escape  through  the  nostrils 
instead  of  being  swallowed.  Consequently  these  children  must  be 
carefully  spoon-fed  with  the  head  thrown  well  back,  otherwise  they 
become  emaciated  and  succumb  to  inanition  or  intercurrent  maladies. 
If  they  grow  up,  articulation  becomes  so  indistinct  that  it  is  often  im- 
possible to  understand  what  they  say,  the  voice  having  a  peculiar 
and  characteristic  intonation.  All  the  letters  known  as  explosives, 
whether  dentals,  labials,  or  gutturals,  requiring  a  certain  amount  of 
air  pressure  within  the  mouth  for  their  due  pronunciation,  are  difficult 
to  produce,  particularly  b,  d,  p,  t,  g,  f,  etc.  Moreover,  the  exposure 
of  the  nasal  mucous  membrane  to  the  air  is  so  much  greater  than 
usual  that  it  is  liable  to  catarrhal  inflammation,  resulting  in  the 
formation  of  scabs  which  undergo  putrefactive  changes  and  lead  to 
a  sort  of  ozaena.  Both  taste  and  smell  are  much  diminished,  partly 
Irom  the  unhealthy  state  of  the  mucous  membrane,  and  also  from 
the  absence  of  an  opposing  surface  against  which  the  food  can  be 
triturated  by  the  tongue.  The  moral  effect  of  this  deformity, 
particularly  when  associated  with  hare-lip,  is  so  serious  as  to  cause 
such  patients  to  shun  publicity  from  a  nervous  feeling  of  self- 
consciousness. 


APFECTIONS  of  THEMOUTH,  throat,  and  (ESOPHAGUS    ^49 


middle  of  the  dorsum,  and  are  often  very  painful.  It  is  sufficient  to 
touch  them  with  lunar  caustic  after  dealing  with  the  cause.  Tuber- 
ciUoiis  ulcers  are  not  common,  and  are  nearly  always  secondary  to 
pulmonary  or  laryngeal  phthisis,  the  organ  being  infected  by  the 
sputum.  They  commence  in  the  form  of  a  submucous  abscess, 
which  bursts  and  leaves  a  small  painful  sore,  rarely  situated  on  the 
posterior  part  of  the  organ,  but  chiefly  at  the  sides  or  on  the  dorsum 
near  the  tip.  Secondary  abscesses  form  around  and  coalesce  with 
the  original  ulcer.  Treatment  is  chiefly  needed  on  account  of  the  pain 
and  discomfort  caused  by  them  ;  it  consists  in  their  complete  excision, 
or  in  cocainizing  and  scraping  the  sores,  touching  the  base  with 
pure  carbolic  acid,  and  dressing  with  iodoform.  Applications  of 
cocaine  may  also  be  made  before  meals,  as  a  palliative  measure  where 
radical  treatment  is  not  undertaken  on  account  of  the  extent  of  the 
pulmonary  mischief.  Lupus  also  attacks  the  tongue,  but  is  very  un- 
common, and  almost  invariably  secondary  to  a  similar  affection  of 
the  skin  of  the  face.  In  a  case  under  our  care  it  appeared  in  the  form 
of  an  irregular  granulating  surface  surrounded  by  nodulated  cica- 
tricial tissue  of  an  exceedingly  dense  character.  The  progress  was 
very  slow,  owing  to  the  amount  of  sclerosis  present.  Treatment 
consists  in  the  application  of  the  X  rays  or  of  radium ;  but  in  some 
cases  it  may  be  advisable  to  undertake  a  preliminary  course  of  treat- 
ment by  scraping  and  cauterization.  Syphilitic  and  cancerous  ulcera- 
tions are  described  below. 

Syphilitic  Disease  of  the  tongue  occurs  in  a  variety  of  different 
forms.  A  primary  sore  presents  a  characteristic  indolent  and  inactive 
surface,  usually  near  the  tip,  with  sub- 
jacent infiltration,  and  much  chronic  en- 
largement of  the  submental  lymphatic 
glands,  which,  however,  do  not  generally 
suppurate.  In  the  secondary  stage  mucous 
tubercles,  fissures,  and  ulcers  form,  and 
usually  on  the  sides  or  near  the  tip. 
Occasionally  one  meets  with  a  broad 
wart-like  condyloma  on  the  dorsum,  which 
may  be  associated  with  longitudinal  fis- 
sures ;  it  is  sometimes  termed  '  Hutchin- 
son's wart.'  In  the  tertiary  period  chronic 
superficial  glossitis  may  develop,  as  also 
diffuse  infiltration  of  the  organ,  or  gum- 
mata. 

Gumma  of  the  tongue  is  not  uncommon, 
occurring  usually  in  patients  under  forty 

years  of  age,  as  a  late  tertiary  phenomenon.  It  starts  as  a  localized 
submucous  or  intramuscular  infiltration  near  the  median  line,  and 
generally  towards  the  middle  or  posterior  part  (Fig.  387)-  The  swell- 
ing is  at  first  hard  and  firm,  but  later  on  becomes  soft  and  fluc- 
tuating, and  in  time  the  overlying  mucous  membrane,  which  was 
unaffected,  yields,  and  gives  exit  to  the  characteristic  contents.     The 

54 


Fig.  387. — Gumma  of  Right 
Side  of  Tongue.  (From 
Wax  Model  in  College 
OF  Surgeons'  Museum.) 


85b  A  MANUAL  OP  SUkGERf 

ulcer  thus  produced  is  oval  or  round  in  shape,  and  deeply  excavated, 
the  base  being  constituted  by  a  slough,  looking  like  '  wet  wash- 
leather.'  There  is  but  little  induration  either  of  the  base  or  edges, 
and  one  of  the  most  characteristic  features  is  the  fact  that  neither 
the  floor  of  the  mouth  nor  the  base  of  the  tongue  is  involved,  so  that 
the  organ  can  be  freely  protruded,  whilst  deglutition  and  articulation 
are  scarcely  interfered  with.  The  patient  complains  of  little  pain, 
and  the  submaxillary  glands  are  only  affected  either  as  part  of  a 
general  enlargement  throughout  the  body,  or  from  the  local  irritation. 
The  progress  is  slow,  and  the  effect  of  antisyphilitic  treatment  very 
decided,  the  gumma  absorbing,  or  the  ulcer,  if  present,  healing 
readily,  but  leaving  a  localized  area  of  sclerosis  or  a  deep  cicatrix, 
from  which  malignant  disease  may  subsequently  originate.  In  some 
cases  a  diffuse  infiltration  of  the  organ  occurs,  leading  to  a  generalized 
sclerosis  rather  than  to  a  localized  gumma.  The  treatment  consists  in 
the  administration  of  iodides  with  or  without  mercury,  whilst  the 
mouth  is  kept  clean  with  a  simple  mouth-wash. 

Innocent  Tumours  are  not  frequent  in  the  tongue,  papilloma,  cysts, 
lipoma,  and  naevi  being  the  chief  varieties,  and  requiring  no  special 
treatment. 

Dermoid  Cysts  also  form  within  or  under  the  tongue,  originating 
usually  in  connection  with  the  thyro-glossal  duct  (p.  8g8). 

Cancer  of  the  Tongue  occurs  in  the  form  of  squamous  epithelioma, 
and  is  both  a  frequent  and  a  very  fatal  variety  of  this  disease.  It  is 
usually  met  with  in  men,  and  may  arise  as  a  result  of  the  irritation 
caused  by  excessive  smoking,  especially  when  neglected,  rough,  and 
carious  teeth  are  present. 

Its  mode  of  onset  varies  somewhat  according  to  the  situation : 
(a)  It  arises  most  commonly  as  an  ulcer  at  the  margin  of  the  organ, 
towards  the  junction  of  the  middle  and  posterior  thirds,  and  is  then 
generally  due  to  the  irritation  caused  by  ragged  and  irregular  bicuspid 
or  molar  teeth  (Plate  IV.) ;  (6)  it  may  start  in  a  crack,  fissure,  or  cicatrix 
on  the  dorsum,  as  a  result  of  chronic  superficial  glossitis,  or  of  a 
preceding  gumma;  (c)  it  may  commence  as  a  wart-like  growth,  the  base 
of  which  becomes  infiltrated,  the  tumour  invading  the  muscular  sub- 
stance, and  spreading  to  the  root  of  the  tongue  ;  (i)  it  may  originate 
as  a  submucous  infiltration,  starting  as  an  ingrowth  from  the  mucous 
membrane,  without  much  external  manifestation  of  its  presence ;  (e)  it 
may  first  be  noticed  as  an  irregular  ulcer  in  the  floor  of  the  mouth  ; 
or  (/)  it  may  spread  into  the  tongue  from  surrounding  parts,  such  as 
the  tonsil  or  larynx. 

In  whatever  way  it  starts,  the  same  features  are  soon  manifested, 
viz.,  a  new  growth  is  noticed,  hard  in  consistence,  indefinite  in  its 
extent,  which  may  or  may  not  be  painful  from  the  first,  and  which 
ulcerates  superficially,  exposing  a  more  or  less  crateriform  cavity, 
with  a  gray,  sloughy,  foul  surface,  readily  bleeding  when  touched, 
and  discharging  a  foul  secretion,  which  causes  extreme  foetor  of  the 
breath.  The  ulcer  is  surrounded  by  an  indurated  mass,  which 
gradually  shelves  off  into  the  neighbouring  healthy  structures,  or  may 


PLATE   IV. 


Epithelioma    of    Tongue,    secondary    to    chronic 
superficial  glossitis. 

TPie  tongue  was  a  characteristic  one,  showing  heapino-  up  of 
the  epithelium,  which  was  white  and  sodden  (ichthyosis),  as 
well  as  cracks  and  fissures-  in  the  middle  line,  due  partly  to 
chronic  interstitial  glossitis  ;  the  epithelioma  developed  late  in 
the  case  on  the  left  side  opposite  a  diseased  and  dirty  tooth. 

\_To  face  page  850. 


AFFECTIONS  OF  THE  MOUTH    THROAT,  AND  (ESOPHAGUS    851 

be  abruptly  limited.  Profuse  salivation  is  produced  by  the  irritation 
of  the  branches  of  the  third  division  of  the  trigeminal,  and  all  the 
movements  of  the  tongue  are  painful  and  limited  on  account  of  the 
infiltration  of  the  base,  so  that  both  swallowing  and  speech  are 
difficult,  the  patient  allowing  the  saliva  to  dribble  out  of  his  mouth. 
The  pain  is  often  severe,  and  usually  extends  along  many  of  the 
branches  of  the  fifth  nerve,  especially  to  the  ear,  so  that  sleep  becomes 
impossible,  and  the  patient's  condition  steadily  and  rapidly  deteriorates. 

The  submental,  submaxillary  and  subparotid  glands  early  become 
involved  in  the  disease  according  to  the  position  of  the  primary 
growth ;  thus,  cancer  of  the  tip  of  the  tongue  usually  affects  the 
submental  glands ;  if  situated  farther  back,  the  submaxillary  glands 
are  involved  ;  whilst  in  the  region  of  the  pillars  of  the  fauces  the  sub- 
parotid  glands  are  first  attacked.  Ultimately  the  disease  spreads  to 
the  deep  glands  lying  along  the  main  vessels,  a  gland  lying  over  the 
bifurcation  of  the  common  carotid  artery  being  early  enlarged. 
These  glands,  if  not  removed,  soon  attain  considerable  dimensions, 
and  become  stony  hard  and  fixed  to  surrounding  structures,  especially 
the  carotid  sheath.  If  the  disease  is  strictly  limited  to  one  half  of  the 
tongue,  the  lymphatic  glands  on  the  other  side  of  the  neck  are  seldom 
affected  except  in  the  last  stages ;  but  if  the  disease  extends  towards 
the  centre  of  the  organ,  the  glands  on  both  sides  are  often  equally 
involved.  These  secondary  growths  are  very  frequently  cystic  in 
character,  from  the  degeneration  of  the  masses  of  epithelium  formed 
within  them  ;  after  a  time  they  approach  the  surface  and  burst, 
leaving  ragged  malignant  ulcers  in  the  neck.  The  lower  jaw  itself 
is  often  invaded  in  the  later  stages  of  the  disease. 

The  occurrence  of  the  typical  cachexia  is  determined  not  only  by 
the  pain  and  consequent  sleeplessness,  but  also  by  the  inability  to  take 
sufficient  nourishment,  the  absorption  of  products  of  putrefaction 
swallowed  with  the  saliva,  the  excessive  salivation,  the  occasional 
haemorrhages,  and  the  extent  of  the  secondary  growths.  The  patient 
rarely  lives,  apart  from  treatment,  for  more  tfian  twelve  months  after 
the  disease  has  been  first  noticed. 

Diagnosis. — When  a  case  is  met  with  where  the  ulcer  is  situated 
at  the  side  or  base  of  the  tongue  in  a  patient  over  forty-five  years  of 
age,  with  the  typical  enlargement  of  the  glands,  profuse  salivation, 
and  impaired  movements,  there  can  be  little  doubt  as  to  the  diagnosis. 
But  when  it  is  seen  in  the  early  stage,  as  an  infiltration  of  a  syphilitic 
fissure  or  cicatrix,  or  as  a  small  wart,  it  may  be  difficult  to  determine 
whether  or  not  malignant  disease  is  present.  The  early  enlargement 
of  the  glands,  the  amount  and  character  of  pain,  the  fixity  of  the 
organ,  and  the  infiltration  of  the  base  of  the  ulcer,  are  important 
guiding  marks  ;  but  in  doubtful  cases  a  small  portion  of  the  edge  of 
the  growth  and  of  the  adjacent  parts  should  be  excised  under  cocaine, 
and  subjected  to  careful  microscopic  examination,  and  thus  its  nature 
ascertained.  Moreover,  the  administration  of  steadily  increasing 
doses  of  iodide  of  potassium,  or  some  suitable  organic  iodide,  will 
generally  bring  about  rapid  improvement  in  a  syphilitic  case,  but 


852  A  MANUAL  OF  SURGERY 

will  do  no  good  to  an  epithelioma,  except  perhaps  temporarily  when 
the  two  diseases  co-exist 

Treatment. — The  only  hope  of  curing  the  patient  lies  in  thorough 
and  early  removal  of  the  growth,  which  it  should  be  remembered  has 
probably  extended  much  farther  than  one  expects.  The  excision 
must  include  not  only  the  tumour,  but  also  a  wide  area  of  tissue 
around  it,  so  as  to  get  beyond  the  zone  of  infiltration  ;  not  only  the 
lymphatic  glands,  which  are  obviously  enlarged,  but  also  the  whole 
13'mphatic  area,  extending  practically  from  the  base  of  the  skull  to  the 
episternal  notch.  It  is  obviously  desirable  to  undertake  such  ex- 
tensive operative  proceedings  in  two  stages,  if  possible,  dealing  first 
with  the  tumour  in  the  mouth,  and  subsequently  with  the  glands. 
When  the  base  of  the  organ  is  free  from  infiltration,  and  the  disease 
appears  to  be  separated  from  the  glandular  area  by  a  sufficient 
margin  of  healthy  tissue,  the  operation  in  two  stages  may  be  under- 
taken ;  and  the  fact  that  recurrence  is  rarely  noted  in  the  portion  of 
the  organ  that  intervenes  between  the  two  operative  areas  indicates 
that  such  a  practice,  though  not  ideal,  is  justifiable.  The  mouth  is 
often  in  a  very  septic  state,  and  the  danger  of  infection  after  making 
an  extensive  dissection  of  the  main  vessels  of  the  neck  is  not  slight. 
On  the  other  hand,  when  there  is  considerable  infiltration  of  the 
deeper  parts  of  the  tongue  with  extensive  glandular  mischief,  it  may 
be  impossible  to  find  a  sufficient  margin  of  healthy  tissue  to  justify 
the  division  into  two  stages  ;  and  then  the  patient  must  run  the  risks 
associated  with  the  removal  of  tongue  and  glands  at  one  time. 

In  all  cases  great  care  must  be  taken  in  the  preparation  of  the 
patient  so  as  to  minimize  the  risk  of  infective  mischief.  Suitable 
antiseptic  mouth-washes  are  employed  for  some  days  ;  dirty  roots 
and  stumps  are  removed,  and  the  remaining  teeth  carefully  cleansed. 
Possibly,  if  time  permit,  a  culture  might  be  made  of  the  chief 
organisms  in  the  mouth,  and  a  vaccine  procured,  which  may  help  to 
guard  the  patient  from  post-operative  infection.  It  is  wise  also  to 
keep  him  indoors  for  a  few  days  beforehand  so  as  to  protect  him 
from  risks  of  cold  and  bronchitis. 

The  actual  operative  details  differ  somewhat  according  to  the 
extent  and  situation  of  the  disease,  but  most  of  the  operations  for 
removing  the  growth  are  a  modification  of  the  intrabuccal  method 
suggested  by  Whitehead. 

If  the  tip  only  is  involved,  it  can  be  removed  by  a  V-shaped 
incision,  made  after  steadying  the  tongue  with  a  deep  suture.  The 
small  ranine  artery  will  spurt  on  each  side,  but  is  easily  secured, 
and  the  gap  closed  by  sutures. 

When  the  disease  involves  one  side  of  the  tongue  and  is  not  very 
extensive,  and  does  not  spread  deeply  into  the  base,  it  will  suffice  to 
remove  the  anterior  half  or  two-thirds  of  the  affected  side  as  a  first  stage 
without  touching  the  glands.  The  patient  having  been  ansesthetized, 
the  mouth  is  opened  with  an  efficient  gag,  and  anaesthesia  is  main- 
tained by  giving  chloroform  through  a  Junker's  apparatus.  A  good 
assistant  is  necessary  in  order  to  prevent  blood  entering  the  larynx, 


AFFECTIONS  OF  THE  MOUTH,  THRCAT,  AND  (ESOPHAGUS     853 

small  swabs  or  pieces  of  sponge  held  in  smooth-nosed,  long-handled 
forceps  or  suitable  sponge-holders  being  used  to  clear  the  pharynx. 
A  coarse  silk  thread  is  passed  through  each  half  of  the  tongue  to 
draw  it  forwards  and  steady  it.  The  tongue,  being  drawn  out  of 
the  mouth  by  these  loops  of  silk,  is  carefully  divided  by  blunt-ended 
straight  scissors  down  the  middle  line  into  two  segments,  which  are 
readily  separated  from  one  another  by  the  finger,  the  scissors  merely 
dividing  the  mucous  membrane.  The  base  of  the  organ  is  freed  by 
cutting  through  the  line  of  attachment  of  the  mucous  membrane  to 
the  alveolus,  and  then  along  the  middle  line  of  the  floor  of  the  mouth 
from  the  tip  of  the  tongue,  so  that  the  sublingual  salivary  gland  can  be 
also  taken  away — a  most  necessary  step.  The  mucous  lining  of  the 
dorsum  is  now  divided  transversely  behind  the  growth,  and  the 
muscular  structure  of  the  organ  slowly  snipped  through  with  scissors. 
During  this  process,  by  the  aid  of  the  finger  or  a  director,  the 
vessels  can  be  seen  and  secured  before  division.  Removal  of  the 
diseased  half  with  the  sublingual  gland  is  thus  easily  accomplished 
by  making  the  incisions  meet,  and  dividing  the  intervening  tissues. 
Bleeding-points  are  picked  up  and  secured  as  they  appear.  It  is 
often  possible  and  advisable  to  expedite  healing  by  closing  the  wound 
in  the  tongue  partially  or  entirely,  either  by  stitching  the  mucous 
membrane  of  the  dorsum  to  that  of  the  base,  or,  better,  by  twisting 
the  half  tongue  on  itself  and  stitching  the  tip  to  the  back  of  the 
organ.  The  patient  will  probably  be  sufficiently  recovered  from  this 
operation  to  enable  the  surgeon  to  deal  with  the  glands  in  a  week  or 
ten  days. 

If  both  sides  of  the  tongue  are  involved,  but  the  disease  has  not 
extended  deeply  into  the  base,  it  is  not  difficult  to  effect  removal  by 
a  modification  of  the  same  procedure.  The  mouth  is  gagged  open, 
and  two  silk  slings  are  inserted,  one  through  the  anterior  portion,  and 
the  other  just  in  front  of  the  epiglottis.  The  mucous  membrane  of 
the  floor  of  the  mouth  is  then  incised  on  either  side,  and  the  muscles 
attached  to  the  genial  tubercles  divided.  By  this  means  the  tongue 
is  somewhat  freed  and  can  be  drawn  well  up  out  of  the  mouth,  so  as 
to  enable  the  section  to  be  made  across  it  with  scissors  at  the  desired 
level.  The  main  vessels  can  generally  be  seen  and  secured  before 
division,  so  that  the  amount  of  bleeding  is  not  excessive.  It  is  often 
possible  to  draw  forward  the  stump  of  the  tongue  and  secure  the 
mucous  membrane  anteriorly,  so  as  to  diminish  the  size  of  the  raw 
area  in  the  mouth. 

If  the  disease  extends  more  deeply  into  the  substance  of  the 
tongue,  so  that  the  whole  organ  has  to  be  removed,  it  is  wise  to 
employ  a  preliminary  division  of  the  lower  jaw,  as  originally  sug- 
gested by  Syme,  and  more  lately  recommended  and  practised  by 
Kocher,*  An  incision  is  made  in  the  middle  line  dividing  the 
lower  lip,  extending  downwards  to  the  hyoid  bone.     The  mandible  is 

*  '  Kocher's  Textbook  of  Operative  Surgery.'  Translated  from  the  fourth 
German  edition  by  Harold  J.  Stiles,  iM.B.,  F.R.C.S.  London:  Adam  and 
Charles  Black,  191 1, 


854  A  MANUAL  OF  SURGERY 

sawn  through  in  the  middle,  and  the  two  halves  separated  widely. 
As  much  of  the  tongue  as  is  considered  necessary  can  be  easily 
removed  by  the  scissors.  The  mucous  membrane  is  divided  close  to 
the  alveolus  laterally,  the  anterior  pillars  of  the  fauces  are  snipped 
across  posteriorly,  and  the  floor  of  the  miouth  is  dissected  up.  The 
lingual  vessels  can  usually  be  secured  before  division.  After  effect- 
ing haemostasis,  a  silk  thread  or  silver  wire  is  passed  through  the 
stump  of  the  tongue  and  epiglottis  in  order  to  control  it  and  prevent 
interference  with  respiration ;  the  halves  of  the  jaw  are  wired 
together  and  the  superficial  wound  closed.  It  is  possible  that  a  pre- 
liminary tracheotomy  may  be  useful  in  these  cases,  but  it  is  not 
essential. 

When  the  tongue,  or  a  portion  of  it,  has  to  be  removed  wnth  the 
glands  en  bloc,  the  lateral  extrabuccal  method,  knowm  as  Kocher's 
operation,  is  perhaps  the  best.  A  preliminary  tracheotomy  is  usually 
associated  with  it.  An  incision  is  made,  commencing  close  to  the 
lobule  of  the  ear,  running  down  along  the  anterior  border  of  the 
sterno-mastoid  to  the  great  cornu  of  the  hyoid  bone,  and  thence 
forwards  nearly  to  the  middle  line,  and  upwards  to  the  symphysis. 
This  flap  of  skin  and  subcutaneous  tissue  is  dissected  up,  and  stitched 
to  the  cheek  out  of  harm's  way.  All  the  lymphatic  glands  in  the 
region — the  submental,  submaxillary,  and  those  lying  over  the 
carotid — are  now  removed,  as  well  as  the  submaxillary  salivary 
giand,  the  lingual  and  facial  arteries  being  tied  close  to  the  carotid. 
If  necessary,  the  incision  is  enlarged  downwards  along  the  anterior 
border  of  the  sterno-mastoid  in  order  to  permit  of  more  thorough 
removal  of  the  glands.  Any  diseased  portion  of  the  jaw  is  isolated 
by  saw-cuts  in  front  and  behind,  and  removed.  Where  only  half  the 
tongue  is  to  be  removed,  it  is  now  split  down  the  middle  line  with 
scissors,  and  the  mucous  membrane  in  the  floor  and  side  of  the 
mouth  divided  so  as  to  leave  that  side  of  the  tongue  attached  merely 
by  the  muscular  structures.  If  the  whole  organ  is  to  be  removed,  it 
is  unnecessary  to  divide  it  in  the  middle  line.  By  detaching  the 
mylo-hyoid  from  the  bone  a  communication  is  made  between  the 
outside  wound  and  the  mouth,  and  the  tongue  is  then  drawn  through 
this  lateral  opening,  and  can  be  removed  as  far  back  as  the  epiglottis 
behind  and  the  hyoid  bone  below,  the  whole  floor  of  the  mouth  being 
effectually  dealt  with  in  this  way.  In  some  cases  it  is  possible  to 
close  the  gap  in  the  floor  of  the  mouth  by  stitching  the  base  of  the 
remaining  half  of  the  tongue  across  the  floor  of  the  mouth,  and 
doubling  its  body  over  on  itself.  The  wound  in  the  neck  is  closed  by 
buried  and  superficial  sutures,  a  drainage-tube  being  inserted  for  a 
few  days. 

The  Aftsr-Treatment  is  much  the  same  in  all  cases.  The  raw 
surface  may  be  painted  with  Whitehead's  varnish  (which  consists  of 
Friar's  balsam,  but  with  the  rectified  spirit  replaced  by  a  saturated 
solution  of  iodoform  in  ether) ;  the  all-essential  thing,  however,  is  to 
keep  the  cavity  well  irrigated  with  antiseptic  lotions,  such  as  weak 
solutions  of  boric  acid,  boroglyceride  ([  in  20),  sanitas  or  lysoform. 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    855 

The  patient  must  be  closely  watched  for  the  first  forty-eight  hours,  to 
see  that  his  respiration  is  not  obstructed  by  the  stump  of  the  tongue 
falling  backwards  ;  but  at  the  end  of  that  time  this  danger  will  be  at 
an  end,  and  the  silk  or  silver  wire  may  be  removed.  The  patient  is 
fed  per  rectum  for  twenty-four  hours^  but  afterwards  a  tube  attached 
to  the  spout  of  a  feeder  is  introduced  into  the  pharynx  or  oesophagus. 
In  the  simpler  cases  he  is  able  to  swallow  freely  and  without  diffi- 
culty in  the  course  of  a  day  or  two,  and  even  in  the  worst  cases  he 
can  feed  himself  with  a  long  tube  passed  into  the  pharynx  in  five  or 
six  days.  The  chief  dangers  of  the  operation  arise  from  septic  con- 
tamination, resulting  in  secondary  haemorrhage  or  septic  pneumonia  ; 
and  these  are  best  avoided  by  careful  and  thorough  preparation  of 
the  patient. 

The  removal  of  a  part,  or  even  the  whole,  of  the  tongue  is  not  such 
a  mutilation  physiologically  as  one  might  expect  at  first.  Deglutition 
is  interfered  with  for  a  time,  but  the  power  is  soon  regained,  and 
even  articulation  may  be  in  great  measure  restored. 

Preliminary  Tracheotomy  is  sometimes  employed  in  operations  on 
the  tongue,  but  is  scarcely  necessary  as  a  rule.  A  Hahn's  trachea- 
tube  (i.e.,  a  large  one  surrounded  with  compressed  sponge  infiltrated 
with  iodoform,  which  will  expand  and  absolutely  shut  off  the  lower 
respiratory  passages  from  the  mouth)  is  inserted,  or  a  Trendelenburg's 
air-tampon  ;  or  an  ordinary  tube  may  be  employed  if  the  pharynx  is 
well  packed  with  a  sponge  so  as  to  prevent  blood  trickling  down- 
wards; the  ansesthetic  can  then  be  administered  through  the  tube. 
The  advantages  of  this  procedure  are  threefold  :  (a)  The  patient  can 
be  kept  in  a  condition  of  complete  anaesthesia  without  hindrance  to 
the  surgeon,  so  that  the  operation  is  more  quickly  finished,  the 
shock  is  less,  and  the  removal  of  the  disease  can  be  more  thoroughly 
accomplished  ;  (V)  the  patient  runs  no  danger  of  asphyxia  during  the 
operation  by  blood  trickling  into  the  lungs,  or  by  fragments  of  tissue 
or  sponge  getting  loose  in  the  mouth  and  being  inhaled,  whilst  later 
on  falling  back  of  the  root  of  the  tongue  does  no  harm  ;  and  (c)  the 
chances  of  septic  pneumonia  are  reduced  to  a  minimum.  Of  course, 
opening  the  trachea  is  not  entirely  devoid  of  danger,  and  therefore 
this  plan  should  not  be  adopted  unnecessarily. 

The  operation  for  removing  the  glandular  area  in  connection  with 
cancer  of  the  tongue  is  a  formidable  proceeding,  as  its  scope  must 
extend  from  the  mastoid  process  to  the  episternal  notch.  If  the 
disease  has  involved  both  sides  of  the  tongue,  both  sides  of  the  neck 
must  be  cleared,  and  even  when  the  disease  has  only  apparently 
affected  one  side  of  the  tongue,  the  glands  on  both  sides  of  the  neck 
may  be  involved.  The  incision  should  extend  along  the  anterior 
border  of  the  sterno-mastoid  throughout  its  whole  length,  and  a 
second  incision  meets  it  extending  from  the  chin  to  just  below  the 
great  cornu  of  the  hyoid  bone.  The  flaps  thus  marked  out  are  dis- 
sected up  and  turned  forwards,  the  platysma  being  included  in  them. 
The  submental  and  submaxillary  regions  are  cleared  of  their  loose 
cellular  tissue,  including  all  lymphatic  glands  and  the  submaxillary 


856  A  MANUAL  OF  SURGERY 

salivary  gland  (except  the  deep  process  and  duct),  which  are  turned 
back  towards  the  main  vessels.  The  internal  jugular  vein  is  then 
laid  bare  and  all  the  lymphatic  glands  lying  upon  it  are  dissected 
upwards  from  below  or  downwards  from  above.  All  the  cellular 
tissue  of  the  anterior  triangle  is  cleared  away  in  one  piece  with  the 
glands,  and  particular  attention  is  directed  to  the  gland  which  lies 
on  the  bifurcation  of  the  carotid  vessels,  and  to  the  glands  which  extend 
along  the  external  carotid  under  cover  of  the  posterior  belly  of  the 
digastric  and  lower  edge  of  the  parotid.  The  facial  and  lingual 
arteries  will  have  to  be  secured  back  and  front ;  the  external  jugular 
vein  will  be  sacrificed,  and  if  need  be  the  internal  should  also  be 
taken  away  ;  but  the  facial  and  spinal  accessory  nerves  must  be 
spared.  Careful  deep  suturing  will  minimize  the  deformity,  but  it  will 
be  necessary  to  drain  the  lower  part  of  the  wound,  and  if  the  parotid 
has  been  encroached  on  a  tube  must  also  be  inserted  above. 

Affections  of  the  Floor  of  the  Mouth. 

Sublingual  Abscess,  when  acute,  is  due  to  infection  of  the  sub- 
mucous tissue,  as  by  puncture  with  a  fishbone,  or  starts  in  a  follicle 
of  the  sublingual  or  in  a  submucous  gland.  The  inflammation  which 
follows  results  in  the  formation  of  a  puffy  swelling  beneath  the 
tongue^  which,  if  not  opened  early,  may  lead  to  an  extension  down- 
wards of  the  mischief  into  the  submental  region.  The  tongue  becomes 
swollen  and  turgid  from  pressure  upon  the  veins,  whilst  oedematous 
laryngitis  may  also  be  induced.  Considerable  constitutional  disturb- 
ance generally  accompanies  this  process.  A  median  incision  through 
the  mucous  membrane,  and  the  insertion  and  opening  of  a  pair  of 
dressing  forceps,  is  the  safest  and  best  method  of  treatment,  the 
cavity  being  subsequently  washed  out  and  drained.  The  more  diffuse 
form  of  sublingual  abscess  is  usually  associated  with  submaxillary 
cellulitis  (p.  81). 

The  sublingual  region  is  also  a  favourite  site  for  Actinomycosis 
(p.  181),  which  manifests  itself  as  a  diffuse  brawny  induration  of  the 
tissues,  progressing  slowly,  and  not  very  tender.  As  it  comes  to  the 
surface,  the  skin  becomes  red  and  dusky,  and  sooner  or  later  a  series 
of  little  pustules  appear  one  after  another  with  a  typical  yellowish 
apex.  These  burst  and  discharge  a  glutinous  fluid  containing  the 
fungus,  and  if  kept  aseptic  and  allowed  to  heal,  are  followed  by 
depressed  and  puckered  cicatrices.  The  administration  of  gradually 
increasing  doses  of  iodides  usually  suffices  to  bring  about  a  cure. 

Cystic  Swellings  are  not  uncommon  about  the  floor  of  the  mouth, 
and  amongst  them  the  following  may  be  described : 

(a)  Mucous  Cysts  result  from  the  distension  of  mucous  glands ;  they 
form  small  translucent  swellings,  elastic  and  fluctuating.  All  that  is 
needed  is  to  open  them,  and  remove  the  anterior  wall. 

(b)  Ranula  is  a  very  similar  condition,  but  larger  and  unilateral, 
containing  a  glairy  mucoid  fluid,  and  sometimes  due  to  obstruction 
and  distension  of  one  of  the  sublingual  ducts  (or  ducts  of  Rivini). 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     S57 

A  similar  condition  has  been  oaused  in  rare  cases  by  a  blocking  oi 
Wharton's  duct,  but  this  has  generally  been  found  to  run  along  the 
outer  surface  of  the  cyst.  The  tumour  may  be  as  large  as  a  walnut 
or  pigeon's  egg.  The  Treatment  consists  in  removing  a  good-sized 
piece  of  the  wall,  so  that  the  cavity  may  be  obliterated  by  a  process 
of  granulation,  or  if  that  should  fail,  the  whole  cavity  must  be 
dissected  out. 

(c)  Dermoid  Cysts  are  frequently  met  with  in  the  floor  of  the  mouth, 
occupying  the  middle  line,  and  also  projecting  into  the  neck  beneath 
the  chin.  They  are  due  to  non-obliteration  of  the  upper  end  of  the 
thyro-glossal  canal  (p.  8g8).  The  contents  are  of  the  usual  sebaceous 
typCc  Such  tumours  should  never  be  dealt  with  from  the  mouth,  as 
they  extend  deeply,  and  need  to  be  carefully  dissected  out.  A  free 
incision  must  be  made  in  the  middle  line  under  the  chin,  and,  if 
feasible,  the  whole  cyst  removed  unopened  ;  the  entire  wall  must  be 
dealt  with,  or  recurrence  will  certainly  ensue. 

Affections  of  Salivary  Glands. 

Inflammation  of  the  Parotid  G-land  is  met  with  in  several  different 
forms. 

1.  Epidemic  Parotitis  (Mumps)  is  an  acute  specific  disease  usually 
seen  in  children,  highly  infectious  in  character,  and  generally  epidemic. 
The  period  of  incubation  is  about  three  weeks,  and  the  attack  itself 
consists  in  a  slight  febrile  disturbance,  associated  with  swelling  of 
one  or  both  parotid  glands ;  one  gland  is  attacked  first,  becoming 
enlarged  and  tender,  whilst  the  other  side  is  similarly  affected  in 
a  day  or  two.  Mastication  becomes  difficult,  owing  to  the  tension  of 
the  parts.  The  swelling,  which  lasts  for  about  a  week  and  then 
gradually  subsides,  extends  below  and  in  front  of  the  ear,  and  the 
socia  parotidis  can  be  distinctly  felt  lying  over  the  masseter  ;  the 
submaxillary,  sublingual,  and  neighbouring  lymphatic  glands  are 
sometimes,  but  not  frequently,  enlarged.  Suppuration  is  rare,  but 
m  adults  metastic  inflammation  of  the  testes,  mammae,  or  ovaries 
is  not  uncommon.  This  complication  is  generally  unilateral,  and  thus, 
although  atrophy  of  the  testis  commonly  follows  orchitis,  sterility 
is  not  produced.  Treatment. — Keep  the  patient  warm  and  quiet,  and 
administer  salines.  In  the  later  stages  friction  with  stimulating 
liniments  will  hasten  resolution.  After  the  acute  attack,  the  gland 
may  remain  enlarged  for  some  time. 

2.  A  Simple  Parotitis  occasionally  results  from  exposure  to  cold 
or  from  injury,  whilst  the  presence  of  a  calculus  in  the  duct  leads  to 
a  chronic  sclerosing  inflammation.  The  symptoms  consist  of  pain 
and  swelling,  together  with  a  certain  amount  of  constitutional  disturb- 
ance. An  extremely  interesting  phenomenon  is  the  parotitis  which 
follows  injuries  or  diseases  of  the  abdominal  or  pelvic  viscera.  This 
condition  is  not  very  unusual,  as  is  evident  by  the  fact  that  Stephen 
Paget  has  been  able  to  collect  10 1  such  cases.  It  was  formerly 
attributed  to  pyaemia,  but  is  now  considered  to  be  due  to  infection 


858  A  MANUAL  OF  SURGERY 

of  a  mild  type  from  the  mouth,  owing  to  a  dirty  state  of  the  teeth 
induced  by  prolonged  rectal  feeding.  In  confirmation  of  this  view 
is  the  fact  that  it  has  been  seen  in  not  a  few  cases  of  gastric  ulcer, 
where  the  patient  had  been  fed  per  rectum  for  some  time.  Treatment  in 
these  simple  cases  consists  in  the  application  of  fomentations,  perhaps 
medicated  with  belladonna. 

3.  Suppurative  Parotitis  is  a  miuch  more  serious  condition.  It  may 
extend  from  the  mouth  along  Stenson's  duct,  or  supervene  in  the 
course  of  pyaemia,  or  as  a  sequela  of  some  of  the  exanthemata — e.g., 
scarlet  or  typhoid  fevers.  If  the  inflammation  spreads  up  from  the 
mouth,  suppuration  occurs  primarily  wathin  the  tubules ;  under  other 
circumstances,  pus  forms  in  the  interstitial  tissues.  The  gland 
becomes  much  enlarged,  with  congestion  and  oedema  of  the  overlying 
skin,  and,  owing  to  the  tension  of  the  fascia,  exceedingly  painful. 
For  the  same  reason,  pus  cannot  readily  find  its  way  to  the  surface, 
and  hence  is  likely  to  burrow  in  various  directions — e.g.,  amongst  the 
muscles  of  the  neck,  or  even  upwards  and  inwards  towards  the  base 
of  the  skull,  or  to  the  cavity  of  the  mouth,  finding  its  way  over  the 
border  of  the  superior  constrictor  (the  so-called  '  sinus  of  Morgagni '). 
The  constitutional  symptoms  from  toxic  absorption  are  usually  very 
severe.  Owing  to  the  fact  that  large  veins  and  arteries  pass  through 
the  parotid  gland,  pyaemic  symptoms  are  not  unlikely  to  supervene, 
and  the  prognosis  is  therefore  somewhat  serious. 

Diagnosis. — Inflammation  of  the  lymphatic  glands  lying  on  the 
outer  surface  of  the  parotid  closely  simulates  the  above  affections, 
but  is  distinguished  from  them  by  the  fact  that  they  are  more 
superiicial,  and  that  the  socia  parotidis  is  not  enlarged. 

Treatment. — In  the  early  stages  fomentations  are  employed,  but 
as  soon  as  there  is  any  indication  that  suppuration  has  occurred,  a 
free  incision  must  be  made,  and  the  pus  let  out.  Every  precaution 
should  he  taken  to  preA^ent  mischief  to  the  facial  nerve,  and  Hilton's 
method  of  operating  may  be  advantageously  employed ;  but  in  the 
more  severe  cases  where  the  patient's  life  is  threatened  and  the  pus 
is  burrowing  in  all  directions,  the  knife  must  be  used  freely,  regard- 
less of  anatomical  considerations. 

Iniiammation  of  the  submaxillary  and  sublingual  glands  may  arise 
in  an  exactly  similar  way,  but  no  special  description  is  called 
for.  Occasionally,  however,  the  process  extends  ^beyond  the  sub- 
maxillary gland  to  the  neighbouring  tissues,  giving  rise  to  what  has 
already  been  described  as  submaxillary  cellulitis,  or  Ludwig's 
angina  (p.  81). 

Obstruction  to  the  Flow  of  Saliva  results  from  various  causes,  such 
as  cicatricial  contraction  in  the  neighbourhood  of  the  entrance  of  the 
duct  into  the  mouth,  or  from  the  presence  in  the  duct  of  a  salivary 
calculus,  consisting  of  phosphate  and  carbonate  of  lime,  and  usually 
fusiform  in  shape.  Calculus  formation  only  occurs  in  connection 
with  the  submaxillary  and  sublingual  glands,  since  the  saliva  secreted 
by  them  is  thick  and  mucoid,  whereas  parotid  saliva  is  limpid  iu 
character. 


AFFECTIONS  OF  THE  MOUTH,   THROAT,  AND  CESOPHAGUS    SSp 


The  chief  Symptom  of  such  obstruction  is  a  painful  enlargement 
of  the  gland  during  and  after  meals,  which  slowly  passes  away  as 
the  saliva  finds  its  way  past  the  block  ;  if  it  persists  for  long,  the 
gland  becomes  chronically  enlarged,  and  its  interstitial  tissue  in- 
creased in  bulk,  whilst  a  certain  amount  of  peri-adenitis  also 
follows.  When  a  calculus  is  present,  there  is  usually  a  consider- 
able discharge  of  offensive  muco-pus  into  the  mouth.  Where  the 
obstruction  is  complete,  a  cyst  may  form,  and  if  this  is  opened, 
or  finds  its  way  to  the  exterior  and  bursts,  a  salivary  fistula 
results. 

Treatment.- — In  cases  of  simple  obstruction,  an  attempt  must  be 
made  to  restore  the  natural  exit,  or  to  make  an  artificial  one.  If  a 
calculus  is  present,  it  can  usually  be  seen  or  felt  at  intervals  project- 
ing from  the  entrance  of  the  duct  ; 
in  such  a  case  the  duct  must  be  in- 
cised from  the  mouth,  and  the  stone 
removed.  Where,  however,  it  is 
located  in  the  substance  of  the  sub- 
maxillary, total  removal  of  the  gland 
may  be  necessary. 

Tumours  of  the  Parotid  Gland  are 
of  considerable  interest,  and  may  be 
simple  or  malignant. 

(a)  The  Simple  parotid  tumour  is 
usually  an  endothelioma,  in  which, 
however,  fibrous  and  adenoid  tissue 
may  occur.  It  usually  commences 
near  the  surface  in  the  endothelium 
lining  the  bloodvessels  and  lymph 
spaces,  and,  owing  to  a  colloid  or 
mucoid  degeneration  of  the  inter- 
stitial tissue,  may  simulate  a  chon- 
droma  or    myxoma.      The   tumour 

feels  hard,  firm,  and  nodular,  but  areas  of  softening  may  be  inter- 
spersed amongst  the  harder  portions.  The  mass  is  situated  between 
the  jaw  and  the  sterno-mastoid,  accessory  processes  also  extending 
over  the  masseter  in  the  region  of  the  socia,  and  later  on  burrowing 
deeply  between  the  mastoid  bone  and  the  styloid  process,  and  be- 
neath the  ramus  of  the  jaw  (Fig.  388).  In  the  early  stages  the 
tumour  is  freely  moveable  on  the  deeper  parts,  as  is  also  the  skin 
over  it,  but  subsequently  the  mass  becomes  fixed  and  adherent.  The 
growth  is  usually  slow,  and  at  first  quite  painless,  and  there  is  no 
tendency  to  invade  lymphatic  glands  or  produce  cachexia.  IMastica- 
tion  is  impaired  in  the  later  stages,  but  otherwise  the  subjective 
symptoms  are  of  but  slight  imiportance,  owing  to  the  fact  that  the 
growth  is  superficial  to  the  gland,  and  to  the  more  important  vessels 
and  nerves.  If  allowed  to  persist,  the  growth  will  finally  take  on 
malignant  characters.  True  adenoma  or  fibroma  of  the  parotid 
gland  is  occasionally  observed. 


3S8.— Parotid  Tumour. 
(Fergusson.) 


863 


A  MANUAL  OF  SURGERY 


{b)  Malignant  tumours  of  the  parotid  (Fig.  389)  occur  in  the  form 
of  endothelioma,  sarcoma,  or  carcinoma,  and  are  not  unfrequently 
grafted  on  to  a  simple  tumour,  the  change  of  type  being  marked  by 
increased  rapidity  of  growth  and  greater  pain.  The  mass  becomes 
more  fixed,  and  signs  of  pressure  upon'  the  vessels  and  nerves 
develop  ;  the  facial  nerve  is  very  likely  to  be  implicated,  leading 
to  paralysis  of  the  face.  Moreover,  the  skin  becomes  hyperaemic 
and  often  adherent  to  the  tumour,  and  finally  ulceration  and  even 
tuiigation  may  obtain.  Secondary  deposits  occur  in  the  neigh- 
bouring lymphatic  glands  or  in  the  viscera,  and  the  patient  soon 
passes  into  a  state  of  malignant  cachexia.  Carcinomatous  tumours 
are  less  common  than  the  sarcomata,  but  run  a  similar  course. 
The  growth  is  an  adenoid  cancer,  not  unfrequently  of  the  soft 
or  encephaloid  type,  and  neighbouring  lymphatic  glands  are  early 
invaded. 

The  Diagnosis  of  simple  parotid  tumours  from  malignant  growths 

is  a  matter  of  the  greatest  im- 
portance from  a  prognostic  point 
of  view,  since  simple  tumours 
are  usually  encapsuled,  and 
their  removal,  except  when 
large  or  deeply  placed,  is  not  a 
matter  of  special  difficulty ; 
malignant  disease  is  more  dif- 
fuse, rendering  extirpation  of 
the  mass  almost  impracticable. 
The  distinction  betvv  een  the  two 
forms  is  made  by  a  considera- 
tion of  the  signs  and  symptoms 
considered  above,  attention 
being  directed  to  the  rate  cf 
growth,  the  condition  of  the 
skin  and  surrounding  parts,  the 
mobility  or  not  of  the  neoplasm, 
and  the  general  aspect  of  the 
patient,  whilst  associated  paral- 
ysis of  the  facial  nerve  is  almost  always  characteristic  of  malig- 
nancy. The  lymphatic  glands  lying  on  the  surface  of  the  parotid, 
when  invaded  by  tubercle  or  by  epithelioma  secondary  to  some 
intrabuccal  growth,  may  closely  simulate  a  true  parotid  tumour,  but 
are  recognised  by  their  more  superficial  position. 

The  Treatment  is  often  a  matter  of  some  difficulty,  owing  to  the 
important  character  of  the  surrounding  tissues.  Removal  should 
only  be  attempted  if  the  skin  is  not  extensively  involved,  if  the 
growth  is  moveable  on  the  deeper  parts,  and  if  there  is  no  evidence 
of  secondary  deposits.  Even  simple  tumours  become  irremoveable 
after  a  time  on  account  of  their  deep  connections  and  change  of  type, 
whilst  it  is  seldom  justifiable  to  touch  malignant  growths  on  account 
of  their  early  and  wide  local  dissemination.     Simple  parotid  tumours 


Fig. 


389. — Malignant  Tumour  of  the 
Parotid  Gland 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     865 

As  to  the  hest  period  at  which  to  interfere  by  operation,  consider- 
able divergence  of  opinion  exists.  Some  surgeons  advocate  its 
performance  at  as  early  a  date  as  possible,  and,  in  fact,  it  has  been 
undertaken  when  the  child  was  but  a  few  days  old.  The  success 
attending  such  practice  has  not  been  gratifying,  since  infants  have 
no  moral  control,  and  are  much  more  likely  to  suck  at  the  stitches 
and  interfere  with  them  by  the  tongue,  whilst  the  buccal  cavity  is 
small,  and  the  tissues  so  delicate  and  friable  that  the  difficulty  of  the 
operation  is  much  increased.  On  the  other  hand,  it  should  not  be 
deferred  too  long ;  bad  habits  of  articulation  will  be  contracted,  and 
subsequent  physiological  success,  as  gauged  by  the  quality  of  the 
speech,  is  much  less  likely  to  follow.  After  an  extended  experience, 
it  may  be  stated  that  the  operation  is  best  undertaken  between  the 
second  and  the  third  years,  when  a  child  can  be  easily  kept  under 
control.  It  is  most  important  that  the  general  health  be  good,  and 
the  mouth  and  throat  free  from  local  disease  or  inflammation.  To 
guard  against  accidents  it  is  well  to  make  a  routine  practice  of  keeping 
a  child  indoors  under  observation  for  a  few  days  before  operating, 
whilst  for  choice  the  spring  or  summer  should  be  selected.  If  the 
tonsils  are  enlarged,  as  is  not  uncommonly  the  case,  it  is  by  no 
means  necessary  to  remove  them  if  no  active  inflammation  is 
present ;  pharyngeal  adenoids,  moreover,  may  sometimes  be  left 
with  advantage,  as  they  subsequently  assist  in  shutting  off  the  nasal 
cavity  during  speech. 

Operation. — The  child  should  be  placed  on  a  suitable  table  with  a 
moveable  headpiece,  if  possible,  as  it  is  often  necessary  to  alter  the 
position  of  the  head  during  the  proceedings.  The  arms  are  fixed  to 
the  sides  by  attaching  them  to  a  strap  or  bandage  passed  round  the 
thighs  below  the  trochanters,  but  the  patient  should  not  be  tied  down 
to  the  table,  so  that,  although  he  cannot  raise  the  hands  to  the 
mouth  during  the  partial  anaesthesia  which  is  often  present,  yet  he 
can  be  turned  easily  to  either  side  so  as  to  allow  blood  to  run  from 
the  mouth.  Anaesthesia  is  induced  in  the  ordinary  way  by  chloro^ 
form  dropped  upon  a  suitable  mask.  The  greatest  care  must  be 
taken  not  to  drop  chloroform  into  the  mouth,  and  even  Junker's 
apparatus  must  be  used  with  caution,  for  fear  of  the  chloroform  vapour 
irritating  the  edges  of  the  cleft.  The  mouth  is  efficiently  gagged 
open,  and  preferably  by  means  of  a  unilateral  instrument,  which  can 
easily  be  slipped!  in  or  out  of  position. 

In  a  case  involving  both  the  soft  and  hard  palate  there  is  no 
reason  why  the  whole  cleft  should  not  be  dealt  with  at  one  sitting. 
When  the  intermaxillary  bone  has  been  previously  removed,  and  a 
considerable  gap  left  anteriorly,  it  is  often  only  possible  to  close  the 
posterior  two-thirds  of  the  cleft,  either  dealing  with  the  anterior 
portion  at  a  later  date,  or  trusting  to  the  application  of  a  suitable 
obturator,  to  which  artificial  incisors  can  also  be  attached.  The 
proceeding  usually  employed  is  practically  identical  with  that  intro- 
duced by  Langenbeck,  and  known  as  uranoplasty.  For  convenience 
it  may  be  described  in  four  stages  : 

55 


866 


A  MANUAL  OF  SURGERY 


Stage  I.  :  Incision  and  Detachment  of  Miico -periosteal  Flaps. — The 
knife  should  be  inserted  close  to  the  last  molar  tooth  and  about  half 
an  inch  from  the  alveolar  margin,  and  carried  forwards  parallel  to 
the  teeth  to  a  spot  just  anterior  to  the  apex  of  the  cleft ;  or,  if  the 
alveolus  is  involved,  the  incision  should  stop  behind  the  lateral  incisor 
to  preserve  the  vascular  supply  of  the  front  of  the  flap  (Fig.  393). 
The  muco-periosteum  is  divided  down  to  the  bone,  and  by  the  use 
of  a  suitable  raspatory  the  soft  structures  of  the  palate  are  stripped 
up  towards  the  middle  line,  until  the  point  of  the  instrument  is  seen 
protruding  into  the  cleft.  Great  care  is  needed  to  ensure  its  total 
detachment  from  the  back  of  the  bony  palate,  and  yet  not  to  damage 
it  at  this,  its  weakest  part.  This  must  be  thoroughly  carried  out  on 
both  sides.     Copious  bleeding  always  accompanies  this  stage  of  the 


Fig.  393. — Diagrams  to  indicate  Extent  of  Incisions  in  Uranoplasty. 

The  thick  black  lines  show  the  primary  incision  ;  the  thick  dotted  lines,  the 
extension  backwards  of  the  same  to  relieve  lateral  tension  ;  the  thin  dotted 
lines  indicate  approximately  the  position  of  the  free  border  of  the  bony 
palate.  The  right-hand  figure  shows  the  position  of  the  sutures,  and  the 
condition  of  the  parts  at  the  close  of  the  operation. 


operation,  and  the  head  should  be  turned  on  one  side  and  lowered, 
and  the  pharynx  kept  clear  by  careful  sponging. 

Stage  II.  :  Paring  the  Edges  of  the  Cleft. — This  is  accomplished  by 
grasping  the  base  of  the  uvula  with  a  suitable  pair  of  angular  catch- 
forceps.  Thus  steadied  and  held,  a  thin  paring  can  be  removed,  in 
one  piece,  if  possible,  on  the  side  seized,  and  the  same  process 
repeated  on  the  other.  The  paring  of  the  edges  is  purposely  deferred 
until  after  the  muco-periosteal  flaps  have  been  detached,  because  the 
freshened  edges  do  not  thus  get  bruised  by  the  frequent  use  of  the 
sponge ;  moreover,  the  bevel  at  which  the  edges  should  be  pared  can 
be  more  accurately  estimated  when  the  flaps  have  been  loosened. 

Stage  III.  :  Passage  and  Tightening  of  Sutures. — The  simplest  plan 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    867 


to  adopt  is  that  known  as  the  '  loop  method '  of  Sir  W.  Fergusson, 
and  it  is  carried  out  as  follows:  A  long-handled  palate  needle  with  a 
suitable  curve,  and  threaded  with  about  iS  inches  of  fine  white  silk, 
is  passed  through  the  muco-periosteal  flap  from  below  upwards,  and 
at  a  spot  about  2  or  3  mm.  from  the  margin  (Fig.  394,  A)  ;  as  a  rule, 
it  is  not  necessary  to  hold  the  flap  to  effect  this.  The  loop  of  silk 
projecting  from  the  cleft  (Fig.  394,  B)  is  now  grasped  with  smooth- 
nosed  forceps  and  drawn  out  of  the  mouth,  whilst  the  needle  is  with- 
drawn. A  similar  loop  is  inserted  through  the  opposite  side  of  the 
cleft  at  an  exactly  corresponding  point,  so  that  there  are  now  two 
loops  emerging  from  behind  through  the  cleft  (Fig.  394,  C,  D).  One 
of  these  is  loosely  threaded  through  the  other  (Fig.  395,  E),  and  the 
latter  gently  withdrawn,  carrying  with  it  the  loop-end  of  the  former 
(Fig.  395,  F),  and  thus  a  double  thread  is  carried  through  both  sides 
of  the  palate,  a  loop  projecting  from  one  side,  and  the  free  ends  from 


Fig.  394.  Fig.  395.  Fig.  396. 

Figs.  394-396.  —  Diagrams  to   illustrate  the  Loop  Method  of  Passing 
Stitches  in  the  Operation  for  Cleft  Palate. 

The  needles  and  silk  thread  are,  for  purposes  of  illustration,  represented 
much  thicker  than  would  be  really  employed. 

the  other.  This  process  is  commenced  anteriorly  and  carried  back- 
wards until  the  base  of  the  uvula  is  reached,  the  stitches  being 
inserted  about  half  a  centimetre  apart,  so  that  nine  or  ten  threads 
may  be  needed  to  secure  the  whole  palate.  They  are  left  loose,  the 
ends  being  held  by  the  assistant  against  the  cheeks  until  all  have 
been  inserted.  A  6-inch  length  of  fine  well-annealed  silver  wire  is 
successively  hooked  over  each  loop  (Fig.  396,  G),  drawn  into  position 
by  the  silk  thread  (Fig.  396,  H),  and  tightened  to  a  suitable  degree 
by  a  wire-twister,  so  that  the  pared  edges  of  the  cleft  are  exactly 
apposed.  This  is  best  undertaken  from  before  backwards.  Finally, 
the  uvula  is  stitched  with  silk  inserted  by  means  of  a  double-curved 
needle  (Fig.  396,  I)  ;  silver  wire  would  irritate  the  back  of  the  tongue 
too  much  and  cause  vomiting. 

Some  surgeons  prefer  to  introduce  the  wire  by  means  of  a  specially 
constructed  hollow  needle  with  a  double  curve,  through  which  the 
wire  is  protruded  by  unwinding  a  drum  in  the  handle.  This  is  passed 
through  both  flaps,  commencing  at  the  uvula,  and  working  forwards, 
tying  each  stitch  as  it  is  Inserted. 


868  A  MANUAL  OF  SURGERY 

Stage  IV. — It  is  now  only  necessary  to  take  steps  for  the  relief  of  all 
lateral  tension,  a  most  important  and  essential  proceeding.  The  best 
way  to  accomplish  this  is  to  prolong  backwards  through  the  soft 
palate  the  lateral  incisions  already  made  so  as  thoroughly  to  divide 
the  levator  palati  (see  the  thick  dotted  lines  in  Fig.  393).  Occa- 
sionally the  anterior  and  posterior  pillars  of  the  fauces,  containing 
respectively  the  palato-glossi  and  palato-pharyngei  muscles,  will  also 
need  to  be  snipped  across. 

The  child  should  now  be  put  to  bed  with  the  head  low,  so  that 
any  accumulation  of  blood  or  mucus  may  gravitate  easily  into  the 
pharynx.  The  mouth  can  be  washed  out  with  a  weak  solution  of 
sanitas,  although  some  surgeons  prefer  not  to  disturb  the  parts  for 
three  or  four  days.  No  nourishment  should  be  given  for  the  first 
four  or  five  hours,  and  but  very  sparingly  for  the  first  twenty-four. 
Milk  and  water,  given  by  a  spoon  or  from  a  feeder,  will  form  the 
staple  article  of  diet.  By  about  the  fifth  day  soft  food,  such  as  soaked 
bread  and  custard  pudding,  may  be  safely  permitted.  The  patients 
are  generally  allowed  up  on  the  sixth  day.  The  silver  stitches  may 
be  left  in  for  ten  days  or  a  fortnight  without  doing  any  harm.  Should 
any  signs  of  inflammation  occur,  the  palate  should  be  sprayed  over 
with  a  solution  of  peroxide  of  hydrogen. 

In  dealing  with  clefts  of  the  soft  palate  alone,  a  modification  of  the 
above  operation  may  be  performed  called  staphylorrhaphy.  The  edges 
are  first  pared,  lateral  incisions  are  then  made  to  divide  the  levatores 
palati,  and  the  stitches  finally  passed  and  tied. 

Results. — It  is  possible  that  in  most  cases  articulation  will  be,  if 
anything,  impaired  as  the  immediate  result  of  the  operation,  since 
the  mechanism  which  the  patient  ordinarily  employs  is  thrown  out 
of  gear  ;  subsequent  education  at  the  hands  of  a  voice-trainer  is  abso- 
lutely essential  in  order  to  correct  this.  Even  then  the  unpleasant 
articulation  occasionally  persists,  owing  to  the  patient  being  unable 
to  draw  up  the  velum  so  as  to  close  the  posterior  nares ;  this  is  due 
to  a  reduction  of  the  depth  of  the  soft  palate  owing  to  the  traction 
required  to  close  the  cleft.  In  spite  of  this,  however,  the  operation 
is  most  beneficial  in  that  it  shuts  off  the  nose  from  the  mouth, 
prevents  the  dropping  of  mudus,  improves  the  sense  of  taste,  and 
adds  greatly  to  the  general  comfort  of  the  patient. 

Davies  CoUey's  Operation. — This  plan  of  treatment,  introduced  by  the  late 
Mr.  Davies  Colley,  consists  in  raising  flaps  of  muco-periosteum  (Fig.  397)  in 
such  a  manner  that  whilst  one  is  turned  over  and  attached  to  the  opposite  margin 
of  the  palate  with  the  mucous  membrane  upwards,  the  second  flap  is  laid  across 
it  with  its  raw  surface  upwards — i.e.,  in  contact  with  the  raw  surface  of  the  first 
flap.  Suitable  sutures  fix  the  flaps  in  position  "(Fig.  398).  As  a  rule,  two  or 
three  subsequent  operations  are  required  to  complete  the  closure  of  the  defect. 
This  proceeding  has  been  much  utilized  by  some  surgeons,  who  perform  it  at  a 
very  early  age  ;  but  we  have  yet  to  be  convinced  as  to  its  superiority  over  the  plan 
described  above. 

Mechanical  Treatment  of  clefts  in  the  palate  by  means  of  obturators  or  artificial 
vela  is  still  advocated  by  some  surgeons  and  dentists  in  preference  to  any 
operative  interference.  An  obturator  consists  of"  an  adjustable  plate  or  plug 
fitted  to  and  closing  an  aperture  in  the  hard  palate.  It  may  be  used  with 
advantage  in  perforations  due  to  traumatism  or  syphilis,  and  in  apertures  left 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     869 

after  operations  in  which  portions  of  the  palate  are  removed,  such  as  excision  of 
the  superior  maxilla.  In  cases  of  double  hare-lip  and  cleft  palate,  where  the  os 
incisivum  has  been  extirpated,  an  aperture  is  often  left  anteriorly  which  cannot 
be  satisfactorily  closed  except  by  an  obturator,  which  also  serves  to  carry  the 
necessary  artificial  incisors,  and  may  have  cheek-plates  attached  to  push  forwards 
the  upper  lip.  For  whatever  purpose  an  obturator  is  needed,  it  should  never 
take  the  form  of  a  closely-fitting  plug,  which,  by  its  constant  pressure  and 
irritation,  causes'  the  aperture  to  become  enlarged,  but  always  that  of  a  plate, 
either  of  thin  vulcanite  or  gold,  which  can  be  fixed  to  the  teeth,  and  maintained 
in  position  by  suction.  It  is  sometimes  found,  however,  that  the  addition  of  an 
intranasal  projection  to  the  upper  surface  of  the  plate  improves  the  articulation 
by  diminishing  the  size  of  the  nasal  cavity.  An  artificial  vdum  consists  of  a  plate 
obturator,  to  which  is  attached  posteriorly  a  moveable  segment  to  take  the  place 
of  the  normal  velum.  Such  consists  either  of  a  hinged  metal  plate,  resting  on 
the  nasal  side  of  the  segments  of  the  soft  palate,  and  moved  by  them,  or  of  a 


Fig.  397, — Davies  Colley's  Opera- 
tion FOR  Cleft  Palate. 

The  incisions  for  the  muco-periosteal 
flaps  are  here  indicated. 


Fig.  398.— Davies  Colley's  Opera- 
tion completed. 

The  left-hand  flap  has  been  turned 
over,  and  its  free  margin  stitched 
to  the  other  side  of  the  palate; 
whilst  the  right-hand  flap  has  been 
dissected  up  and  laid  across  the 
former  with  the  raw  surfaces  in 
contact. 


thin  indiarubber  bagr  filled  with  air,  sewn  to  the  back  of  the  obturator.  They  are 
complicated  and  difficult  to  keep  in  order,  and  as  a  general  rule  the  results  of 
operative  interference  are  superior. 

tJlceration  of  the  Palate  occurs  in  a  variety  of  forms,  e.g.,  (a)  simple, 
as  an  accompaniment  of  general  stomatitis  :  (b)  syphilitic,  which  may 
involve  either  the  hard  or  soft  palate ;  if  superficial,  it  is  usually  a 
late  secondary  phenomenon  ;  if  deep,  it  involves  the  bones,  and  often 
leads  to  necrosis,  and  is  then  due  to  tertiary  mischief:  (c)  lupoid,  a 
somewhat  uncommon  condition,  which  may  result  in  great  destruction 
of  tissue ;  it  is  usually  seen  in  children,  and  often  associated  with  a 
similar  disease  of  the  nose,  from  which,  indeed,  it  may  have  spread  : 
(d)  Uihercnlous,  due  to  the  breaking  down  of  a  tuberculous  abscess 


870  A  MANUAL  OF  SURGERY 

under  the  periosteum,  and  then  complicated  with  caries  of  the  bony 
palate :  (e)  malignant,  usually  resulting  from  the  growth  of  epithe- 
lioma, either  starting  primarily  in  the  palatal  mucous  membrane,  or 
extending  to  it  from  the  tongue,  tonsil,  or  upper  jaw. 

Acquired  Perforations  of  the  Palate,  though  occasionally  caused  by 
traumatism  or  lupus,  are  in  almost  all  cases  due  to  tertiary  syphilis. 
The  ethmo-vomerine  septum  is  often  involved  in  the  destructive 
process,  giving  rise  to  a  most  offensive  discharge  from  the  nose.  If 
the  soft  palate  is  alone  affected,  the  velum  may  become  fixed  by 
cicatricial  adhesions  to  the  back  of  the  pharynx,  and  pharyngeal 
stenosis,  or  considerable  loss  of  substance  of  the  velum,  results.  A 
nasal  intonation  of  the  voice  is  always  caused  by  any  condition  which 
interferes  with  the  closure  of  the  naso-pharynx  by  the  velum  during 
articulation.  The  treatment  of  these  conditions  should  follow  the 
usual  antisyphilitic  course.  Perforations  are  best  remedied  by  the 
use  of  plate  obturators.  We  have  seen  out-patients  make  efficient 
obturators  out  of  a  piece  of  sheet  indiarubber  maintained  in  situ  by 
suction,  or  of  two  pieces  stitched  together  in  the  middle,  one  piece 
passing  above  and  the  other  below  the  opening.  Occasionally  when 
the  aperture  is  small,  the  local  disease  soundly  cured,  and  the  general 
health  good,  an  attempt  may  be  made  to  close  it  by  stripping  up 
muco-periosteal  flaps,  paring  the  edges  and  suturing  them  together. 
The  results  are,  however,  seldom  satisfactory. 

Any  of  the  ordinary  forms  of  inflammation  of  bone  may  be  met 
with  in  the  hard  palate.  Necrosis  is  usually  due  to  tertiary  syphilis, 
or  may  accompany  acute  subperiosteal  suppuration,  extending  from 
an  alveolar  abscess.  In  either  case  the  surgeon  must  wait  till  the 
sequestrum  is  loose,  and  then  it  may  be  removed.  Caries  is  generally 
due  to  syphilis  or  tubercle. 

The  following  tumours  occur  on  the  hard  palate.  Simple  epulis 
(p.  80.9)  may  extend  from  the  alveolus,  or  an  identical  condition  may 
start  in  the  middle  line.  An  adenoma  of  the  palatal  glands  is  occa- 
sionally met  with.  It  presents  as  a  smooth  or  papillated  tumour, 
somewhat  resembling  epithelioma,  but  distinguished  from  it  by  its 
slower  rate  of  growth,  and  the  absence  of  ulceration,  pain,  or 
glandular  enlargement.  An  operation  limited  to  the  soft  parts  is 
probably  all  that  is  necessary.  Sarcoma  may  be  primary,  and  is  then 
often  my xo- sarcomatous  in  type,  or  secondary.  In  the  former  case 
it  simulates  rather  closely  a  diffuse  alveolar  abscess,  but  is  recognised 
by  its  slower  growth,  less  pain,  absence  of  inflammation,  and,  if  need 
be,  by  the  results  of  an  exploratory  puncture.  Epithelioma  also  occurs, 
but  is  uncommon.  Treatment  for  the  two  latter  conditions,  if  limited 
to  the  palate,  would  consist  in  partial  removal  of  the  affected  superior 
maxilla. 

Elongation  of  the  Uvula  is  frequently  the  result  of  a  chronic  re- 
laxed throat.  At  first  it  merely  lasts  for  a  time,  and  by  the  use  of 
astringents  disappears  ;  but  later  on  the  elongation  becomes  chronic, 
and  causes  great  irritation  of  the  back  of  the  tongue  and  fauces,  re- 
sulting in  a  troublesome  throat-cough  and  even  vomiting. '    Under 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    871 

such  circumstances  it  should  be  removed.  After  well  cocainizing  the 
part,  it  is  grasped  by  a  pair  of  hook-forceps,  which  seize  not  only 
the  mucous  membrane,  but  also  the  muscular  structures  beneath, 
and  a  sufficient  amount  is  then  removed  by  snipping  it  across  near 
the  base  with  a  pair  of  blunt-ended  scissors,  leaving  about  a  third  of 
an  inch  of  the  organ  behind. 

Affections  of  the  Tonsils. 

Acute  Tonsillitis  results  either  from  cold  or  from  the  inhalation  of 
impure  air,  or  of  sewer-gas.  It  is  often  seen  amongst  the  residents 
in  hospitals  (hospital  throat),  and  may  precede  an  attack  of  acute 
rheumatism.     Three  varieties  are  described  : 

(a)  Amte  superficial  tonsillitis,  which  consists  of  a  slight  superficial 
inflammation,  the  result  of  cold,  etc.,  in  which  the  tonsil  participates 
with  the  pharynx  and  velum.  There  is  but  little  swelling  of  the  part, 
which,  however,  becomes  red  and  painful,  rendering  swallowing 
difficult.  Ordinary  anti- catarrhal  remedies  are  necessary,  and  a 
chlorate  of  potash  gargle. 

{h)  Acute  follicular  tonsillitis  is  characterized  by  a  general  enlarge- 
ment of  the  organ,  which  is  dusky  red  in  colour  and  painful,  causing 
obstruction  to  both  breathing  and  swallowing,  the  tonsils,  perhaps, 
almost  meeting  in  the  middle  line.  There  is  a  good  deal  of  yellow 
patchy  exudation  from  the  follicles,  which  may  coagulate  on  the 
surface  and  form  a  false  membrane,  distinguished  from  that  of 
diphtheria  by  its  want  of  adhesion  to  the  subjacent  tissue,  being 
readily  detached  by  a  camel's-hair  pencil,  and  by  the  absence  of  the 
Klebs-Lofller  bacillus  on  cultivation.  The  temperature  is  high  ;  the 
glands  below  the  angle  of  the  jaw  become  enlarged  and  tender,  and 
may  suppurate  ;  the  tongue  is  covered  with  a  thick,  whitish  fur,  and 
the  bowels  are  confined.  Such  a  condition  may  herald  in  an  attack 
of  so-called  blood-poisoning,  or  septicaemia. 

{c)  Acute  suppurative  tonsillitis,  or  quinsy,  is  an  acute  inflammation  of 
the  tonsil,  with  suppuration  around  it  within  its  capsule  (peritonsillar 
abscess).  Both  sides  are  affected,  but  the  suppuration  is  often  uni- 
lateral, or  if  bilateral,  one  tonsil  is  affected  before  the  other.  The 
swelling  is  great,  so  that  breathing  and  swallowing  are  alike  difficult ; 
the  temperature  is  high,  pain  is  severe,  and  the  cervical  glands  are 
considerably  enlarged.  QEdema  of  the  glottis  may  result.  Other 
symptoms  are  much  the  same  as  in  the  above. 

The  Diagnosis  must  be  made  from  scarlet  fever  by  the  absence  of 
the  characteristic  rash  and  red  tongue  of  the  latter  condition,  and  by 
the  redness  being  more  dusky  and  less  diffuse  in  tonsillitis.  From 
erysipelas  of  the  fauces,  it  is  known  by  the  redness  being  more  con- 
centrated, the  oedema  less  marked  and  more  limited,  by  the  glands 
at  the  angle  of  the  jaw  being  less  enlarged,  and  by  the  absence  of  any 
external  manifestation  of  the  disease. 

Treatment  should  always  be  commenced  by  a  good  calomel  purge, 
which  may  be  followed  by  the  administration  either  of  salicylate  of 


872 


A  MANUAL  OF  StlRGERY 


soda  (20  grains,  thrice  daily),  or  of  chlorate  of  potash  and  sulphate 
of  magnesia,  to  which  a  few  drops  of  tincture  of  aconite  may  be 
added  if  the  constitutional  symptoms  are  severe.  The  patient  will 
experience  much  relief  by  inhaling  the  steam  from  hot  water  (150°  F.), 
in  which  a  little  creasote  or  carbolic  acid  is  dissolved,  or  the  tonsils 
may  be  scarified.  Suppuration  is  dealt  with  by  a  free  incision,  the 
knife  entering  at  a  spot  on  the  line  drawn  from  the  base  of  the  uvula 
to  the  last  molar  tooth,  and  nearer  the  inner  than  the  outer  end 
(Fig.  399,  X),  as  recommended  by  Dr.  St.  Clair  Thomson..  Hot 
flannels  or  fomentations  may  be  applied  to  the  neck  and  throat,  and 


Fig.  399. Diagram  to  indicate  the  Situation  to  Open  a  Peritonsillar 

Abscess viz.,  on  a  Line  drawn  from  the  Base  of  the  Uvula  to  the 

Last  Molar  Tooth,  but   nearer  the  Uvula.      (After    Dr.  St.  Clair 

Thomson.) 

plenty  of  fluid  nourishment  administered.  This  is  followed  as  soon 
as  possible  by  iron,  bark,  and  other  tonics. 

Chronic  Tonsillitis  appears  in  tv^ro  distinct  forms  : 

(a)  Chronic  infiammatory  tonsillitis  occurs  in  children  whose  tonsils, 
after  one  acute  attack,  remain  enlarged,  painful,  congested,  and  very 
liable  to  recurrence,  which  often  runs  on  to  suppuration  and  ulceration. 
After  a  time  the  tonsils  shrink  back  and  atrophy,  becoming  hard 
and  fibroid. 

{b)  Chronic  hypertrophic  tonsillitis  is  met  with  in  weakly  children 
predisposed  to  tubercle,  and  is  usually  associated  with  the  presence 
of  adenoids  in  the  naso-pharynx.  The  tonsils  are  enlarged,  pale  in 
colour,  and  firm  in  consistence  ;  the  orifices  of  the  crypts  are  often 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    873 

patent,  and  in  them  are  seen  plugs  of  mucous  secretion,  which  may 
become  infiltrated  with  lime  salts,  forming  concretions  (tonsilloliths), 
or  may  persist  as  cysts.  Sometimes  the  tonsils  project  inwards,  and 
may  meet  in  the  middle  line  beneath  the  uvula,  causing  obstruction 
both  to  swallowing  and  respiration  ;  sometimes  they  are  buried  and 
lie  under  cover  of  the  anterior  pillar  of  the  fauces,  but  their  enlarge- 
ment may  be  recognised  by  pressing  inwards  from  the  neck.  The 
patient  usually  breathes  with  the  mouth  open,  owing  to  the  con- 
current naso-pharyngeal  obstruction,  and  from  the  same  cause  speaks 
thickly,  as  if  he  had  some  loose  body  in  the  mouth,  and  necessarily 
snores  during  sleep.  Hearing  is  often  interfered  with  from  the 
mucous  lining  of  the  Eustachian  tube  becoming  thickened  and 
inflamed.  Recurrent  attacks  of  inflammation  occur  from  time  to 
time,  with  or  without  suppuration. 

The  Treatment  of  these  cases  consists  in  first  attending  to  con- 
stitutional weakness  by  removal  of  the  patient  to  fresh  or  seaside  air, 
and  by  the  administration  of  iron  and  cod-liver  oil ;  at  the  same  time 
the  throat  should  be  painted  twice  a  day  with  glycerine  of  tannic  acid, 
or  with  equal  parts  of  glycerine  and  tinct.  ferri  perchloridi.  Failing 
this,  tonsillotomy  should  be  performed  ;  in  children  the  organ  may 
be  cut  away  as  far  back  as  possible,  but  in  patients  over  the  age  of 
twenty  only  a  thin  slice  should  be  removed,  and  never  the  whole 
organ,  since  there  is  much  more  risk  of  grave  haemorrhage  ;  the 
galvano-cautery  should  usually  be  employed  in  adults.  It  has  also 
been  suggested  that  the  voice  is  weakened  by  tonsillotomy,  but  this 
is  somewhat  doubtful. 

Tonsillotomy  may  be  undertaken  in  the  following  ways  : 

(a)  By  the  guillotine.  The  fauces  having  been  carefully  and  re- 
peatedly brushed  or  sprayed  with  a  5  per  cent,  solution  of  cocaine,  the 
mouth  is  opened  and  one  of  the  many  forms  of  tonsil  guillotine  intro- 
duced ;  iMackenzie's  spade  guillotine  is  as  good  as  any.  The  ring  of 
the  instrument  is  passed  over  the  projecting  organ,  external  pressure 
behind  the  angle  of  the  jaw  assisting  in  this  manoeuvre.  By  the 
pressure  of  the  thumb  the  projecting  mass  is  cut  off  by  the  sharp 
blade.  In  dealing  with  the  right  side,  unless  the  surgeon  is  ambi- 
dextrous, he  had  better  stand  behind  the  patient's  head,  looking  over 
into  the  mouth. 

(li)  By  the  bistoury.  The  tonsil  is  seized  at  its  lowest  point  and 
drawn  well  inwards  by  means  of  hooked  forceps,  and  the  projecting 
mass  removed  by  a  straight  blunt-ended  bistoury,  the  base  of  the 
blade  being  guarded,  if  preferred,  by  a  piece  of  plaster  wrapped  round 
it.  The  incision  should  be  made  from  below  upwards,  and  the  edge 
of  the  knife  kept  rather  in  than  out,  so  as  to  avoid  all  risk  of 
wounding  the  internal  carotid,  which  is  in  close  contiguity  to  the  outer 
surface  of  the  gland.  The  surgeon  must  stand  behind  the  patient's 
head  in  dealing  with  the  right  side,  and  in  front  when  operating  upon 
the  left.  Care  must  be  taken  to  include  the  lowest  portion  of  the 
tonsil,  which  often  hangs  down  into  the  pharynx,  and  is  liable  to  be 
left  behind. 


874  A  MANUAL  OF  SURGERY 

(c)  Tn  children  the  hypertrophic  type  of  enlarged  tonsil  may  be 
enucleated  without  much  difficulty  by  dividing  the  mucous  membrane 
in  front  of  it,  and  shelling  it  out  of  its  bed,  the  posterior  reflection  of 
mucous  membrane  being  subsequently  snipped  through  with  bistoury 
or  scissors. 

The  haemorrhage,  though  brisk  for  the  moment,  soon  ceases  if  care 
is  taken  not  to  cut  too  deeply,  or  encroach  upon  the  surrounding 
mucous  membrane.  Should  the  bleeding  continue,  it  can  generally 
be  arrested  by  douching  the  face  with  iced  water,  or  by  the  local 
pressure  of  wool  pledgets  soaked  in  iced  boric  acid  lotion,  or  in 
adrenalin.  Occasionally  a  bleeding  vessel  can  be  seen  and  secured 
by  ligature ;  but  in  bad  cases  of  persistent  or  recurrent  bleeding  it 
may  be  necessary  to  stitch  the  anterior  and  posterior  pillars  of  the 
fauces  together  over  a  gauze  plug  which  is  retained  for  twenty-four 
hours.  Serious  bleeding  is  more  likely  to  occur  in  adults  than  in 
children. 

SypMlitic  Disease  of  the  Tonsil  is  met  with  in  various  stages.  The 
primary  chancre  is  seen  occasionally,  arising  in  one  case  we  know  of 
through  infection  from  a  stick  of  caustic  which  had  been  previously 
used  to  cauterize  a  syphilitic  ulcer  and  insufficiently  cleaned  before 
being  applied  to  the  tonsil,  the  surface  of  which  was  abraded.  The 
glandular  enlargement  in  the  neck  is  very  marked  in  such  cases,  and 
the  course  of  the  disease  as  a  rule  severe.  Secondary  ulcers  of  the 
'  snail-track '  type  (^plaques  muqueuses)  are  common  in  this  region, 
being  usually  symmetrical.  In  the  tertiary  period  a  diffuse  gummatous 
infiltration  occurs,  involving  also  the  palate  and  fauces  (p.  876),  and 
leading  to  pharyngeal  stenosis. 

Tumours  of  the  Tonsil  are  almost  always  malignant  in  type,  but  are 
not  very  common.  Epithelioma  occurs  as  a  firm  indurated  infiltration, 
rapidly  spreading  to  adjacent  parts^  and  involving  the  lymphatic 
glands.  It  generally  starts  either  in  the  root  of  the  tongue  or  in  the 
pillars  of  the  fauces,  and  presents  a  ragged  ulcerated  surface  with 
a  hard  margin  and  sloughing  base.  It  runs  a  rapidly  fatal  course, 
if  left  to  itself.  Lymphosarcoma  of  the  tonsil  arises  in  the  organ 
itself;  it  presents  a  smooth,  dusky  red  appearance,  the  mucous 
membrane  being  stretched  over  it,  and  feels  soft  and  almost  fluctuating. 
In  the  early  stages  it  may  be  freely  moveable,  but  ere  long  it  infil- 
trates surrounding  structures,  and  affects  the  neighbouring  lymphatic 
glands.  Round-celled  sarcoma  also  attacks  the  tonsil  as  a  primary 
growth,  and  is  less  limited  and  defined  than  the  former.  In  all  "these 
varieties  the  growth  extends  into  the  pharynx,  impeding  deglutition 
and  respiration,  and  ulceration  with  or  without  serious  haemorrhages 
may  ensue  ;  indeed,  the  latter  complication  is  a  frequent  cause  of  the 
fatal  result. 

Extirpation  of  Malignant  Tumours  of  the  tonsil  is  often  imprac- 
ticable from  the  extent  of  the  disease  and  the  early  implication  of 
the  surrounding  structures,  although  it  has  now  been  shown  that  they 
are  more  amenable  to  treatment  than  was  formerly  thought  to  be  the 
case.     The  disease  may  be  dealt  with  in  two  ways  :  (a)  From  the  mouth 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS    875 

in  the  case  of  the  loosely  encapsuled  and  freely  moveable  lympho- 
sarcomata.  The  capsule  is  divided  preferably  by  a  galvano-cautery, 
and  the  growth  shelled  out  sometimes  with  the  utmost  ease,  and  with 
very  little  haemorrhage.  Recurrence  in  the  lymphatic  glands  is, 
however,  almost  certain  to  follow,  {b)  From  the  neck.  The  best  plan 
is  to  make  an  incision  along  the  anterior  border  of  the  sterno-mastoid, 
and  carefully  dissect  down  to  the  pharyngeal  wall,  removing  all 
lymphatic  glands  which  are  enlarged  or  suspicious,  and  securing  the 
external  carotid  or  its  anterior  branches.  The  mass  is  then  isolated 
from  the  surrounding  structures  and  removed.  A  good  many  cases 
have  now  been  reported  which  were  treated  in  this  manner  with 
complete  success,  even  when  the  tongue,  palate,  or  pharynx  were 
invaded.  It  is  sometimes  necessary  to  make  an  incision  from  the 
angle  of  the  mouth  backwards  through  the  cheek;  the  tonsil  is  thus 
well  exposed,  and  can  be  dealt  with  satisfactorily. 

Affections  of  the  Pharynx. 

Acute  Pharyngitis  is  usually  associated  with  a  similar  inflamma- 
tory condition  of  the  velum  palati,  nasal  mucous  membrane,  and 
tonsils,  and  results  from  exposure  to  cold,  from  absorption  of  sewer- 
gas,  and  from  general  diseases  of  the  exanthematous  type — e.g.,  scarlet 
fever.  It  is  characterized  by  redness,  pain,  and  swelling  of  the 
mucous  membrane,  which  becomes  covered  with  mucus  or  muco-pus. 
An  irritable  cough,  with  perhaps  sneezing,  interference  with  nasal 
respiration,  and  great  pain  on  swallowing,  are  produced  by  this 
condition,  and  if  it  spreads  to  the  Eustachian  tube  temporary  deaf- 
ness is  induced.  Ulceration  of  the  velum  and  fauces  occasionally 
follows. 

The  Treatment  consists  in  attending  to  the  general  condition, 
especially  if  of  exanthematous  origin,  and  when  due  to  catarrh,  in 
administering  antiphlogistic  remedies  {^.g.,  purgatives,  sudorifics,  and 
diuretics)  and  soothing  local  applications  (e.g.,  ice  to  suck,  chlorate 
of  potash  gargle,  etc.).  Great  relief  is  often  given  by  inhaling  steam 
from  water  at  150°  F.  to  which  a  little  Friar's  balsam  has  been  added. 

Erysipelas  of  the  Fauces  and  Palate  has  been  already  alluded  to 
(p.  122). 

Chronic  Pharyngitis  is  commonly  met  with  in  clergymen  and  public 
speakers  who  are  called  upon  to  exert  their  voices  for  any  length  of 
time,  in  costers  and  street-hawkers  who  shout  their  wares,  and  in 
drinkers  and  smokers.  It  may  commence  as  a  chronic  inflammation, 
or  may  follow  an  acute  attack.  The  mucous  membrane  is  more  or 
less  red  and  infiltrated,  with  vessels  coursing  over  it,  and  there  is 
often  a  good  deal  of  muco-purulent  discharge.  If  the  buccal  side  of 
the  velum  palati  is  affected,  there  is  usually  much  less  secretion  than 
from  the  pharyngeal  aspect,  where  a  considerable  amount  of  dark- 
green  viscid  material  may  collect  and  cling  to  the  pharyngeal  wall, 
constituting  scabs,  which  may  decompose  and  cause  the  breath  to  be 
somewhat  offensive.     Two  main  varieties  are  described  : 

1.  Chronic  follicular  pharyngitis,   in    which    the  lymphoid    follicles 


876  A  MANUAL  OF  SURGERY 

scattered  throughout  the  mucous  membrane  become  enlarged.  This 
is  specially  evident  upon  the  soft  palate,  but  is  often  greater  in 
amount  upon  the  upper  wall  and  sides  of  the  pharynx,  where  there 
is  a  mass  of  lymphoid  tissue,  sometimes  known  as  the  pharyngeal  or 
Lftschka's  tonsil  (vide  Adenoids,  p.  840).  The  uvula  may  be  also 
elongated  and  hypertrophic  in  this  condition. 

2.  Chronic  atrophic  pharyngitis  is  generally  associated  with  the 
atrophic  form  of  rhinitis  sicca  (p.  831),  and  possibly  with  chronic 
laryngitis.  The  mucous  membrane  is  smooth,  dry,  and  glazed,  and  the 
exudation  forms  adherent  scabs.  The  throat  feels  dry  and  irritable, 
and  the  voice  is  often  husky. 

The  Treatment  of  chronic  pharyngitis  varies  with  the  condition 
and  character  of  the  affection.  In  many  cases  the  nasal  trouble  is 
the  more  urgent,  and  if  it  is  treated  effectively  the  pharynx  improves 
rapidly.  In  simple  relaxed  throats  all  sources  of  irritation- — such  as 
smoking,  spirits,  and  condiments — must  be  avoided,  the  bowels  and 
digestion  attended  to,  and  astringent  sprays, -gargles,  or  applications 
made  use  of.  The  most  useful  reagents  are  the  glycerine  of  tannic 
acid,  and  equal  parts  of  glycerine  and  tinct.  ferri  perchloridi,  whilst 
chloride  of  ammonium  inhalations  are  sometimes  valuable,  as  also 
sprays  of  menthol  dissolved  in  paroleine.  When  the  inflammation  is 
of  the  follicular  type,  it  may  be  further  necessary  to  destroy  the 
follicles  with  the  galvano-cautery  after  cocainizing  the  surface ; 
enlarged  and  varicose  vessels  may  be  divided  in  the  same  way.  In 
the  dry  form  of  pharyngitis,  inhalations  of  chloride  of  ammonium  are 
recommended,  or  chloride  of  ammonium  lozenges ;  whilst  lozenges 
containing  liquorice  and  menthol  are  useful. 

Syphilitic  Affections  of  the  Pharynx  may  be  met  with  in  the 
secondary  or  tertiary  stages.  In  the  former  they  are  of  a  superficial 
character,  such  as  mucous  tubercles,  snail-track  ulcers,  etc. ;  in  the 
latter  they  appear  in  the  shape  of  a  diffuse  gummatous  infiltration,  which 
is  often  of  considerable  consequence,  both  at  the  time  and  subse- 
quently. It  manifests  itself  as  a  widespread  nodular  thickening  of 
the  mucous  membrane,  especially  in  the  neighbourhood  of  the  fauces 
and  soft  palate,  which  rapidly  runs  on  to  ulceration,  and  may  impede 
both  respiration  and  deglutition.  The  administration  of  salvarsan,  or 
of  mercury  and  iodide  of  potassium  usually  causes  a  rapid  improve- 
ment, but  the  subsequent  cicatrization  may  bind  down  the  velum,  and 
lead  to  pharyngeal  stenosis  of  such  a  character  as  to  constitute  a 
fibro-cicatricial  septum,  with  an  opening  through  it  perhaps  only 
large  enough  to  allow  a  small  bougie  to  pass.  For  such  a  condition 
much  may  be  done ;  the  opening  may  be  more  or  less  dilated  by 
careful  division  of  some  of  the  bands  and  the  passage  of  bougies  ;  ■ 
and  the  soft  palate  can  be  set  free  from  the  dorsum  of  the  tongue. 
Of  course,  there  is  a  great  tendency  for  the  opening  to  contract  again, 
and  treatment  by  bougies  must  be  persisted  in. 

A  localized  gumma  may  form  in  the  submucous  tissue,  not  unfre- 
quently  involving  the  posterior  pharyngeal  wall,  and  running  its 
ordinary  course  with  or  without  ulceration. 


AFFECTIONS  OF  THE  MOUTH.  THROAT,  AND  (ESOPHAGUS    S77 

Tmnoiirs  of  the  pharynx  are  rarely  primary.  They  may  extend  into 
it,  however,  from  surrounding  parts — e.g.,  naso-pharyngeal  polypi 
arising  from  the  base  of  the  skull,  or  retro-pharyngeal  growths  from 
the  spine. 

Epithelioma  either  involves  the  pharynx  primarily,  or  spreads  to 
it  from  adjacent  parts,  such  as  the  tongue  or  tonsil.  The  usual  type 
of  tumour  develops  with  some  amount  of  ulceration  ;  lymphatic 
glands  become  secondarily  affected,  and  the  tumour  gradually  invades 
surrounding  tissues,  although  it  is  interesting  to  note  that  for  some 
time  it  is  limited  to  the  mucous  membrane,  extending  superficially 
over  it,  but  not  involving  the  underlying  pharyngeal  muscles.  Death 
results  from  haemorrhage  due  to  ulceration  into  large  vessels,  from 
interference  with  swallowing  or  breathing,  from  pressure  on  important 
nerves,  or  from  general  dissemination. 

Treatment. — It  is  only  within  the  last  decade  that  any  attempt  has 
been  made  to  deal  with  these  cases  ;  even  now  the  mortality  is  very 
high,  and  statistics  prove  that  if  the  operation  involves  removal  of 
portions  of  the  upper  or  lower  jaw,  a  fatal  issue  is  likely  to  follow. 
The  same  precautions  as  to  cleansing  the  teeth,  etc.,  must  be  taken 
as  in  dealing  with  nasopharyngeal  or  buccal  growths.  As  a  general 
rule,  an  incision  along  the  anterior  border  of  the  sterno-mastoid  is 
the  best  to  employ,  although  occasionally  a  second  may  be  required, 
splitting  the  cheek  towards  the  angle  of  the  jaw.  The  external 
carotid  is  tied,  all  glands  are  removed,  and  then  the  growth  is 
extirpated,  partly  from  without,  partly  from  within.  It  is  always 
advisable  to  perform  a  preliminary  tracheotomy,  and  feeding  must 
be  undertaken  for  some  days  by  means  of  a  stomach-tube.  Trans- 
hyoid  pharyngotomy  is  a  useful  means  of  approach  in  some  of  these 
cases  (p.  920). 

Retro-pliaryngeal  Abscess  is  acute  or  chronic  in  its  course.  The 
aciik  ioxm  results  from  infection  through  the  mucous  membrane,  as 
by  fishbones,  etc. ;  or  arises  from  an  inflammation  of  the  lymphatic 
glands  which  are  found  in  this  situation  in  children,  but  atrophy  in 
adults,  and  derive  their  lymph  from  the  interior  of  the  nose  and  naso- 
pharynx. The  chrome  variety  generally  follows  tuberculous  caries  of 
the  spine,  or  disease  of  the  bones  at  the  base  of  the  skull.  Whether 
acute  or  chronic,  the  abscess  forms  a  tense  elastic  swelling,  situated 
behind  the  posterior  pharyngeal  wall ;  in  the  former  case  it  is  asso- 
ciated with  high  fever,  and  locally  much  redness  and  inflammatory 
oedema,  which  may  even  extend  to  the  glottis,  and  cause  dyspnoea ; 
in  the  latter,  where  the  affection  is  chronic,  there  is  less  local  inflam- 
matory reaction,  but  signs  of  cervical  spinal  disease  are  present. 
The  abscess  may  burst  into  the  pharynx,  or  may  burrow  outwards  on 
either  side,  being  guided  by  the  pre-vertebral  fascia,  and  point  either 
in  front  of  or  behind  the  sterno-mastoid. 

Treatment  should  never  be  delayed,  from  fear  of  the  supervention 
of  oedema  of  the  glottis.  The  abscess  should  be  opened  from  the  neck 
in  all  cases,  as  then  an  aseptic  course  can  be  maintained,  and  there  is 
no  fear  that  the  pus  will  enter  the  air-passages.     If  pointing  in  front 


878 


A  MANUAL  OF  SURGERY 


of  the  sterno-mastoid,  the  abscess  is  opened  in  that  situation ;  but 
otherwise  an  incision  should  be  made  along  the  posterior  border  of  the 
muscle,  which  must  be  drawn  forwards,  and  the  transverse  processes 
of  the  cervical  vertebrae, defined.  Possibly  the  abscess  will  be  opened 
by  the  necessary  manipulation  of  the  wound  ;  if  not,  the  index  finger 
of  the  left  hand  should  be  placed  against  the  abscess  wall  in  the  mouth 
to  guard  it  from  injury,  and  a  pair  of  sinus  forceps  thrust  into  it  in 
front  of  the  vertebrae  by  the  right  hand.  A  drain-tube  is  then  inserted, 
and  the  case  runs  an  ordinary  aseptic  course. 

Affections  of  the  (Esophagus. 

Malformations  of  the  oesophagus  are  congenital  or  acquired. 

A  Congenital  communication  may  exist  between  the  oesophagus 
and  trachea,  either  in  the  form  of  a  small  fistula,  or  the  upper  end  of 
the  oesophagus  ends  blindly,  whilst  the  lower  end  opens  into  the 
trachea  near  its  bifurcation.  Life  is  impossible  under  such  con- 
ditions, and  the  children  die  shortly  after  birth.  Congenital  stricture 
may  also  be  met  with  near  the  cardiac  orifice,  resulting  in  general 
distension  and  dilatation  of  the  oesophagus  {oesophagoccele).  The 
A.cquired  malformations  consist  in  the  development  of  the  so-called 
Diverticula.  Two  forms  have  been  described  by  Zenker  ;  (a)  Pressure 
Diverticula,  which  are  the  more  common,  and  seem  to  be  associated 
with  some  congenital  weakness  of  the  wall,  probably  connected  with 
the  branchial  clefts.  They  vary  much  in  size,  perhaps  becoming  as 
large  as  a  child's  head,  and  rarely  come  under  observation  before  the 
age  of  thirty.  They  usually  spring  from  the  posterior  wall,  close  to 
the  junction  of  the  pharynx  and  oesophagus,  constituting  what  is 
sometimes  known  as  a  '  pharyngocoele  ';  the  cavity  extends  downwards 
between  the  oesophagus  and  vertebral  column.  The  symptoms  are  due 
to  distension  of  the  cavity  with  food  which  stagnates  and  putrefies, 
forming  a  swelling  in  the  neck  which  can  be  emptied  by  pressure  ; 
the  difficulty  of  obtaining  sufficient  food  gradually  leads  to  emaciation. 
When  a  bougie  is  used,  it  generally  passes  into  the  diverticulum,  and 
hence  its  onward  course  is  arrested ;  by  careful  manipulation  it  may 
be  kept  on  the  sound  wall,  and  so  slipped  past  the  orifice  into  the 
stomach.  Treatment,  where  possible,  consists  in  exposing  the  diver- 
ticulum in  the  neck,  through  a  lateral  incision  in  front  of  the  sterno- 
mastoid,  removing  it,  and  stitching  up  the  opening  in  the  pharyngeal 
or  oesophageal  wall,  {b)  Traction  Diverticula  are  much  rarer  ;  they 
usually  occur  on  the  anterior  wall,  near  the  bifurcation  of  the  trachea, 
and  are  due  to  cicatricial  traction  from  without,  as  by  an  inflamed 
bronchial  gland.  They  are  always  of  small  size,  often  multiple,  and 
cause  no  symptoms,  unless  a  foreign  body  lodges  in  them,  when  ulcera- 
tion and  perforation  may  lead  to  suppurative  mediastinitis  and  death. 
They  cannot  be  recognised  ante  mortem. 

Foreign  Bodies  not  unfrequently  lodge  in  the  oesophagus,  especially 
in  children  and  lunatics.  Portions  of  food,  coins,  fishbones,  pins, 
plates  of  false  teeth,  etc.,  are  the  substances  usually  met  with.     The 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     879 

patient  complains  that  something  has  lodged  in  the  gullet,  causing  a 
feeling  of  pain  and  distension,  whilst  swallowing  is  painful  or  impos- 
sible, and  respiration  may  be  more  or  less  hampered.  Large  bodies 
are  often  impacted  at  the  entrance  to  the  gullet,  and  then  cause 
sudden  death  from  dyspnoea;  if  the  obstruction  is  not  so  great  and 
remains  unrelieved,  oedema  of  the  glottis  may  supervene.  Impaction 
lower  down  is  likely  to  be  followed  by  ulceration,  perforation, 
and     death,      either     from 

haemorrhage   owing   to  one  y''  \ 

of  the   large   vessels   being  ^m 
opened,  or  from  suppurative  ||^ 
cellulitis.  In  some  instances, 
however  (Konig  states  about 
50    per   cent.),    the    foreign  ^ 

body    spontaneously    passes  ^ig.  400.  —  Expanding   Probang  for   the 
. .,  -^       •    ,        ,1  ii  Removal  of  Foreign  Bodies  from  the 

either   mto    the    mouth    or      oesophagus. 

stomach.      In  the  case  or  a    it  is  introduced  closed  as  at  A,  and  opened  as 
metallic  body,  diagnosis  both  at  B  on  withdrawal. 

as  to  its  presence  and  situa- 
tion can  be  made  by  radiography,  and  attempts  at  removal  under- 
taken with  the  assistance  of  the  radiographic  screen.  By  means  of 
an  oesophagoscope  (Killian's)  it  is  possible  to  see  the  foreign  body 
and  sometimes  to  remove  it.  This  apparatus  is  a  straight  tube, 
which  is  passed  with  the  head  thrown  well  back  and  the  pharynx 
cocainized.  A  suitable  source  of  illumination  enables  the  surgeon 
to  see  the  interior  of  the  gullet  (p.  913). 

The  Treatment  varies  much  according  to  the  nature,  size,  and 
situation  of  the  obstructing  body.  If  small  and  incapable  of  being 
detected  by  a  sound — e.g.,  a  fishbone — it  is  best  removed  by  an 
expanding  probang  (Fig.  400),  being  caught  in  the  loops  of  thick 
horsehair  forming  part  of  the  apparatus.  If  a  coin  or  small  hard 
substance  is  impacted,  it  may  be  removed  by  oesophageal  forceps,  or 
by  a  coin-catcher.  If  it  is  impossible  to  draw  it  up,  it  may  sometimes 
be  pushed  down  into  the  stomach.  A  large  bolus  of  food  may  be 
removed  by  forceps  from  the  upper  part  of  the  oesophagus,  and  large 
foreign  bodies — e.g.,  plates  of  teeth — may  be  similarly  extracted, 
though  great  care  must  be  taken  not  to  tear  the  mucous  membrane. 

If  impacted  in  the  upper  part,  cesophagotomy  may  be  performed. 
An  incision,  4  inches  long,  is  made  along  the  anterior  border  of  the 
sterno-mastoid,  preferably  on  the  left  side,  because  the  oesophagus 
naturally  curves  that  way.  The  platysma  and  deep  fascia  are 
divided,  and  the  muscle  drawn  outwards;  the  omo-hyoid  needs 
division,  and  the  surgeon  then  carefully  works  his  way  between  the 
carotid  sheath  on  the  outer  side  and  the  larynx  and  trachea  on  the 
inner,  avoiding  the  thyroid  vessels  and  nerves.  The  projection  of 
the  foreign  body  will  indicate  the  situation  of  the  tube,  and  this  is 
carefully  incised  and  the  obstruction  dealt  with.  The  oesophageal 
wound  may  then  be  closed  by  sutures  which  do  not  include  the 
mucous  membrane,  whilst  the  external  wound  is  either  packed  with 


8So  A  MANUAL  OF  SURGERY 

gauze  plugs  or  drained.  When  located  in  the  upper  part  of  the 
thoracic  portion  of  the  oesophagus,  the  tube  is  opened  as  low  as 
possible  by  cutting  down  on  the  point  of  a  bougie  passed  from  the 
mouth,  and  then  it  is  often  possible  to  extricate  it. 

When  impacted  in  the  thorax  and  removal  by  one  of  the  suggested 
methods  is  impossible,  it  has  been  proposed  to  open  the  oesophagus 
from  behind  in  the  posterior  mediastinum,  after  excising  the  necks  of 
one  or  more  ribs ;  but  a  successful  case  has  not  yet  been  published. 

When  the  foreign  body  is  impacted  near  the  cardiac  orifice,  and 
cannot  be  moved  either  up  or  down,  the  stomach  may  be  opened, 
the  fingers  or  even  the  hand  inserted  into  it,  the  cardiac  orifice 
dilated,  and  the  obstruction  removed. 

When  once  the  foreign  body  has  passed  into  the  stomach,  purga- 
tives and  emetics  should  be  avoided,  and  if  not  of  large  size  and 
irregular  shape,  the  case  is  left  to  Nature,  the  treatment  being  merely 
expectant.  The  patient  is  kept  quiet,  and  fed  on  pultaceous  food — 
such  as  brown  bread,  porridge,  etc. — and  the  motions  are  carefully 
examined.  Should,  however,  the  foreign  body  be  large,  and  gastric 
symptoms  develop,  it  should  be  removed  by  gastrotom}'. 

Inflammation  of  the  oesophagus,  with  or  without  ulceration,  is 
caused  by  swallowing  corrosives  or  irritants,  and,  in  a  more  localized 
form,  by  the  impaction  of  foreign  bodies.  The  symptoms  are  pain 
and  difficulty  in  deglutition,  and  the  treatment  consists  in  the  restric- 
tion of  the  diet  to  liquids,  whilst  in  bad  cases  rectal  feeding  may  be 
necessary.  Chronic  catarrh  results  from  the  continual  drinking  of 
raw  spirits,  and  stenosis  from  cicatricial  contraction  may  gradually 
follow. 

Varix  of  the  veins  in  the  lower  portion  of  the  oesophagus  is  occa- 
sionally met  with  as  the  result  of  pressure  on  the  portal  vein,  or  from 
cirrhosis  of  the  liver.  This  is  due  to  the  fact  that  these  branches 
open  into  the  gastric  division  of  the  portal  system,  passing  through 
the  cesophageal  opening  in  the  diaphragm.  Hsematemesis  may 
result,  and  has  even  proved  fatal. 

Spasm  of  the  CEsophagus,  or  hysterical  stricture,  arises  in  neurotic 
young  women,  usually  under  twenty -five  years  of  age,  and,  although 
sometimes  independent  of  organic  lesion,  is  often  associated  -with 
some  slight  abrasion  or  ulceration  of  the  mucous  membrane,  perhaps 
originated  by  the  impaction  at  an  earlier  date  of  a  fishbone.  The 
symptoms  complained  of  are  difiiculty  in  swallowing,  and  a  sensation 
as  of  a  ball  arising  in  the  throat  (globus  hystericus),  due  to  a  spasmodic 
action  of  the  pharjmgeal  constrictor  muscles.  At  times,  when  the 
patient's  attention  is  diverted,  deglutition  occurs  quite  normally. 
The  best  course  of  treatment  is  anti-neurotic  in  character  (e.g.,  cold 
douches  to  the  spine,  massage,  the  administration  of  purgatives, 
valerian,  etc.),  whilst  the  passage  of  a  full-sized  oesophageal  bougie 
is  useful. 

Organic  Stricture  of  the  CEsophagns  occurs  in  two  forms — the 
fibrous  and  the  malignant : 

I.  Fibrous  Stricture  of  the   (Esophagus   is   usually  located  near   its 


AFFECTIONS  OF  THE  MOUTH,  THROAT,  AND  (ESOPHAGUS     88 1 


commencement,  just  behind  the  cricoid  cartilage,  and  is  most  fre- 
quently caused  by  the  swallowing  of  corrosives,  and  the  cicatrization 
of  the  wounds  caused  thereby ;  it  also  results  from  syphilitic  disease. 
At  the  cardiac  orifice  it  may  arise 
from  the  healing  and  contraction  of 
a  gastric  ulcer.  The  main  symptom 
produced  is  a  gradually  increasing 
difficulty  in  the  swallowing,  firstly 
of  solids,  but  finally  even  of  fluids. 
If  the  obstruction  is  placed  at  the 
upper  end  of  the  tube,  food  is  re- 
turned immediately ;  but  if  lower 
down,  the  oesophagus  may  become 
dilated,  and  in  this  pouch  or  oeso- 
phagocoele  the  food  collects  for  a 
time,  and  then  returns  unchanged. 
There  is  but  little  pain  in  this  form 
of  stricture,  although  the  patient  is 
usually  able  to  indicate  the  level  of 
the  obstruction.  As  the  case  pro- 
gresses, he  becomes  steadily  ema- 
ciated from  sheer  starvation,  and 
may  even  die  from  this  cause. 

2.  Malignant  Stricture  of  the  (Eso- 
phagus is  usually  epitheliomatous 
in  type,  occurring  in  subjects  over 
forty  years  of  age,  and  situated 
either  at  the  junction  of  the  pharynx 
and  oesophagus,  i.e.,  behind  the 
cricoid  cartilage  (Fig.  401),  or  in 
the  middle  of  the  tube,  where  it  is 
crossed  by  the  left  bronchus,  or  at 
the  cardiac  orifice  of  the  stomach: 
in  the  latter  site,  columnar  carcinoma  is  the  form  usually  found. 
The  growth  involves  the  whole  circumference  of  the  tube,  and  sooner 
or  later  ulcerates,  perhaps  perforating  the  trachea,  pleural  cavity,  or 
one  of  the  large  vessels.  Secondary  deposits  occur  in  the  lymphatic 
glands,  either  of  the  neck  or  posterior  mediastinum,  visceral  compli- 
cations being  uncommon.  The  symptoms  are  similar  in  character  to 
those  of  fibrous  stenosis  detailed  above,  but  in  addition  the  vomited 
materials  may  contain  blood,  and  there  is  a  good  deal  of  cough  and 
pain,  referred  usually  to  the  site  of  the  disease.  Should' the  growth 
be  at  the  upper  end  of  the  tube,  a  tumour  may  be  distinctly  felt, 
placed  deeply  in  the  neck  and  more  marked  on  the  left  side  ;  in  the 
earlier  stages  nothing  can  be  felt  externally,  although  the  side-to-side 
movements  of  the  larynx  may  be  impeded.  Perforation  of  the  trachea 
leads  to  the  entrance  of  food  into  the  air-passages,  and  rapidly  results 
in  septic  pneumonia  and  death.  When  the  upper  part  of  the  gullet 
is  affected,  the  growth  may  spread  to  the  back  of  the  larynx,  and 

56 


Fig.  401. — Cancerous  Growth  of 

THE  CESOPHAGUS.    (TrEVES'  '  SUR- 
GERY.') 


882  A  MANUAL  OF  SURGERY 

cause  hoarseness  and  even  aphonia.  Occasionally  the  pneumogastric 
nerves  may  be  involved  in  the  mass,  leading  to  interference  with  the 
action  of  the  heart,  whilst  implication  of  the  recurrent  laryngeal  nerve, 
causes  constant  cough  and  uni-  or  bi-lateral  paralysis  of  the  larynx. 

The  Diagnosis  of  oesophageal  stricture  is  made  by  examining  the 
condition  of  the  tube  with  an  oesophageal  bougie.  A  conical-ended 
instrument  of  medium  size  should  be  employed  for  diagnostic  pur- 
poses, and  by  this  means  the  situation  of  the  obstruction  can  be 
ascertained.  To  pass  an  oesophageal  bougie  :  The  surgeon  stands  in 
front  and  slightly  to  the  right  of  the  patient,  who  is  seated  with  the 
head  held  forwards — if  thrown  backwards,  the  larynx  is  pressed 
against  the  spine,  and  the  difficulty  of  introducing  the  instrument 
increased.  The  bougie  is  well  warmed  and  smeared  with  glycerine, 
and,  having  been  suitably  curved,  is  guided  by  the  surgeon's  left 
index -finger  over  the  epiglottis  into  the  oesophagus.  This  stage 
usually  causes  a  certain  amount  of  discomfort  and  retching  on  the 
part  of  the  patient.  Once  past  the  entrance  to  the  larynx,  the  bougie 
is  pushed  steadily  onwards  ;  if  there  is  no  stricture,  the  instrument 
will  enter  the  stomach  about  i6  inches  from  the  teeth.  If  any  ob- 
struction is  present,  the  large  instrument  is  withdrawn,  and  the 
passage  of  a  smaller  one  attempted.  The  greatest  care  must  be 
taken,  especially  in  suspected  malignant  disease,  as  it  is  by  no  means 
difficult  to  perforate  the  walls  and  open  up  the  mediastinal  tissues, 
causing  thereby  a  fatal  cellulitis.  A  cancerous  stricture  sometimes 
feels  rough  and  is  painful ;  a  simple  stricture  is  smooth,  regular,  and 
almost  painless.  It  is  by  no  means  easy  to  distinguish  the  two 
forms,  and  the  history  of  the  case  and  general  condition  of  the 
patient  will  need  to  be  investigated  thoroughly ;  a  hacking  cough 
with  no  special  pulmonary  symptoms  is  always  a  bad  and  suggestive 
sign.  The  use  of  the  oesophagoscope  in  skilful  hands  will  enable  the 
upper  surface  of  the  stricture  to  be  seen. 

Treatment  of  Fibrous  Stricture  of  the  CEsophagus.— (a)  Dilatation 
of  the  stricture  by  means  of  gradually  increasing  bougies ;  for  this 
purpose  it  is  better  to  use  conical-ended  instruments  rather  than  the 
usual  type,  which  are  of  the  same  calibre  throughout.  An  interval 
of  some  days  should  elapse  between  the  attempts  at  dilatation,  and 
during  this  period  the  patient  should  be  given  as  much  food  as  he 
can  take  in  the  shape  of  strong  broths,  minced  meat,  raw  eggs,  etc., 
or,  if  need  be,  rectal  alimentation  must  be  resorted  to.  (p)  If  it  is 
impossible  to  dilate,  or  if  the  stricture  recurs,  a  Symond's  Tube  may 
be  inserted.  It  consists  of  a  gum-elastic  funnel-shaped  tube,  passed 
through  thestricture  by  a  whalebone  introducer,  the  funnel  resting 
against  the  face  of  the  stricture.  A  thread  attached  to  the  upper  end 
is  brought  out  of  the  mouth  in  order  to  remove  and  clean  it,  a  pro- 
ceeding needed  about  once  a  fortnight,  (c)  When  the  contraction 
is  at  the  pharyngeal  extremity,  it  may  be  possible  to  open  the 
oesophagus  below,  and  either  divide  and  dilate  the  stenosed  portion, 
or  oesophagosiomy  may  be  performed  by  sewing  the  mucous  membrane 
to  the  skin,  thus  forming  an  entrance  to  the  alimentary  canal  in  the 


AFFECTIONS  OF  THE  MOUTH,  THROAT.  AND  (ESOPHAGUS     883 

neck.-  .  Under  these  circumstances,  it  is  better  practice  to  divide  the 
oesophagus  completely,  closing  the  upper  end  by  sutures,  and  fixing 
the  lower  end  to  the  margin  of  the  wound,  (d)  If  the  cardiac  orifice 
of  the  stomach  is  contracted,  the  stomach  may  be  opened  as  in  gas- 
trotomy,  and  the  fingers  used  to  dilate  the  stricture  (retrograde 
dilatation),  (e)  Where  these  proceedings  are  not  possible,  or  if  tried 
have  failed,  the  stomach  may  be  opened,  and  division  of  the  stricture 
by  Abbe's  string  saw  attempted.  The  patient  is  made  to  swallow  one 
end  of  a  piece  of  string,  or  a  small  shot  may  be  clamped  on  a  piece 
of  fine  silk,  and  allowed  to  find  its  way  into  the  stomach.  When  this 
viscus  is  opened,  the  free  end  is  secured,  and  by  its  means  a  coarse 
silk  thread  is  carried  through  the  obstruction  ;  by  up-and-down  saw- 
ing movements  the  stricture  can  be  thereby  divided,  enabling  the 
surgeon  to  introduce  bougies.  Excellent  results  have  been  reported 
from  such  practice.  (/)  Gastrostomy  is  the  final  resource  ;  occasion- 
ally, when  the  oesophagus  has  by  this  means  been  kept  at  rest  for 
some  time,  the  stricture  will  yield,  and  dilatation  by  bougies  becomes 
practicable.  In  such  a  case  the  opening  in  the  stomach  may  be 
allowed  to  close. 

Treatment  of  Malignant  Disease  of  the  CEsophagus. — Dilatation  by 
bougies  should  not  be  employed  as  a  routine  practice,  for  fear  of  in- 
creasing the  ulceration,  causing  severe  haemorrhage,  or  perforating 
the  walls  of  the  tube.  It  may,  however,  be  used  as  a  temporary 
measure  in  the  earlier  stages  to  enable  the  patient  to  take  an 
increased  amount  of  food,  and  thus  for  a  time  improve  his  general 
condition  and  render  him  more  fitted  to  undergo  further  treatrnent. 
Symond's  method  of  tuhage  may  be  utilized  in  malignant  disease,  the 
patients  often  bearing  the  inserted  tube  well,  even  when  the  cardiac 
orifice  is  involved,  the  lower  end  then  projecting  into  the  cavity  of 
the  stomach.  Unfortunately  these  tubes  occasionally  slip  through 
into  the  stomach,  or  the  guiding  string  is  swallowed  ;  moreover, 
under  the  best  circumstances  the  tube  needs  changing  every  fortnight, 
and  the  ulceration  may  be  increased  thereby.  Hence,  gastrostomy, 
performed  as  soon  as  possible  by  one  of  the  modern  methods,  is  a 
much  more  satisfactory  plan  of  treatment.  Temporary  improvement 
has  followed  the  use  of  radium  in  these  cases,  the  metal  being  enclosed 
in  small  cylinders  which  are  placed  within  the  grasp  of  the  stricture. 
Swallowing  is  usually  improved,  but  the  patients  are  not  cured. 

By  the  term  Dysphagia  is  meant  a  condition  in  which  swallowing  is  painful  or 
difficult.     The  Causes  are  very  numerous,  and  may  be  arranged  as  follows  : 

i.  Pharyngeal — e.g..  acute  or  chronic  inflammation,  whether  simple,  scarlatinal, 
diphtheritic,  etc. ;  ulceration  of  syphilitic  or  malignant  origin  ;  stenosis,  as  a 
result  of  ulceration;  paralysis  {e.g.,  labio-glosso-laryngeal  or  bulbar)  or  spasm  ; 
impaction  of  foreign  bodies  ;  naso-pharyngeal  polypi  projecting  behind  the 
velum  ;  retro-pharyngeal  abscess  or  tumour,  etc. 

ii.  Laryngeal — e.g.,  acute  or  chronic  laryngitis ;  tuberculous,  syphilitic,  or 
malignant  disease. 

iii.  (Esophageal — e.g.,  acute  or  chronic  inflammation,  impaction  of  foreign 
bodies,  the  presence  of  diverticula,  cesophagospasm,  and  simple  or  malignant 
stricture. 


884  ^  MANUAL  OF  SURGERY 

iv.  Extrinsic.  In  the  Jieck :  goitre,  enlarged  glands,  aneurisms,  etc.  ;  in  the 
thorax:  mediastinal  growths  or  glands,  aneurisms  of  the  aorta  and  large  vessels, 
tumours  growing  from  the  vertebral  bodies,  pericardial  effusion,  and  displace- 
ment backwards  of  the  sternal  end  of  the  clavicle. 

To  investigate  a  case  of  dysphagia,  note  :  (i.)  the  method  of  onset,  whether  acute 
or  chronic — if  the  former,  it  is  probably  due  to  a  foreign  body  ;  (ii)  the  condition 
of  the  pharynx  as  seen  from  the  mouth  and  on  digital  exploration;  (iii.)  the 
condition  of  the  neck  as  seen  and  felt  from  without,  whether  or  not  a  tumour 
is  to  be  felt  behind  the  cricoid,  or  whether  a  goitre  or  aneurism  exists ;  (iv.)  the 
character  of  the  voice,  as  indicative  or  not  of  laryngeal  mischief — if  the  voice 
is  husky,  a  laryngoscopic  examination  must  be  made;  (v.)  the  chest  must  be 
carefully  examined  for  aneurisms,  etc. ;  (vi.)  the  oesophagus  may  be  auscultated 
along  the  vertebral  groove  whilst  the  patient  drinks  water  to  ascertain  the 
situation  of  the  mischief;  (vii.)  it  must  be  examined  finally  by  bougies  or  the 
cesophagoscope.  If  the  obstruction  is  in  the  oesophagus,  the  patient's  age  and 
general  condition  will  give  prima  facie  evidence  as  to  whether  or  not  it  is  due  to 
malignant  disease ;  but  it  must  not  be  forgotten  that  the  stenosis  perse  causes  some 
of  the  loss  of  flesh  and  of  weight.  The  presence  of  blood  and  offensive  mucus 
on  the  bougie  or  in  the  material  vomited,  and  the  existence  of  enlarged  glands 
in  the  neck,  will  also  assist  in  establishing  a  diagnosis. 


CHAPTER  XXX. 
AFFECTIONS  OF  THE  EAR. 

The  Examination  of  the  Ear  is  carried  out  by  inspecting  the  membrana  tympani 
through  a  speculum  by  means  of  light  reflected  from  a  frontal  mirror  ;  by  testing 
the  power  of  hearing  ;  and  by  ascertaining  whether  or  not  the  Eustachian  tube  is 
permeable,  and  the  effect  on  the  hearing  of  inflation  through  this  channel. 

I.  Visual  Inspection  by  means  of  a  speculum  and  frontal  mirror.  In  introduc- 
ing the  speculum  the  auricle  is  held  between  the  third  and  fourth  fingers  of  the 
operator  (the  left  hand  being  used  for  the  right  ear,  and  vice  versa)  and  drawn 
backv/ards,  upwards,  and  outwards  so  as  to  straighten  the  cartilaginous  portion  of 
the  meatus.  The  speculum  held  by  the  operator's  thumb  and  first  finger  is  then 
gently  inserted  and  held  in  position.  The  reflected  light  illuminates  the  tympanic 
membrane,  unless  the  presence  of  wax,  epithelial  debris,  or  pus  obstructs  the 
view,  when  they  must  be  removed  by  cotton-wool  mops  or  by  syringing.  The 
following  points  are  to  be  noted  in  the  normal  membrana  tympani  (Fig.  403)  :  The 


Fig.  402. — Eustachian  Catheter. 

projection  of  the  short  process  and  handle  of  the  malleus  which  runs  from  the 
centre  upwards  and  forwards  ;  behind  this  the  processus  gracilis  of  the  incus  and 
the  tendon  of  the  stapedius  ;  and  at  the  upper  border  Shrapnell's  membrane 
(Fig.  405).  The  motility  of  the  membrane  should  be  considered,  as  also  its  colour, 
whilst  pathologically  the  presence  of  perforations,  polypi,  or  adhesions,  should  be 
noted. 

2.  The  Investigation  of  the  Hearing  is  usually  carried  out  by  testing  the 
greatest  distance  at  which  the  patient  can  hear  the  ordinary  conversational  voice 
or  the  tick  of  a  watch  ;  the  whispered  voice  is  also  an  important  test. 

The  cause  and  location  of  deafness  is  ascertained  by  Rinne's  Tuning-Fork  Test. 
To  perform  it  a  tuning-fork  of  about  five  hundred  and  twelve  vibrations  is  placed 
in  contact  with  the  mastoid  process,  and  retained  there  until  the  patient  can  hear 
it  no  longer.  If  now  it  is  placed  opposite  the  external  auditory  meatus,  the  sound 
should  again  be  heard  if  the  middle  ear  is  normal,  but  will  not  be  noted  if  disease 
is  present.  Weber's  Test  consists  in  placing  a  vibrating  tuning-fork  in  the  middle 
line  of  the  forehead.  In  cases  of  pure  middle-ear  disease,  the  sound  will  be 
noticed  more  in  the  affected  ear  than  on  the  healthy  side. 

3.  Inflation  of  the  Tjmipanic  Cavity  is  required  both  as  a  test  of  the  perme- 
ability of  the  Eustachian  tube  and  also  as  a  means  of  treatment  in  various  con- 
ditions.    The  methods  of  effecting  it  are  as  follows ; 


886 


A  MANUAL  OF  SURGERY 


Valsalva's  Method  consists  in  closing  the  lips,  holding  the  nose,  and  expiring 
forcibly  ;  the  air  is  thereby  driven  up  the  Eustachian  tubes  if  they  are  patent. 

In  Politzer's  Method  an  indiarubber  bag  with  a  teat-like  end  is  introduced  into 
one  nostril  so  as  to  occupy  it  completely.  The  other  nostril  is  closed  by  the 
surgeon's  finger.  The  patient  is  instructed  to  take  a  sip  of  water  and  to  hold  it 
in  the  mouth  with  closed  lips  until  told  to  swallow.  As  he  swallows,  the  bag  is 
forcibly  compressed,  and  air  is  thereby  driven  up  the  tubes.  An  auscultating 
tube  may  pass  from  the  patient's   meatus  to   the  surgeon's  ear,   and  various 


Fig.  403. 


Fig.  404. 


Fig.  405. 


Fig,  406. 


Figs.  403-406.- 


-Appearance  of  the  Membrane  in  Various  Circumstances 
ON  Examination  through  a  Speculum. 
(By  permission,  from  Mr.   Albert  A.  Gray's  '  Diseases  of  the  Ear."     London  : 
Bailliere,  Tindall  and  Cox.) 

Fig.  403. — Normal  membrane  (right  side). 

Fig.  404. — Perforation  below  and  in  front  of  head  of  malleus  (left  ear)  in 

acute  otitis  suppurativa. 
Fig.  405. — Perforation  through  Shrapnell's  membrane  in  chronic  otorrhcea. 
Fig.  406. — Polypi  protruding  through  perforation  in  membrane. 

sounds,  whistling,  bubbling,  etc.,  may  be  detected,  according  to  the  character  of 
the  lesion. 

The  Eustachian  Catheter  (Fig.  402)  can  be  passed  into  the  Eustachian  tube,  and 
the  degree  of  inflation  more  accurately  controlled.     The  instrument,  carefully 


AFFECTIONS  OF  THE  EAR 


887 


sterilized,  is  passed  with  the  beak  downwards  along  the  inferior  meatus  of  the 
nose  until  the  posterior  pharyngeal  wall  is  reached.  '  As  soon  as  its  tip  touches 
the  posterior  wall  of  the  naso-pharynx,  the  anterior  end  of  the  instrument  is 
slightly  raised,  and  is  withdrawn  for  about  half  to  three-quarters  of  an  inch 
until  the  beak  is  felt  to  be  in  contact  with  the  posterior  end  of  the  hard  palate. 
The  catheter  is  then  rotated  through  a  quarter  of  a  circle  until  the  beak  points 
directly  outwards.  It  is  then  pushed  a  little  onwards,  and  is  usually  felt  to  slip 
easily  into  the  opening  of  the  Eustachian  tube  '  (Lambert  Lack). 

The  External  Ear  is  the  site  of  various  affections  which  may  come 
under  the  observation  of  the  general  surgeon.  Thus,  the  pinna  may 
be  congenitally  absent,  and  even  the  external  meatus  closed,  a  mal- 
formation often  associated  with  macrostoma.  Nothing  can  be  done 
for  this  want  of  development,  and  the  surgeon  must  never  be  tempted 
to  try  and  dig  out  the  concealed  membrana  tympani.  More  fre- 
quently accessory  auricles  are  present,  consisting  merely  of  fibro- 
cartilage  covered  with  fat  and  skin.  Large 
and  prominent  ears  constitute  a  very  un- 
sightly deformity,  for  which  operative  inter- 
ference is  occasionally  required.  The  size 
may  be  diminished  by  removing  a  V-shaped 
portion  from  the  upper  part ;  the  prominence, 
by  excising  a  portion  of  skin  and  cartilage 
through  an  incision  on  the  posterior  aspect. 
The  wounds  thus  produced  are  accurately 
sutured  together,  and  considerable  improve- 
ment in  the  appearance  results.  Hsematoma 
of  the  ear  is  usually  due  to  injury,  but  is 
occasionally  idiopathic  in  origin,  especially 
amongst  the  insane.  The  auricle  becomes 
swollen  and  enlarged,  and  of  a  bluish-red 
colour  in  traumatic  cases  (Fig.  407) ;  unless 
inflamed  it  should  not  be  interfered  with, 
as  a  general  rule,  although,  if  the  appearance 
of  the  patient  is  important,  it  may  be  ad- 
visable to  remove  the  blood,  since  its  organization  and  subsequent 
contraction  may  lead  to  considerable  deformity.  Eczema,  boils,  and 
other  inflammatory  affections,  as  also  sebaceous  cysts,  are  met  with 
in  the  external  ear  and  pinna,  but  call  for  no  special  mention. 

Plugs  of  wax  (cerumen),  which  become  dark  and  indurated,  not 
unfrequently  block  the  meatus,  leading  to  more  or  less  complete 
deafness  ;  this  may  come  on  suddenly  after  bathing,  owing  to  the 
plug  rapidly  swelling  up.  If  they  encroach  on  the  membrana 
tympani,  subjective  symptoms  of  giddiness,  vomiting,  and  rushing 
noises  in  the  ear  may  also  be  caused.  On  examination  with  an  ear 
speculum  their  presence  is  readily  detected.  Treatment  consists  in 
washing  them  away,  after  previously  softening  with  oil  or  glycerine. 
A  large  syringe  with  a  fine  nozzle  should  be  used,  and  a  stream  of 
warm  water  injected  along  the  roof  of  the  meatus  ;  as  it  returns,  the 
softened  masses  of  wax  are  washed  away.  Foreign  bodies  in  the 
meatus,  such  as  buttons  or  beads,  are  similarly  removed,  if  possible, 


Fig. 


407.  —  HEMATOMA 
AURIS. 


888  A  MANUAL  OF  SURGERY 

by  syringing ;  if  this  fails,  a  fine  pair  of  forceps  is  employed  for  the 
purpose,  but  it  must  be  remembered  that  behind  the  foreign  body  lie 
delicate  structures,  which  can  readily  be  harmed  by  the  exhibition, 
of  impatience  or  force.  Where  all  other  plans  fail,  the  auricle  may 
be  turned  forwards  and  the  meatus  opened  from  behind^  Exostoses 
are  occasionally  met  with  springing  from  the  bony  walls  of  the 
meatus  ;  they  give  rise  to  deafness  by  obstructing  the  passage,  and 
may  be  removed  by  the  dental  drill. 

Affections  of  the  Middle  Ear. 

Traumatic  Rupture  of  the  Tympanic  Membrane  is  due  to  direct  or 
indirect  violence  ;  the  former  includes  the  introduction  of  foreign 
bodies,  or  the  ill-advised  efforts  of  friends  or  even  of  medical 
practitioners  to  remove  the  same ;  the  latter  causes  rupture  of  the 
membrane  by  the  sudden  compression  of  the  air  in  the  external 
meatus — e.g.,  by  boxing  the  ear,  loud  noises  as  from  explosions 
or  big-gun  practice,  or  from  diving.  The  lesion  also  occurs  not 
uncommonly  in  fractures  of  the  middle  fossa  of  the  skull.  The 
patient  complains  of  pain  and  deafness,  and  blood  escapes  from  the 
meatus,  but  not  to  any  great  extent.  On  inflating  the  drum-chamber, 
as  by  Valsalva's  or  Politzer's  methods,  air  can  be  heard  to  escape 
through  the  opening,  perhaps  with  a  whistling  sound.  As  a  general 
rule,  these  cases  do  well,  the  wound  cicatrizing,  and  the  hearing 
being  fully  restored ;  but  the  surgeon  must  at  first  give  a  guarded 
opinion,  as  there  may  be  some  deeper  lesion  which  does  not  at  first 
become  apparent.  The  greatest  care  must  be  taken  to  sterilize  the 
meatus,  although  it  is  not  wise  to  use  a  syringe  for  the  purpose ; 
the  meatus  is  filled  with  i  in  20  carbolic  lotion,  which  is  allowed 
to  soak  in  ;  by  this  means  infection  of  the  tympanic  cavity  with 
pyogenic  organisms  may  be  prevented.  A  strip  of  gauze  is  then 
gently  inserted  into  the  meatus,  and  an  external  dressing  applied. 

Otitis  Media. — Inflammation  of  the  middle  ear  is  an  exceedingly 
common  affection,  and  constitutes  the  great  bulk  of  all  ear  diseases. 
It  must  be  remembered  that  the  tympanic  cavity  is  lined  by  a 
mucous  membrane  which  is  in  direct  communication  through  the 
Eustachian  tube  with  that  of  the  naso-pharynx  ;  and  since  this 
membrane  is  adherent  to  the  periosteal  lining  of  the  cavity,  every 
case  of  otitis  media  is  likely  to  be  associated  with  an  internal 
periostitis  of  the  temporal  bone. 

The  cause  is  almost  invariably  an  extension  of  inflammation  along 
the  Eustachian  tube,  and  the  organisms  usually  present  are  the 
pneumococcus  or  ordinary  pyogenic  cocci.  The  inflammation  may  be 
catarrhal  or  suppurative,  acute  or  chronic.  We  can  here  only  refer 
very  briefly  to  that  most  commonly  associated  with  surgical  lesions. 

Acute  Inflammation  of  the  Middle  Ear  is  very  common  in  children, 
being  secondary  to  lesions  of  the  naso-pharynx,  such  as  an  ordinary 
cold,  adenoids,  scarlatina,  measles,  etc.  It  is  ushered  in  by  severe  pain 
in  the  ear  (earache)  of  a  boring,  persistent  character,  together  with 
deafness  and  perhaps  some  degree  of  fever.     The  pain  increases  as 


AFFECTIONS  OF  THE  EAR  889 

the  secretion  accumulates,  and  if  the  Eustachian  tube  becomes  closed 
in  consequence  of  the  inflammatory  hyperaemia  of  its  lining  wall,  the 
tympanic  membrane  bulges  outwards  into  the  meatus  and  finally 
ruptures  (Fig.  404),  the  pain  being  at  once  relieved.  The  discharge  is 
mucous,  or  purulent  from  the  first ;  in  the  former  instance,  if  infection 
from  the  meatus  is  guarded  against,  the  inflammation  may  subside, 
the  perforation  heal,  and  no  ill  result  follow.  In  many  instances, 
however,  especially  when  the  child  is  suffering  from  measles,  or  if  his 
resisting  powers  to  microbic  invasion  are  low,  pyogenic  infection 
follows,  and  the  catarrhal  otitis  media  is  transformed  into  a  suppura- 
tive lesion,  which  may  persist  as  a  chronic  otorrhcea  for  a  lengthy 
period,  and  may  lead  to  the  most  serious,  and  even  fatal,  results  from 
intracranial  complications. 

It  is  therefore  obvious  that  the  greatest  care  should  be  taken  in  the 
Treatment  of  all  cases  of  acute  otitis  media.  In  the  first  place,  the 
possibility  of  infection  from  the  external  meatus  must  be  guarded 
against  by  thoroughly  purifying  it ;  the  external  ear  is  well  washed 
with  soap  and  water,  and  the  meatus  is  filled  with  i  in  20  carbolic 
'otion,  which  is  allowed  to  soak  in  and  act  for  some  minutes.  An 
antiseptic  dressing  is  then  placed  within  and  over  it.  The  child  is 
kept  in  a  warm  room,  and  his  general  condition  attended  to  by  suitable 
diet,  diaphoretic  medicine,  and  a  smart  purge.  In  mild  cases  a  blister 
behind  the  ear  will  often  act  beneficially,  whilst  in  more  acute  ones 
leeches  may  be  applied.  Solution  of  cocaine  or  drops  of  laudanum 
instilled  into  the  meatus  may  relieve  pain,  and  in  adults  it  may  be 
possible  to  cocainize  the  orifice  of  the  Eustachian  tube  in  the  pharynx, 
thereby  relieving  the  hyperaemia  and  opening  up  the  tube,  and  thus 
giving  an  exit  to  the  retained  discharge.  Pain  is  often  relieved  by 
fomenting  the  ear  or  by  the  application  of  dry  heat,  as  in  the  form  of 
a  hot-water  bottle  or  a  baked  bran-bag. 

When  the  membrane  is  seen  (by  speculum)  to  be  bulging,  it  is  wise 
to  incise  it,  as  a  clean  cut  often  heals  better  than  the  ragged  perfora- 
tion made  by  Nature.  Local  or  general  anaesthesia  is  required,  and 
the  incision  is  usually  made  from  just  behind  and  slightly  above  the 
handle  of  the  malleus  downwards  and  backwards.  An  antiseptic 
dressing  is  left  in  and  over  the  meatus  until  healing  has  occurred. 

Chronic  Otorrlioea,  as  already  explained,  is  a  common  sequence  of 
an  acute  attack,  which  may  have  been  purulent  from  the  first,  or  may 
have  been  the  result  of. a  pyogenic  infection  from  without  of  a  simple 
catarrhal  otitis  media.  The  membrane  is  perforated,  and  the  discharge 
varies  in  amount  and  character.  In  uncomplicated  cases,  treatment 
consists  in  :  (i)  Improvement  of  the  general  health,  as  by  the  adminis- 
tration of  tonics,  residence  in  fresh  country  air,  and  avoidance  of 
chills.  (2)  The  naso-pharyngeal  condition  must  be  attended  to,  so  as 
to  ensure  a  patulous  condition  of  the  Eustachian  tube,  by  which  dis- 
charges may  escape.  Gargles  may  be  ordered,  and  adenoids  and 
enlarged  tonsils  may  require  removal.  (3)  The  middle  ear  must  be 
kept  free  from  any  accumulation  of  discharge  which  might  undergo 
decomposition.    When  the  discharge  is  abundant,  external  syringing 


890  A  MANUAL  OF  SURGERY 

with  sterilized  salt  solution  or  weak  boric  acid  solution  is  needed,  and 
the  tympanic  cavity  is  inflated  from  the  Eustachian  tube  by 
Valsalva's  method,  Politzer's  bag,  or  even  the  Eustachian  catheter, 
once  or  twice  a  day.  If  the  discharge  is  offensive,  or  difficult  to  dis- 
lodge, peroxide  of  hydrogen  (10  volume  strength)  will  be  found  useful. 
1  f  the  discharge  is  slight,  the  meatus  may  be  packed  with  boric  acid 
powder,  and  syringing  avoided.  Not  unfrequently,  however,  a  per- 
sistent discharge  from  the  ear  is  due  to  some  of  the  complications 
mentioned  below,  and  further  operative  treatment  may  be  required. 

The  Surgical  Complications  of  Chronic  Otorrhcea  are  frequently 
serious,  and  call  for  prompt  treatment ;  they  may  be  classified  under 
three  main  headings — the  extracranial,  the  cranial,  and  the  intra- 
cranial. 

The  extracranial  complications  of  otorrhcea  are  comparatively 
unimportant. 

(a)  Eczema  of  the  meatus  is  frequently  seen,  and  merely  needs  the 
parts  to  be  kept  dry  and  clean,  and  possibly  a  little  boric  acid 
powder  insufflated  ;  it  readily  disappears  when  the  discharge  ceases, 
but  is  not  unfrequently  associated  with  enlargement  of  the  cervical 
glands,  which  may  suppurate,  or  in  predisposed  individuals  may 
become  the  seat  of  tuberculous  disease. 

(b)  Boils  arise  from  infection  of  the  sebaceous  glands  in  the  meatus 
with  pyogenic  cocci  from  the  discharge,  and  are  exceedingly  painful 
owing  to  the  denseness  of  the  tissues  involved.  They  should  be 
fomented,  and  opened  when  pus  has  formed. 

(c)  Inflammation  may  occasionally  spread  from  the  meatus  to  the 
tympanic  plate  of  the  temporal  bone,  leading  to  subperiosteal  abscess 
and  necrosis  ;  or  it  may  extend  into  the  temporo-maxillary  articula- 
tion, giving  rise  to  suppurative  arthritis  and  disorganization  of  that 
joint  (p.  822). 

The  cranial  complications  of  otitis  media  are  often  of  a  grave 
nature,  and  may  end  in  permanent  deafness,  or  even  endanger  the 
life  of  the  individual. 

(a)  The  ossicles  frequently  necrose,  and  are  cast  off  in  the  dis- 
charge, and  thus  hearing  may  be  impaired,  although  not  necessarily 
destroyed  ;  ankylosis  of  the  ossicles  one  to  another  may  also  be 
determined,  leading  to  considerable  loss  of  function. 

(b)  The  inflammation  may  extend  from  the  lining  membrane  of 
the  tympanum  to  the  bony  walls  surrounding  it,  giving  rise  to  a 
limited  caries  or  necrosis  of  the  temporal  bone.  This  may  be  as- 
sociated with  suppuration  within  the  skull,  and  any  of  the  intra- 
cranial complications  mentioned  below.  The  roof  of  the  tympanic 
cavity  (tegmen  tympani),  which  is  very  thin,  is  especially  liable  to  be 
affected  in  this  way.  If  diseased  bone  can  be  felt  through  the 
external  auditory  meatus  with  a  probe,  an  attempt  should  be  made 
to  remove  it ;  if  this  is  impossible,  the  part  must  be  kept  clean  by 
the  injection  of  mild  antiseptics,  retention  of  discharges  being  pre- 
vented by  the  regular  use  of  Politzer's  bag. 

(c)  Polypi  may  also  develop,  consisting  essentially  of  granulation 


AFFECTIONS  OF  THE  EAR  891 

tissue  protruding  through  the  opening  in  the  membrane  (Fig.  406) ; 
they  lead  to  considerable  obstruction,  and  may  do  harm  by  keeping 
back  the  discharge.  They  should  be  removed  by  the  snare  or  curette, 
and  the  base  touched  with  a  saturated  solution  of  chromic  acid  ;  the 
part  is  subsequently  syringed  with  a  weak  carbolic  solution  and 
dressed  antiseptically. 

{d)  Facial  Paralysis  not  uncommonly  arises  from  sclerosis  and 
thickening  of  the  bony  tissue  surrounding  the  aqueductus  Fallopii, 
causing  pressure  on  the  nerve  in  that  region.  It  must  be  remembered 
that  the  bony  canal  lies  immediately  behind  the  tympanic  cavity, 
and  to  the  inner  side  of  the  passage  from  the  attic  to  the  mastoid 
antrum  (adifus  ad  antrum).  All  the  muscles  on  that  side  of  the  face 
are  involved,  and  possibly  also  the  palate  and  uvula.  No  radical 
treatment  is  practicable,  but  nerve  anastomosis  (p.  385)  may  be 
attempted  at  a  later  date,  and  in  the  meantime  the  face  should  be 
regularly  faradized,  so  as  to  maintain  as  far  as  possible  the  tone  of 
the  muscles. 

(e)  Involvement  of  tlie  Internal  Ear  or  Labyrinthitis  results  from 
the  spread  of  the  infection  inwards,  either  through  the  wall  of  the  ex- 
ternal semicircular  canal,  or  through  the  fenestrum  rotundum  or 
ovale  ;  in  the  former  case  the  posterior  or  vestibular  portion  is 
involved,  in  the  latter  the  cochlea.  Invasion  of  the  semicircular 
canals  is  usually  evidenced  by  vertigo,  a  tendency  to  fall  towards  the 
affected  side,  nystagmus  and  vomiting;  pain  and  fever  are  present 
in  the  more  acute  forms.  Involvement  of  the  cochlea  is  generally 
a  later  manifestation,  and  results  in  tinnitus  and  absolute  deafness. 
Infection  of  the  meninges  sometimes  arises  by  spread  of  inflammation 
along  the  internal  auditory  meatus. 

(/)  Inflammation  may  also  extend  into  the  mastoid  cells,  giving 
rise  to  the  condition  known  as  mastoiditis.  The  mastoid  process  is 
a  triangular  mass  of  bone,  which  is  practically  undeveloped  until  the 
£?ge  of  puberty.  Before  that  period  a  single  cell  relatively  of  large 
size  communicates  with  the  posterior  portion  of  the  tympanic  cavity 
and  represents  the  antrum  ;  it  is  comparatively  superficial,  being 
immediately  under  cover  of  the  squamous  flake  of  bone,  and  is  in 
reality  petro-squamosal  rather  than  mastoid  in  origin.  After  puberty 
the  whole  bone  may  become  hollowed  out  into  a  series  of  spongy  cells, 
lined  with  mucous  membrane,  which  open  into  the  floor  of  the 
antrum ;  or  it  may  develop  but  few  cells,  and  remain  more  or  less  solid. 
These  cells  lie  below  and  superficial  to  the  antrum,  which  is  there- 
fore more  deeply  placed  in  the  adult  than  in  the  child.  The  com- 
munication with  the  tympanic  cavity,  which  in  a  child  is  widely  open, 
becomes  encroached  on  in  the  adult,  and  narrowed  to  the  small  track 
known  as  the  aditus  ad  antrum.  When  the  inflammation  in  otitis 
media,  which  has  almost  always  become  purulent,  extends  into  the 
antrum,  severe  local  and  general  symptoms  are  likely  to  result.  The 
patient  complains  of  intense  pain  in  the  ear,  with  tenderness  on 
pressure,  and  perhaps  redness  and  cedema  over  the  mastoid  process. 
The  discharge  from  the  ear  often  ceases  for  a  time  at  the  commence- 


892  A  MANUAL  OF  SURGERY 

ment  of  these  symptoms,  but  reappears  later  on.  As  the  case  pro- 
gresses, febrile  symptoms  of  an  intermittent  type,  and  even  rigors, 
may  supervene,  whilst  the  patient  becomes  drowsy,  or  may  be  irritable 
and  restless.  An  abscess  may  form  under  the  periosteum  covering 
the  mastoid  process,  with  or  without  caries  or  necrosis  oi  the  outer 
table  of  the  bone;  in  children,  where  this  bony  lamella  is  thin,  it  is 
not  unfrequently  absorbed,  and  on  incising  the  abscess  protuberant 
masses  of  granulations,  springing  from  the  interior  of  the  bone,  may 
be  seen.  When  such  an  abscess  has  developed,  the  auricle  is 
characteristically  displaced  downwards  and  outwards.  Not  un- 
frequently the  suppuration  extends  through  the  bone  cells  and  may 
encroach  on  the  inner  aspect  rather  than  the  outer,  and  hence  is 
likely  to  lay  bare  the  dura  mater  and  expose  the  lateral  sinus  ;  iii  such 
circumstances  intracranial  complications  are  probable.    Occasionally 


Fig.  408. — Incision  for 
Mastoid  Operations. 


Fig.  409. — Site  for  Drilling 
Bone  in  Order  to  Open  the 
Mastoid  Antrum. 


It  is  often  well  to  apply  a  chisel  over  the  desired  area  so  as  to  include  a  triangle, 
the  centre  of  which  corresponds  to  the  apex  of  the  so-called  supra-meatal 
triangle.  As  soon  as  the  outer  layers  of  the  bone  have  been  removed  by  the 
chisel,  the  gouge  is  used  to  reach  the  deeper  parts. 

a  few  thin-walled  cells  occupy  the  tip  of  the  mastoid ;  and  these,  if 
involved,  may  perforate  downwards,  and  thus  an  abscess  may  form 
under  cover  of  the  sterno-mastoid,  and  track  into  the  neck ;  this  is 
known  as  Bezold's  perforation.  At  times  the  trouble  is  of  a  more 
chronic  type,  and  is  then  associated  with  the  more  solid  form  of 
mastoid  process.  Sometimes  it  is  tuberculous  in  nature,  the  cells 
being  choked  up  with  lymph  and  inflammatory  material  of  a  cheesy 
nature,  whilst  the  bone  itself  becomes  thickened  and  condensed. 
The  process  feels  distinctly  enlarged,  and  is  the  seat  of  a  good  deal 
of  deep-seated  pain  of  an  aching  character,  and  worse  at  night. 

When  the  discharge  is  inspissated  and  mixed  with  epithelial  cells 
and  cholesterine,  so  as  to  form  flaky  masses  like  the  layers  of  an 
onion,  the  condition  is  known  as  cholesteatoma.  It  is  often  the  cause 
of  great  distension  of  the  antrum,  which  in  one  case  operated  on 
measured  quite  1^  inches  across.    The  symptoms,  at  first  of  a  chronic 


AFFECTIONS  OF  THE  EAR  893 

type,  are  likely  to  be  followed  sooner  or  later  by  an  acute  attack 
of  suppurative  inflammation. 

Treatment. — In  the  early  acute  stage  belladonna  fomentations  may 
be  employed,  and  the  patient  kept  quietly  in  bed,  whilst  the  diet  is 
regulated  and  a  suitable  purgative  administered  ;  accumulated  dis- 
charge is  removed  from  the  tympanum  by  the  use  of  Politzer's  bag. 
Two  or  three  leeches  may  also  be  applied  over  the  mastoid  process, 
and  relief  to  the  pain  thus  obtained,  though  it  is  often  only  of  a 
temporary  character.  It  is  most  important  not  to  rely  upon  such 
palliative  measures  for  too  long,  but  if  the  symptoms  are  well 
marked,  the  mastoid  antnnn  must  he  laid  open  and  its  contents 
evacuated  without  interfering  with  the  tympanic  structures  which 
in  acute  cases  are  capable  of  effective  repair  (Schwarize's  operation). 


Fig.  410.— Stacke's  Operation  completed. 

The  antrum  (A)  has  been  thoroughly  opened  up,  and  the  bridge  of  bone  covering 
the  aditus  removed,  thus  bringing  the  antrum  into  free  communication  with 
the  tympanic  cavity  (B),  which  is  curetted  and  the  ossicles  removed. 

A  curved  incision  is  made  immediately  behind  the  ear,  which  is 
drawn  well  forwards  (Fig.  408),  and  a  gouge  or  burr  worked  by  a 
surgical  engine,  applied  on  a  level  with  the  roof  of  the  external 
auditory  meatus,  and  about  |  inch  behind  its  centre  (Fig.  409).  A 
small  dimple  in  the  bone  can  often  be  felt  at  the  required  spot, 
which  can  also  be  found  by  taking  the  point  of  junction  of  two  lines 
drawn  as  tangents  to  the  roof  and  posterior  wall  of  the  bony  meatus 
respectively  (Fig.  357,  C).  The  direction  taken  by  the  gouge  should 
be  slightly  downwards,  forwards,  and  inwards,  and  a  useful  guide 
will  be  found  in  a  probe  passed  down  the  external  auditory  meatus, 
the  boring  being  made  exactly  parallel  to  this.  In  an  adult  the 
mastoid  antrum  is  reached  about  three-fifths  of  an  inch  from  the  sur- 
face of  the  bone.  The  surgeon  recognises  that  he  has  opened  the 
cavity  by  the  probe,  or  by  the  loss  of  resistance  and  escape  of  offen- 
sive pus.    The  opening  is  enlarged  by  the  use  of  the  gouge  and  spoons. 


894  A  MANUAL  OF  SURGERY 

SO  as  to  expose  all  the  affected  bone  cells  and  remove  all  diseased 
bone,  and  the  cavity  is  then  syringed  out.  The  wound  is  packed 
\yith  sterile  gauze  and  should  be  syringed  daily.  A  Bezold's  perfora- 
tion must  be  enlarged,  and  possibly  an  incision  in  the  neck  may  be 
prevented,  if  the  case  is  treated  early. 

In  the  more  chronic  cases,  where  tympanic  complications  are 
present,  a  more  extensive  proceeding  known  as  Stackers  operation  is 
usually  required.  In  it  the  auricle  is  detached  posteriorly  from  the 
bony  margins  of  the  meatus,  and  then  the  antrum  is  opened  and  the 
whole  of  the  osseous  tissue  intervening  between  it  and  the  meatus 
and  tympanic  cavity  in  front  is  gouged  away.  A  metal  guide  is 
passed  from  the  opening  in  the  antrum  into  the  attic  along  the 
aditus,  and  all  the  bone  superficial  to  the  guide  may  be  safely 
removed.  The  facial  nerve  and  superior  semicircular  canal  lie 
behind,  and  are  protected  by  the  guide.  The  remains  of  the 
membrane  and  the  ossicles  are  then  removed,  and  the  cavity  curetted 
(Fig.  410).  The  deep  portion  of  the  posterior  wall  of  the  cartilagin- 
ous meatus  is  incised  longitudinally  and  the  margins  of  the  aperture 
stitched  to  the  posterior  edge  of  the  wound,  the  meatus  thus  leading 
to  the  whole  of  the  opening  in  the  bone,  which  can  in  this  way  be 
syringed  out  and  cleansed  more  efficiently. 

The  intracranial  complications  of  otorrhoea  are  subcranial  abscess, 
locaHzed  or  diffuse  meningitis,  thrombosis  of  the  lateral  sinus,  and 
abscess  in  the  cerebrum  or  cerebellum. 

(a)  Subcranial  Abscess. — For  general  phenomena  connected  with 
this  condition,  see  p.  777.  Accumulations  of  pus  occur  most  commonly 
along  the  summit  of  the  petrous  portion  of  the  temporal  bone,  and 
in  the  sulcus  in  which  the  lateral  sinus  is  lodged.  The  patient  com- 
plains of  pain  and  headache,  which  increase  for  a  time  and  are  then 
followed  by  drowsiness,  which  may  pass  into  coma.  The  tempera- 
ture is  raised,  but  rigors,  even  if  present  at  first,  are  by  no  means  a 
constant  feature  of  the  case.  The  pulse  is  of  the  usual  febrile  type, 
viz.,  quick,  full,  and  bounding.  There  is  no  pain  in  the  neck  along 
the  course  of  the  jugular  vein,  but  retraction  of  the  head  occurs  if 
basal  meningitis  is  present,  and  vomiting  is  a  marked  symptom. 
Optic  neuritis  may  be  observed  in  consequence  of  the  inflammation 
extending  to  the  membranes  at  the  base  of  the  brain.  There  may 
be  some  tenderness  on  pressure  over  the  temporal  region,  and  possibly 
oedema.  In  some  cases  the  pus  finds  its  way  outwards  along  the 
mastoid  emissary  vein,  or  through  the  suture  between  the  occipital 
and  temporal  bones. 

The  Diagnosis  from  cerebral  abscess  is  sometimes  a  matter  of  cou:- 
siderable  difficulty.  The  symptoms,  however,  set  in  somewhat  more 
acutely,  whilst  the  temperature  is  raised,  and  the  signs  of  irritation 
of  the  membranes,  such  as  retraction  of  the  neck,  all  suggest  that 
the  lesion  is  extradural,  and  not  cerebral  in  origin.  The  pulse  is 
fast,  and  not  slow,  and  focal  symptoms  are  less  likely  to  develop. 

The  Treatment  consists  in  trephining  above  and  behind  the  meatus, 
so  as  to  escape  the  lateral  sinus,  and  in  much  the  same  sitiiation  as 


AFFECTIONS  OF  THE  EAR  895 

for  a  temporo-sphenoidal  abscess  (q.v.).     The  pus  is  washed  out, 
and  a  drainage-tube  inserted  for  a  few  days. 

(b)  Meningitis  may  be  locahzed  or  diffuse.  The  former  often 
accompanies  some  other  condition,  and  is  in  itself  of  little  moment. 
It  may  produce  fixed  headache,  but,  if  non-suppurative,  usually  dis- 
appears when  the  originating  disease  has  been  cured.  The  diffuse 
variety  is  generally  infective  in  nature,  and  secondary  to  some  sup- 
purative affection  in  the  neighbourhood,  or  to  thrombosis  of  the  lateral 
sinus.  (For  symptoms,  see  p.  778.)  Occasionally  a  simple  serous 
effusion  occurs  within  the  meninges,  leading  to  increased  pressure 
and  consequent  drowsiness,  but  disappearing  entirely  when  the  cause 
has  been  removed,  or  the  excess  of  fluid  withdrawn  by  lumbar 
puncture. 

(c)  Thrombosis  of  the  Lateral  Sinus  arises  from  direct  extension  of 
the  inflammatory  process  from  the  middle  ear  through  the  mastoid 
bone,  or  it  may  be  set  up  by  an  infective  thrombosis  of  the  mastoid 
emissary  vein  spreading  to  the  sinus.  A  clot  forms  within  it,  which, 
gradually  increasing  in  size,  leads  finally  to  occlusion  of  its  lumen. 
Infection  with  pyogenic  organisms  determines  disintegration  of  the 
clot  ;  infected  emboli  are  detached,  and  thus  pyaemic  symptoms 
originated.  In  well-marked  cases  the  thrombus  extends  as  far  back 
as  the  Torcular  Herophili,  and  downwards  along  the  jugular  vein. 

The  most  marked  Symptom  of  the  case  is  the  sudden  appearance 
of  a  high  temperature,  which  is  usually  remittent,  and  associated 
with  rigors,  vomiting,  and  localized  pain  in  the  head,  perhaps  most 
marked  over  the  point  of  emergence  of  the  emissary  vein  at  the 
posterior  border  of  the  mastoid  process.  The  pulse  is  rapid,  feeble, 
and  easily  compressible,  and  in  the  later  stages  the  patient  is  drowsy 
and  dull,  probably  from  serous  exudation  within  the  meninges.  The 
discharge  from  the  ear,  which  may  have  been  previously  offensive, 
usually  ceases.  Optic  neuritis  may  or  may  not  exist,  being  often 
preceded  by  photophobia.  If  the  thrombus  extends  into  the  neck, 
a  firm,  tender,  elongated  swelling  is  felt  in  the  region  of  the  jugular 
vein,  and,  owing  to  the  interference  with  the  venous  circulation,  the 
face  often  becomes  dusky.  The  cervical  lymphatic  glands  become 
enlarged,  and  stiffness  of  the  muscles  at  the  back  of  the  neck  is  an 
evidence  of  associated  basal  meningitis,  as  is  also  the  optic  neuritis. 
Suppuration  may  occur  outside  the  sinus,  or  around  the  vein  in  the 
neck,  which  becomes  swollen,  red,  and  oedematous. 

In  well-marked  cases  the  Diagnosis  is  easily  made,  but  in  the  early 
stages,  and  especially  in  children,  it  is  often  a  matter  of  some 
difficulty.  The  abrupt  onset,  the  oscillating  temperature,  the  re- 
current rigors,  the  pain  in  the  neck,  and  the  deep  tenderness  on 
pressure  over  the  course  of  the  lateral  sinus  or  jugular  vein,  are  the 
most  trustworthy  signs  of  this  affection. 

Treatment. — A  radical  mastoid  operation  is  usually  undertaken 
first,  and  by  extending  its  scope  backwards  the  sinus  can  be  exposed. 
Apart  from  this,  the  sinus  is  laid  bare  by  applying  a  trephine  at  a 
spot  about  J  inch  above  Reid's  base-line,  and  about  i  inch  behind 


896  A  MANUAL  OF  SURGERY 

the  centre  of  the  external  auditory  meatus  (Fig.  357,  A  or  B).  A 
puncture  with  a  fine  needle  readily  determines  whether  the  sinus 
contains  fluid  blood  or  thrombus.  If  it  is  thrombosed,  there  is  often, 
some  evidence  of  inflammation  or  pus  around  it,  between  the  dura 
mater  and  the  bone.  Having  thus  verified  the  diagnosis,  an  incision 
is  made  along  the  anterior  border  of  the  sterno-mastoid,  through 
which  the  jugular  vein  is  tied  at  a  spot  below  the  lowest  point  of  the 
thrombus,  so  as  to  prevent  the  escape  of  any  more  emboli  into  the 
general  circulation.  In  old-standing  cases  this  may  involve  exposing 
the  vein  in  the  lowest  part  of  the  neck,  and  placing  the  ligature  close 
to  the  innominate.  The  lateral  sinus  is  now  freely  incised,  and  the 
infected  thrombus  partly  scraped,  partly  washed  away,  the  opening  in 
the  bone  being  increased  in  size,  if  necessary.  It  is  desirable,  but  not 
essential  in  the  simpler  cases,  to  remove  completely  the  lower  part  of 
the  thrombus ;  if  such  is  attempted,  the  jugular  must  be  opened 
above  the  ligature,  and  the  clot  syringed  or  scraped  away.  Bleeding 
occurs  from  the  posterior  part  of  the  upper  opening  as  soon  as  all 
the  coagulum  is  removed,  but  is  easily  controlled  by  plugging  the 
sinus  with  a  small  piece  of  aseptic  gauze.  The  wound  in  the  neck 
should  be  lightly  packed  and  not  closed,  since  infection  and  suppura- 
tion are  almost  certain  to  follow.  The  upper  wound  is  also  packed 
in  the  same  way,  and  allowed  to  granulate. 

(d)  Abscess  in  the  cerebrum  or  cerebellum,  a  complication  not 
unfrequently  met  with,  has  been  already  discussed  (p,  782). 


CHAPTER  XXXI. 
SURGERY  OF  THE  NECK. 

Affections  of  the  Neck. 

Affections  connected  with  the  Branchial  Clefts. — In  the  second  or  third  week  of 
intra-uterine  life  a  series  of  branchial  arches  form  in  the  human  embryo  as  in 
other  mammalia,  constituting  the  foundation  from  which  the  future  structures  of 
the  neck  are  developed.  In  the  majority  of  mammals  five  such  post-oral  arches 
occur,  separated  from  one  another  by  the  so-called  branchial  clefts;  but  in  man 
the  fourth  and  fifth  are  amalgamated.  They  project  from  the  side  of  the 
primitive  spinal  column,  and  consist  of  mesoblast  lined  on  either  side  by 
epithelium.  They  unite  across  the  median  line  at  an  early  date,  and  also  one 
with  another,  thereby  leading  to  a  large  extent  to  the  obliteration  of  the  clefts. 
Occasionally,  however,  this  union  is  imperfect,  and  sundry  malformations  result. 

It  must  be  remembered  that  the  mandible  and  the  processus  gracilis  of  the 
malleus  arise  from  the  first  arch ;  the  Eustachian  tube,  tympanic  cavity,  external 
auditory  meatus,  and  Glaserian  fissure  from  a  normally  unobliterated  portion 
of  the  first  cleft ;  the  styloid  process,  stylo-hyoid  ligament,  and  lesser  cornu  of 
the  hyoid  bone  from  the  second  arch ;  the  body  and  great  cornu  of  the  hyoid 
bone  from  the  third  arch  ;  and  the  rest  of  the  cervical  tissues  from  the  remaining 
arch  ;  whilst  the  second,  third,  and  fourth  clefts  are,  under  ordinary  circum- 
stances, totally  obliterated. 

Branchial  Fistulse  are  due  to  imperfect  closure  of  the  branchial  clefts.  They 
consist  of  narrow  sinuous  tracts  extending  inwards  from  the  skin,  and  perhaps 
communicating,  but  not  necessarily  so,  with  the  pharynx.  The  external  opening 
is  usually  situated  along  the  anterior  border  of  the  sterno-mastoid,  and  most 
commonly  near  its  lower  end,  close  to  the  episternal  notch,  the  fistula  then 
arising  from  the  lowest  cleft.  They  are  lined  with  epithelium,  and  secrete  a 
glairy  or  mucoid  fluid.  They  are  not  uncommonly  associated  with  other 
abnormalities,  such  as  macrostoma,  absence  of  the  pinna,  or  accessory  auricles 
situated  either  near  the  orifice  of  the  fistula  or  close  to  the  ear.  In  the  majority 
of  cases  they  may  be  disregarded,  but  if  troublesome  should  be  laid  open  and 
the  lining  membrane  either  dissected  away  or  destroyed  with  the  galvano- 
cautery. 

Branchial  Cysts  arise  from  incomplete  closure  of  a  branchial  cleft,  the 
unobliterated  portion  being  distended  with  secretion.  They  usually  appear  in 
adolescents,  often  between  the  ages  of  ten  and  twenty,  and  are  frequently 
attributed  to  a  blow,  which,  it  may  be  presumed,  brings  into  activity  structures 
which  would  otherwise  have  remained  passive.  They  grow  slowly  and  painlessly, 
forming  rounded  swellings,  often  rather  soft,  with  more  or  less  distinct  fluctua- 
tion, according  to  the  depth  at  which  they  are  situated ;  their  contents,  if  near 
the  cutaneous  end  of  the  cleft,  are  sebaceous  in  character,  similar  to,  but  more 
fluid  than,  that  found  in  dermoid  cysts  (viz.,  flattened  epithelial  cells,  choles- 
terine  plates,  and  fatty  granules).  If  placed  nearer  to  the  pharynx  they  are 
occupied  by  a  glairy  mucoid  fluid.  They  are  usually  lined  with  squamous 
epithelium,  but  a  few  cases  have  been  recorded  in  which  the  cells  were  columnar, 

8c  7  57 


ggi!  A  MANUAL  OF  SURGERY 

and  even .  ciliated,  in  character.  The  most  common  situation  is  in  the  third 
cleft,  the  cyst  then  lying  between  the  thyroid  cartilage  and  the  anterior  border 
of  the  sterno-mastoid,  in  relation  with  the  great  wing  of  the  hyoid  bone ;  when 
of  large  size,  they  may  extend  beneath  that  muscle,  displacing  it  outwards. 
More- rarely  a  cyst  arises  from  the  second  cleft,  being  then  located  in  the  upoer 
third  of  the  neck,  and  tending  to  spread  up  towards  the  styloid  process ;  it  may 
even  reach  from  the  mastoid  process  to  the  hyoid  bone,  running  parallel  to  the 
posterior  border  of  the  jaw,  and  fluctuation  may  be  detected  through  the  mouth. 
Treatment  consists  in  extirpation  when  the  condition  has  attained  sufficient  size 
to  be  troublesome. 

Branchial  Carcinoma. — Considerable  doubt  has  been  expressed  as  to  whether 
it  is  possible  for  carcinoma  to  originate  in  the  unobliterated  remains  of  the 
branchial  clefts,  cases  which  might  have  been  considered  of  this  nature  being 
ascribed  to  developments  of  epithelioma  in  the  deep  lymphatic  glands  which 
have  undergone  cystic  degeneration,  and  secondary  to  some  undiscovered  or 
aborted  lesion  in  the  pharynx  or  larynx.  The  balance  of  evidence  is,  however, 
in  favour  of  the  fact  that  carcinoma  can  start  in  this  way,  giving  rise  to  what 
has  been  described  as  a  malignant  cyst  of  the  neck.  It  is  characterized  by  the 
formation  of  a  tumour  placed  deeply  beneath  the  sterno-mastoid,  indefinite  in 
outline,  and  of  firm  consistence.  Considerable  pain  is  experienced,  and  lymphatic 
glands  become  secondarily  enlarged.  The  disease  runs  its  ordinary  course,  but. 
may  destroy  life  through  haemorrhage  from  the  main  vessels,  which  are  invaded 
by  the  tumour.  The  cyst  sometimes  gives  way  into  the  pharynx,  and  a 
malignant  ulcer  of  the  pharyngeal  wall  is  thus  induced.  Pathologically,  the 
condition  is  an  interesting  one,  since  the  tumour  does  not  always  possess  the 
characters  of  an  epithelioma.  Its  embryonic  origin  is  sometimes  indicated  by 
the  fact  that  myxomatous  and  cartilaginous  tissue  is  included  in  its  substance.* 
Treatment  is  usually  impracticable  owing  to  the  deep  connections  of  the  growth. 

Various  other  congenital  conditions  may  be  met  with  in  the  neck.  Congenital 
induration  of  the  sterno-mastoid  in  all  probability  arises  from  injury  during 
parturition,  and  usually  occurs  in  head  presentations,  probably  from  bruising  of 
the  side  of  the  neck  against  the  under  surface  of  the  symphysis  ;  it  is  said  to  be 
more  common  on  the  left  side  than  on  the  right.  In  cases  that  have  been 
examined  microscopically,  the  indurated  mass  has  been  found  to  consist  of 
fibrous  tissue.  It  disappears  spontaneously  after  a  time,  but  may  lead  to 
torticollis  at  a  later  date.  The  congenital  form  of  torticollis  (p.  426),  cysts  in 
connection  with  the  thyro-glossal  duct,  and  cystic  hygroma,  may  also  be 
mentioned. 

Cysts  of  the  Neck. 

I.  Cysts  of  Congenital  Origin. — {a)  Dermoids  occur  here  as  in  any  other 
region  where  congenital  remains  are  found.  As  already  mentioned, 
they  may  develop  from  the  branchial  clefts,  but  may  also  be  found 
in  the  middle  line,  or  in  connection  with  the  thyro-glossal  duct. 
(h)  The  thyro-glossal  duct  (Fig.  411)  consists  of  a  tubular  outgrowth 
from  the  embryonic  pharynx  passing  downwards  behind  the  body  of 
the  hyoid  bone  in  front  of  the  larynx  and  trachea  as  far  as  the  isthmus 
of  the  thyroid  gland,  which  is  subsequently  developed  from  it,  and 
unites  with  the  lateral  lobes,  which  in  turn  spring  from  the  deeper 
parts  of  the  branchial  arches.  The  upper  end  of  this  duct  is  situated 
at  the  foramen  caecum  of  the  tongue,  and  thence  traverses  the 
substance  of  that  organ  between  the  genio-hyo-glossi  muscles  to 
reach  the  hyoid  bone  ;  the  lower  end  is  represented  by  the  pyramid  of 
the   thyroid   isthmus.     The   whole   of    this   tube   disappears   under 

•  For  pathological  report  of  a  case  see  Veau,  Revue  de  Chinirgie,  March,  1900. 


SURGERY  OF  THE  NECK 


899 


ordinary  circumstances ;  if,  however,  the  upper  part  remains  unob- 
hterated,  a  dermoid  cyst  may  originate  from  it,  placed  either  in  the 
substance  of  the  tongue  or  immediately  below  it  fp.  857).  If  the 
lower  portion  remains  patent,  a  cyst  develops  containing  mucoid 
or  glairy  fluid,  which,  however,  is  not  present  at  birth.  If  it  bursts 
spontaneously,  or  is  opened,  a  so-called  median  cervical  fistula  results, 
which  requires  the  same  treatment  as  a  branchial  fistula,  viz., 
incision,  and  complete  removal  or 
destruction  of  the  epithelial  lining. 
Accessory  thyroid  growths  of  an 
adenomatous  nature  may  develop 
from  any  part  of  the  duct,  but 
especially  from  the  lower  end ; 
they  are  quite  innocent  in  nature, 
and  unless  troublesome  may  be 
left  alone,  (c)  Cystic  hygroma,  is 
sometimes  congenital,  but  may  also 
be  acquired.  It  consists  of  a  multi- 
locular  swelling,  the  spaces  com- 
posing it  being  due  to  dilatation  of 
lymphatic  spaces,  and  filled  with 
lymph.  The  tumour  is  often  of 
considerable  size,  with  a  sinuous, 
irregular  outline,  and  may  pro- 
duce great  deformity  and  marked 
pressure  effects.  The  skin  over  it 
may  be  occupied  by  dilated  capil- 
laries or  lymphatics.  Unless  ex- 
tending to  inaccessible  parts,  such 
as  the  superior  mediastinum,  it 
should  be  dealt  with  by  excision 
(p.  361). 

2.  Acquired  Cysts  of  the  Neck  are 
of  the  following  types  :  (a)  Sebaceous 
cysts  develop  in  the  skin  as  else- 
where, but  need  no  separate  notice. 
(b)  Bursal  cysts  are  stated  to  occur 
in  connection  with  the  larynx  and 
hyoid  bone.  There  is  usually  a 
bursa  over  a  prominent  pomum 
Adami,  and  this  may  become  enlarged  and  distended  with  fluid.  A 
bursa  is  also  stated  to  exist  between  the  back  of  the  hyoid  bone  and 
the  thyroid  cartilage,  which  might  easily  be  mistaken  for  one  of 
thyro-glossal  origin;  In  doubtful  cases  a  microscopical  examination 
of  the  lining  wall  will  quickly  settle  the  diagnosis,  since  if  it 'is  bursal 
in  origin  it  is  lined  with  end-othelium,  whilst  if  it  is  thyro-glossal  it 
is  lined  with  epithelium.  In  the  former  case  incision  and  drainage 
usually  suffice  to  bring  about  a  cure,  although  excision  is  preferable ; 
in  the  latter  case  the  lining  wall  must  be  entirely  removed,     (c)  Uni- 


Fig.  411. — Median  Section   of 
Tongue,  Larynx,  and  Trachea, 

SHOWING     ThYRO  -  GLOSSAL      DuCT 

Extending  from  the  Foramen 
C^cuM  OF  the  Tongue  Down- 
wards Behind  the  Hyoid  Bone, 
AND  IN  Front  of  the  Trachea 
to  the  Isthmus  of  the  Thyroid 
Body.  (Semi-diagrammatic,  from 
College  of  Surgeons'  Museum.) 

A  small  dermoid  cyst  in  the  centre  of 
the  tongue  is  also  represented. 


900 


A  MANUAL  OF  SURGERY 


loculav  serous  cysts  are  sometimes  met  with  in  the  lower  part  of  the 
posterior  triangle,  constituting  the  condition  known  as  '  hydrocele  of 
the  neck.'  They  contain  serous  fluid,  with  perhaps  an  admixture  of 
blood.  Their  origin  has  not  been  defined  with  any  certainty,  but  they 
are  probably  due  to  a  dilatation  of  the  lymph  spaces,  and  are  best 
treated  by  excision,  [d)  True  hydatid  cysts  also  occur  in  this  region 
(p.  227).  (e)  Blood  cysts  have  been  found  in  close  connection  with 
the  large  vessels  of  the  neck.  They  are  possibly  due  to  the  dilata- 
tion of  a  vein,  and  may  communicate  or  not  with  some  vascular 
channel,  such  as  the  jugular,  being  then  partly  emptied  on  pressure. 
Where  no  communication  with  a  venous  trunk  exists,  the  lining 
membrane  is  intensely  vascular.  If  their  vascular  origin  is  recog- 
nised, they  should  be  left  alone  unless  causing  urgent  symptoms.  If, 
however,  a  blood  cyst  is  opened  by  mistake,  the  supplying  vessels 
must  be  secured,  if  possible,  and,  failing  that,  the  cavity  must  be 
packed  with  gauze  soaked  in  adrenalin.  (/)  Cysts  are  also  occa- 
sionally met  with  in  connection  with  the  salivary  glands  and  the 
thyroid  body,  (g)  Malignant  cysts  arise,  as  already  mentioned,  from  the 
remains  of  the  branchial  clefts,  or  from  a  degeneration  of  epithelio- 
matous  lymphatic  glands.  They  are  often  of  large  size,  and  their 
removal  is  impracticable  owing  to  the  adhesions  which  they  contract 
to  the  deeper  structures. 

Cut  Throat. 

Injuries  of  the  neck  are  commonly  met  with  in  cases  of  attempted 
homicide  or  suicide,  and  vary  much  in  severity  according  to  the 
extent  and  position  of  the  wound.  A  right-handed  suicide  usually 
cuts  his  throat  from  left  to  right,  and  therefore  the  incision  is  bold 
and  clean  on  the  left  side,  tailing  off  towards  the  right ;  in  a  left- 
handed  suicide  the  incision  runs  in  the  opposite  direction.  A  homi- 
cidal cut  throat  varies  in  its  direction  according  to  whether  it  is  done 
from  behind  or  in  front,  and  also  with  the  hand  employed.  If  the 
front  of  the  neck  is  mainly  involved,  the  air-passages  are  laid  open, 
and  the  patient's  life,  though  much  endangered,  is  not  necessarily 
destroyed.  If,  however,  the  wound  chiefly  affects  the  side,  the  great 
vessels  and  nerves  may  be  divided,  and  death  from  haemorrhage  is 
very  liable  to  ensue.  The  course  and  treatment  of  the  latter  class  of 
case  require  no  particular  notice,  since  the  general  principles  relating 
to  all  wounds  must  be  adhered  to.  Where,  however,  the  air-passages 
have  been  opened,  special  complications  arise,  requiring  suitably 
modified  treatment. 

Wounds  involving  the  Air-passages,  the  result  of  cut  throat,  may 
be  situated  at  four  different  levels :  (a)  above  the  hyoid  bone,  en- 
croaching on  the  base  of  the  tongue ;  (b)  through  the  thyro-hyoid 
space,  the  most  common  situation  ;  (c)  in  the  larynx ;  and  (d)  opening 
or  dividing  the  trachea. 

The  immediate  effects  of  such  lesions  are  due  to  shock,  haemor- 
rhage, asphyxia,  or  the  entrance  of  air  into  veins.  When  above  the 
hyoid  bone,  the  root  of  the  tongue  and  submaxillary  region  are  involved, 


SURGERY  OF  THE  NECK  9°! 

and  haemorrhage  from  the  lingual  or  facial  arteries  or  their  branches 
follows ;  if  the  wound  extends  far  enough,  the  main  vessels  are 
divided,  and  death  results.  In  the  less  severe  cases  the  patient  runs 
considerable  risk  of  being  suffocated  by  the  epiglottis  and  base  of  the 
tongue  falling  back  over  the  larynx.  Much  difficulty  will  be  subse- 
quently experienced  in  feeding  the  patient,  owing  to  impairment 
of  the  movements  of  the  tongue.  When  the  thyvo-hyoid  space  is 
opened,  the  facial  and  lingual  arteries  are  again  in  danger,  as  also  the 
upper  part  of  the  superior  thyroid.  The  base  of  the  epiglottis  is 
divided,  and  portions  of  mucous  membrane  around  the  entrance  of 
the  larynx  may  be  detached,  and  cause  obstruction  to  respiration. 
Blood  may  also  trickle  down  the  larynx  into  the  trachea,  and  lead  to 
asphyxia.  Wounds  of  the-  larynx  are  usually  transverse,  and  not 
very  extensive,  owing  to  the  resistance  offered  to  the  knife  by  the 
cartilage.  The  thyroid  body  may  be  wounded  and  bleed  freely, 
otherwise  there  is  but  little  haemorrhage.  Blood  may  find  its  way 
into  the  trachea  or  lungs,  and  asphyxiate  the  patient.  When  the 
trachea  is  involved,  the  common  carotid  and  inferior  thyroid  vessels 
are  very  liable  to  be  wounded,  giving  rise  to  severe,  if  not  fatal, 
haemorrhage.  Asphyxia  may  be  brought  about  by  displacement  of 
the  severed  portions  of  the  tube,  or  from  the  entrance  of  blood  into 
the  air-passages,  whilst  air  may  also  be.  sucked  into  opened  veins. 
The  recurrent  laryngeal  nerve  may  be  divided,  causing  paralysis  of 
the  larynx. 

The  secondary  effects  following  cut  throat  are  mainly  inflammatory 
in  origin,  (a)  Any  form  of  septic  inflammat  on  may  occur  in  the 
wound,  possibly  giving  rise  to  cellulitis,  which  may  spread  downwards 
to  the  mediastinum.  Where  it  involves  the  tissues  above  the 
entrance  to  the  larynx,  oedema  of  the  glottis  may  be  produced. 
Secondary  haemorrhage  also  arises  from  this  cause,  and  even  general 
pyaemia,  (b)  Inflammation  of  the  air-passages,  tracheitis,  bronchitis,  or 
broncho-pneumonia,  frequently  foliows,  partly  as  a  result  of  the 
entrance  of  cold  air,  partly  from  the  admission  of  septic  material, 
such  as  food,  decomposing  blood-clot,  or  discharges.  The  patient 
may  become  cyanosed  from  these  causes,  and  in  consequence  of  the 
partial  asphyxia  the  sensibility  of  the  mucous  membrane  of  the 
glottis  is  diminished,  allowing  of  the  passage  into  it  of  food  which 
appears  at  the  mouth  of  the  wound ;  in  some  cases  this  may  have 
arisen  from  division  of  the  superior  laryngeal  nerve,  but  the  depth 
at  which  this  structure  is  situated  in  the  neck  makes  it  difficult  to 
conceive  how  it  could  be  divided  without  injury  to  the  main  vessels. 
(c)  Surgical  emphysema,  or  the  entrance  of  the  atmospheric  air  into 
the  cellular  tissue,  may  also  follow  a  wound  of  the  air-passages. 
It  is  not  limited  to  the  neck,  but  extends  to  the  trunk,  being  recognised 
by  the  puffy  distension  of  the  part,  and  by  a  soft  crackling  crepitus 
elicited  on  pressure.  It  is  of  no  great  consequence,  and  usually 
disappears  in  a  few  days,  (d)  Septic  traumatic  fever  is  almost  always 
present  in  these  cases,  the  temperature  varying  with  the  extent  of 
the  inflammation  in  the  cellular  tissue  or  in  the  lungs. 


902  A  MANUAL  OF  SURGERY 

The  Treatment  consists  in  securing  all  bleeding-points,  if  possible, 
but  occasionally  they  are  placed  so  deeply  that  it  is  necessary  to  tie 
the  external  carotid ;  general  oozing  from  ^  the  surface  must  be 
attended  to,  for  fear  of  blood  being  sucked 'into  the  air-passages. 
Every  effort  should  be  made  to  render  the  wound  aseptic,  and  if 
there  is  a  reasonable  prospect  that  this  has  been  attained,  it  may  be 
closed  by  sutures  in  the  ordinary  way.  Where,  however,  asepsis  is 
doubtful,  only  the  ends  of  the  incision  should  be  drawn  together,  the 
central  portion  being  left  open. 

The  treatment  of  the  air-passages  varies  with  the  site  of  the  lesion. 
If  the  trachea  has  been  roughly  divided,  the  portions  should  be 
steadied  by  a  stitch  on  either  side,  and  a  tracheotomy-tube  inserted — 
at  any  rate,  for  a  few  days ;  when  cleanly  cut,  total  closure  without 
the  use  of  a  tube  can  be  safely  permitted.  When  the  wound  involves 
the  larynx,  it  is  desirable  to  close  the  opening  at  once,  since  the 
larynx  does  not  readily  tolerate  the  presence  of  a  tube  ;  if  necessary, 
it  is  better  to  perform  a  high  tracheotomy.  When  the  wound  involves 
the  thyro-hyoid  space,  or  is  situated  above  the  hyoid  bone,  it  is  quite 
safe  in  many  cases  to  close  the  wound,  layer  by  layer -after  carefully 
disinfecting  it.  The  mucous  membrane  is  first  dealt  with  by  stitches 
which,  do  not  penetrate  its  whole  thickness,  and  then  a  more  thorough 
purification  can  be  undertaken ;  if  the  epiglottis  is  divided,  it  must 
be  'accurately  sutured.  If  there  is  any  doubt  as  to  the  advisability 
of  this  proceeding,  a  high  tracheotomy  is  first  performed,  and  then 
the  wound  closed  as  far  as  possible. 

In  every  instance  the  head  should  be  flexed  on  the  chest,  and  in 
suicidal  cases  a  careful  watch  maintained  to  prevent  the  patient 
tearing  the  wound  open.  Loss  of  blood  is  dealt  with  by  the  infusion 
of  saline  solution,  and  the  patient's  general  condition  attended  to. 
Feeding  should  always  be  undertaken  through  a  tube  passed  into  the 
cesophagus,  whether  that  structure  is  wounded  or  not,  and  such 
should  be  continued  until  the  patient's  natural  powers  of  swallowing 
are  restored. 

The  following  Seq.Tielse  occasionally  result  from  a  cut  throat : 
(a)  An  aerial  fisUda  is  a  persistent  abnormal  communication  between 
the  air-passages  and  the  external  air,  and  occurs  most  often  in  the 
thyro-hyoid  space,  the  skin  and  mucous  membrane  being  continuous 
one  with  the  other  around  the  margins  of  the  opening.  In  some 
cases  it  may  be  closed ;  but  if  laryngeal  stenosis  or  adhesions  are 
present,  it  must  be  left  alone  for  a  time  until  these  conditions  have 
been  treated.  The  operation  consists  in  separating  the  skin  from 
the  mucous  membrane,  and  in  order  to  accomplish  this,  the  external 
wound  must  be  enlarged  vertically.  The  edges  of  the  mucous  mem- 
brane are  then  pared,  and  stitched  together  horizontally.  The  external 
wound  is  either  closed  vertically,  or  left  partially  open  and  packed. 
{h)  Laryngeal  or  tracheal  stenosis,  due  to  the  cicatrization  of  wounds  in 
these  regions,  may  be  remedied  by  wearing  an  O'Dwyer's  tube 
(p.  927)  for  a  tirr;e,  or  may  necessitate  the  constant  use  of  a 
t-racheotomy-tube.     (c)  Aphonia  may  arise  from  division  of  the  recur- 


SURGERY  OF  THE  NECK  903 

rent  laryngeal  nerve,  and  is  then  usually  persistent,  (d)  Oesophageal 
or  pharyngeal  fistula  may  also  in  rare  instances  complicate  the  healing 
of  an  extensive  wound  in  the  throat,  but  tend  to  close  of  themselves, 
and  require  no  special  treatment. 

Diseases  of  the  Thyroid  Body.* 

Goitre.— Enlargement  of  the  thyroid  body,  or,  as  it  is  termed, 
bronchocele  or  goitre,  is  a  condition  frequently  seen  in  this  country, 
and  is  of  general,  and  not  merely  local,  importance,  since  the  thyroid 
body  exercises  considerable  influence  over  metabolism  and  nutrition. 
Total  absence  or  removal  of  the  gland  or  its  qomplete  degeneration 
leads  to  accumulation  of  mucin  in  the  body,  producing  myxcedema 
in  adults,  and  cretinism  in  children  ;  whilst  the  excessive  absorption 
'of  normal  or  vitiated  thyroid  secretion  is  probably  responsible  for 
Graves'  disease,  and  possibly  to  some  forms  of  skeletal  trouble. 

The  Causes  of  bronchocele  are  still  enshrouded  in  a  good  deal  of 
uncertainty.  It  occurs  endemically  in  this  and  some  other  countries, 
being  especially  frequent  in  the  hilly  parts  of  Derbyshire  and 
Gloucestershire  (and  known,  in  fact,  as  Derbyshire  neck)  ;  it  is  also 
exceedingly  common  in  Switzerland  and  the  valleys  of  Northern 
Italy.  There  can  be  little  doubt  that  the  disease  is  due  to  the 
presence  or  absence  of  some  mineral  constituent  of  the  drinking- 
water,  and  possibly  an  absence  of  iodine  is  the  cause  of  the  trouble. 
At  any  rate,  iodine  is  to  be  found  in  the  normal  thyroid  secretion  in 
close  combination  with  albumen,  whilst  it  is  .absent  in  cases  of  goitre, 
the  enlargement  of  the  gland  being  looked  on  in  the  light  of  a  com- 
pensatory hyperplasia.  Other  causes  which  have  been  suggested  are 
want  of  sunshine  and  air,  as  in  the  case  of  individuals  who  live  in 
valleys  into  which  the  air  does  not  readily  penetrate,  or  in  the  under- 
ground kitchens  and  cellars  of  large  towns,  defective  sanitary  con- 
ditions and  the  habit  of  carrying  weights  upon  the  head  also  possibly 
assisting.  The  ordinary  type  of  goitre  seen  in  this  country  is  much 
more  common  in  women  than  in  men  ;  it  is  not  hereditary  to  any 
great  extent,  and  is  not  influenced  by  intermarriage ;  but  it  may  be 
congenital,  and  then  is  associated  with  skeletal  changes,  defective 
growth,  and  intellectual  weakness,  constituting  the  condition  known 
as  cretinism. 

Varieties  and  Clinical  Features. — Four  chief  forms  of  goitre  are 
described,  viz.  :  The  parenchymatous  or  simple,  the  cystic,  the  fibro- 
adenomatous,  and  the  exophthalmic ;  but  the  thyroid  body  may 
become  enlarged  in  other  ways,  giving  rise  to  the  conditions  known 
as  malignant  goitre  and  acute  goitre,  whilst  acute  inflammation  is 
sometimes  seen. 

General  Features. — In  all  these  cases  the  thyroid  body  is  the  site 
of  a  swelling  involving  its  whole  substance,  or  one  or  other  of  its  lobes, 
or  possibly  the  isthmus  alone.     Its  consistence  varies  with  the  nature 

*  For  fuller  information  than  can  be  given  here,  see  Berry,  '  Diseases  of  the 
Thyroid  Gland  and  their  Surgical  Treatment.'     J.  and  A.  Churchill. 


904 


A  MANUAL  OF  SURGERY 


of  the' growth,  but  it  always  moves  with  the  larynx  on  deglutition.  In 
every  form  there  is  probably  a  certain  amount  of  anaemia,  whilst 
some  of  the  symptoms  characteristic  of  the  exophthalmic  variety  are 
often  produced  even  in  simple  cases,  possibly  from  the  excessive 
absorption  of  thyroid  secretion.  Pressure  on  surrounding  structures 
leads  to  dyspnoea  or  dysphagia,  and  cerebral  symptoms  may  arise 
from  interference  with  the  main  vessels,  which  are  displaced  out- 
wards. The  trachea  is  especially  liable  to  changes  of  situation  and 
shape  from  its  compression ;  it  is  usually  flattened  from  side  to  side 
(scabbard  trachea),  and  is  sometimes  pushed  an  inch  or  more  from  the 
middle  line.  Atrophy  of  the  cartilaginous  rings  may  also  be  induced, 
and  if  this  results  from  the  pressure  of  a  cyst  or  adenoma  of  the 


Fig.  412. — Front  and  Lateral  View  of  a  Parenchymatous  Goitre. 
The  right  lobe  had  been  removed  by  a  former  operation 

isthmus,  severe  dyspnoea  may  be  caused  thereby  If,  as  sometimes 
happens,  the  goitre  develops  downwards,  pushing  behind  the  sternum 
(retro-sternal  goitre),  the  trachea  is  likely  to  be  compressed  from  before 
backwards,  and  respiration  may  then  be  accompanied  by  stridor,  but 
with  no  aphonia.  Pressure  on  the  recurrent  laryngeal  nerve  leads  to 
harshness  or  loss  of  voice,  and  to  spasmodic  attacks  of  dyspnoea, 
which  may  even  prove  fatal.  It  must  be  clearly  understood,  however, 
that  the  effects  produced  by  a  goitre  are  not  necessarily  proportionate 
to  its  size ;  some  of  the  smaller  growths  at  times  produce  severe 
symptoms. 

Simple  or  Parenchymatous  Goitre  (Fig.  412)  consists  of  a  diffuse 
overgrowth  of  the  whole  thyroid  body,  the  parts  retaining  to  a  great 
extent  their  usual  proportions.  The  enlargement  is  due  partly  to  an 
overgrowth  of  the  glandular  tissue,  bat  also  to  au  accumulation  oi 


SURGERY  OF  THE  NECK  905 

colloid  material  within  the  vesicles  ;  a  normal  amount  of  fibrous 
stroma  is  usually  present.  The  whole  gland  is  generally  involved, 
but  possibly  one  lobe  is  larger  than  the  other.  It  is  soft  and  elastic 
to  the  touch,  quite  painless,  and  there  may  be  some  amount  of  lobula- 
tion. Not  uncommonly  it  is  associated  with  a  cystic  development  or 
new  formation  of  an  adenomatous  type.  When  the  interstitial  tissue 
is  abnormally  abundant,  as  often  occurs  in  the  later  stages,  the 
tumour  feels  harder  than  usual,  and  is  more  definitely  lobulated.  It 
is  then  termed  a  fibrous  goitre,  and  if  the  sclerosis  is  very  marked, 
myxoedema  may  supervene. 

The  Fibro-adenomatous  Goitre  (Figs.  413  and  414)  consists  in  the 
development  of  one  or  more  encapsuled  adenomatous  nodules  in  the 
substance  of  the  thyroid  body,  which  is  itself   often    concurrently 


Fig.  413.  — FoeiAL  Adenoma  of  Right  Lobe  of  Thyroid    Body  in  a 
Woman,  aged  Twenty-five  Years. 

(From  photograph  kindly  lent  by  Mr.  James  Berry.) 

enlarged.  These  nodules  may  occupy  one  or  other  lobe,  or,  when 
multiple,  be  scattered  through  the  substance  of  the  organ  ;  occasion- 
ally they  develop  in  the  isthmus  alone.  If  situated  near  the  surface, 
their  limitation  and  free  mobility  in  the  gland  can  be  easily  detected  ; 
but  when  placed  deeply,  their  special  features  cannot  be  recognised. 
Two  varieties  have  been  described :  (a)  The  fcetal,  in  which  the 
growth  is  solid  and  homogeneous,  consisting  of  closely  apposed 
alveoli  in  which  there  is  no  colloid  development,  and  identical  in 
structure  with  embryonic  thyroid  tissue.  Such  growths  are  usually 
seen  in  young  people ;  they  are  seldom  very  large,  but  frequently 
rather  vascular,  (b)  The  more  ordinary  type  of  adenoma  resembles 
ordinary  adult  thyroid  tissue  more  closely,  and  shows  a  considerable 


9o6 


A  MANUAL  OF  SURGERY 


tendency  to  cyst  formation.  It  is  impossible  to  draw  an  exact  line 
of  separation  between  this  latter  condition  and  the  simple  hypertrophy, 
which  is  often  of  a  diffuse  adenomatous  nature. 

Cystic  Goitre  (Cysto -adenoma)  arises  from  the  dilatation  into  cypts 
of  alveolar  spaces  in  the  normal  gland  tissue  or  in  a  localized 
adenoma,  the  interalveolar  walls  being  absorbed.  They  may  be  single 
or  multiple,  and  contain  either  a  thin  fluid  or  a  thick  grumous  colloid 
material,  somewhat  like  furniture  polish.  Intracystic  growths  of  a 
papillary  nature  are  not  unfrequent.  The  lining  membrane  of  these 
cysts  is  epithelial  in  nature,  the  individual  cells  being  cuboidal  when 
the  cyst  is  small,  and  flattened  out  or  even  squamous  when  large. 


Fig.  414.- 


-multiple  fibro-adenomatous  goitre. 
,    Hospital  Musedm.) 


(King's  College 


It  is  sometimes  intensely  vascular,  and  haemorrhage  into  the  cysts  is 
by  no  means  uncommon,  causing  the  contents  to  be  brown  or  blood- 
stained. 

Secondary  changes  occur  in  any  of  these  varieties,  chiefly  affecting 
the  interstitial  tissue,  which  may  develop  into  cartilage  or  bone,  or 
may  calcify,  but  only  in  very  chronic  cases.  Haemorrhage  into  the 
alveolar  spaces  or  cysts  is  not  uncommon  ;  acute  infective  inflamma- 
tion may  also  involve  the  mass,  and  malignant  disease,  usually  of  a 
cancerous  nature,  sometimes  supervenes. 

As  a  rare  complication  may  be  mentioned  general  dissemination,* 
giving  rise  to  secondary  growths,  which  are  usually  found  in  the  short 

*  Patel,  'Tumeurs  benignes  du  corps  thyroide '  donnant  des  metastases,'  Rev. 
de  Chirurgie,  1904. 


SURGERY  OF  THE  NECK  907 

and  flat  bones,  especially  the  cranium  and  vertebrae,  but  occasionally 
in  the  viscera.  Their  texture  is  usually  identical  with  normal  thyroid 
tissue,  but  may  be  more  cellular  and  of  a  cancerous  type,  and  may  be 
sufficiently  vascular  to  pulsate.  They  produce  local  symptoms  of 
varying  gravity.  The  thyroid  body  may  be  apparently  normal  or  the 
site  of  a  simple  goitre. 

The  Treatment  of  the  three  preceding  forms  of  goitre  may  be  con- 
sidered together,  as  they  are  very  different  in  nature  to  those  which 
follow.  In  the  early  stages  palliative  measures  can  be  employed, 
consisting  in  the  use  of  soft  or  distilled  water,  the  improvement  of 
the  general  health,  and  the  correction  of  errors  in  the  personal  and 
sanitary  hygiene.  Change  of  air  to  the  seaside  is  often  advisable,  whilst 
iron  and  iodides  may  be  administered  internally,  and  iodine  paint  or 
iodide  of  potassium  ointment  applied  locally.  In  India  cures  are  often 
produced  by  inunction  of  iodide  of  mercury  ointment,  the  part  being 
subsequently  exposed  to  the  rays  of  the  midday  sun ;  such  treatment 
is  generally  impracticable  in  this  country.  The  deficient  amount  of 
iodine  present  in  the  gland  in  these  cases  explains  why  this  drug  is 
so  pre-eminently  useful,  and  it  has  been  found  that  the  active 
principle  of  the  gland  isolated  by  Baumann  and  called  '  thyro-iodine '  is 
the  best  form  in  which  it  can  be  administered.  The  exhibition  of 
thyroid  extract  is  sometimes  followed  by  a  diminution  of  a  simple 
goitre,  and  the  same  explanation  of  its  value  probably  holds  good. 

In  cases  where,  in  spite  of  such  treatment,  the  growth  persists  or 
increases  in  size,  other  measures  must  necessarily  be  employed,  and 
there  is  no  doubt  that  removal  of  the  tumour  or  of  a  part  of  the  gland 
is  the  best  practice  to  adopt.  Total  extirpation,  as  already  mentioned, 
results  in  myxcedema ;  but  .as  long  as  a  sufficient  portion  of  the 
secreting  substance  is  left,  whether  it  is  derived  from  the  isthmus  or 
from  one  of  the  lobes,  no  such  sequela  need  be  feared.  In  fact  goitres 
should  be  treated  in  the  same  way  as  other  new  growths,  viz.,  by 
removal  when  small  ;  there  is  still,  unfortunately,  a  considerable 
tendency  amongst  practitioners  and  patients  to  leave  them  untouched 
until  they  are  of  large  size,  thus  greatly  increasing  the  risk  of  the 
operation. 

Partial  thyroidectomy  is  conducted  as  follows  :  An  incision  is  made 
over  the  most  prominent  part  of  the  tumour,  either  along  the  lower 
third  of  the  anterior  border  of  the  sterno-mastoid,or  transversely  across 
the  neck  in  order  that  the  scar  may  be  less  visible.  The  platysma  and 
deep  fascia  are  divided,  and  the  sterno-mastoid,  sterno-hyoid,  sterno- 
thyroid, and  omo-hyoid  drawn  aside,  or,  if  need  be,  divided.  The  lobe 
to  be  removed  is  thus  exposed  within  its  capsule,  which  should  not 
be  opened.  The  limits  of  the  mass  are  defined  by  the  finger  or  a 
blunt  dissector,  and  the  vessels  entering  or  leaving  it  are  secured. 
The  superior  thyroid  vessels  are  doubly  ligatured  and  divided  at  the 
upper  end  of  the  growth,  the  middle  thyroid  vein  is  secured  at  the 
middle  of  its  outer  border,  whilst  the  inferior  thyroid  vessels  are 
dealt  with  below,  special  care  being  taken  to  avoid  the  inferior  or 
recurrent  laryngeal  nerve  by  tying  the  vessels  as  near  to  the  gland  as 


9o8 


A  MANUAL  OF  SURGERY 


possible.  The  lobe  is  now  freed  from  the  underlying  structures,  as 
also,  if  need  be,  the  isthmus  from  the  trachea. .  In  detaching  the  latter, 
the  surgeon  must  not  forget  that  the  cartilaginous  rings  may  have 
been  absorbed,  and  that  the  walls  of  the  trachea,  being  then  merely 
fibrous  in  nature,  are  easily  wounded.  The  isthmus  is  divided,  and 
any  bleeding  vessels  secured  ;  or  if  necessary,  it  may  be  ligatured 
before  division.  The  wound  is  closed  by  buried  sutures  for  muscles 
and  fasciae,  and  a  Halstead's  intradermic  stitch  for  the  skin.  A 
drainage-tube  may  be  required  for  twenty-four  hours,  as  it  is  difficult 
to  employ  much  pressure  on  the  neck.  Healing  by  first  intention 
should  be  the  invariable  result,  and  the  scar  almost  invisible. 

The  question  as  to  the  desirability  or  not  of  employing  a  general 
anaesthetic  in  these  operations   has   been   much    discussed.     Some 

surgeons,  and  notably  Kocher,  advise 
that  local  anaesthesia  (Schleich's  infil- 
tration method)  should  be  always 
employed  ;  many  others  reserve  that 
procedure  for  the  worst  cases,  and 
trust  to  a  skilled  anaesthetist  to  ad- 
minister safely  a  general  anesthetic 
to  the  majority  of  the  patients.  With 
this  latter  view  we  personally  concur. 
Fihro-ademmata,  or  Cysts,  when  mul- 
tiple or  deeply  placed,  are  treated  by 
extirpation  of  the  affected  lobe ;  but 
if  the  new  growth  is  single  and  super- 
ficial, it  may  be  safely  enucleated  by 
dividing  the  skin  and  muscles  as 
before,  incising  the  gland  substance 
and  capsule  down  to  the  growth, 
which  is  readily  shelled  out. 

Exophthalmic   Goitre,  or,   as   it   is 
often  termed,  Graves'  or  Basedow's 
Fig.  415.— Exophthalmic  Goitre,  disease  (Fig.  415),  is  a  condition  char- 
(From  a  Photograph.)  acterized  by  a  diffuse  enlargement  of 

the  thyroid  body,  which  often  pulsates 
forcibly  owing  to  the  dilatation  of  the  vessels  (particularly  those  in 
the  capsule),  associated  with  marked  anaemia,  severe  palpitation  and 
cardiac  irritability  (tachycardia),  and  protrusion  of  the  eyeball- 
(exophthalmos  or  proptosis).  The  disease  is  probably  due  to  some 
derangement  of  the  sympathetic  or  central  nervous  system,  associated 
with- definite  changes  in  the  thyroid  body  which  result  in  the  exces- 
sive absorption  of  thyroid  secretion,  either  normal  or  vitiated  in 
character.  The  enlargement  of  the  thyroid  body  is  not  always 
marked,  and  indeed  may  be  scarcely  noticeable,  but  microscopic 
changes  will  always  be  found.  The  gland  is  more  solid  in  texture 
than  usual ;  the  alveoli  are  small  and  crowded  together,  and  often 
contain  no  colloid  ;  papillary  proliferation  of  the  columnar  epithelium 
lining  the  walls  is  present.     The  gland  is  always  extremely  vascular. 


SURGERY  OF  THE  NECK  909 

The  patients  usually  affected  are  females,  about  the  middle  period 
of  life,  whose  menstrual  functions  are  often  impaired.  Overwork, 
worry,  and  severe  mental  strain,  are  apparently  responsible  for  the 
onset  of  the  symptoms  in  many  instances,  and  a  sudden  shock  or 
fright  accounts  for  others.  The  protrusion  of  the  eyeball  is  a 
marked  feature  of  most  cases,  and  is  sometimes  due  to  an  increase 
of  the  orbital  fat.  Contraction  of  the  so-called  muscle  of  Mliller 
(unstriped  muscular  fibres  stretched  across  the  spheno-maxillary 
fissure)  has  also  been  suggested  as  a  more  plausible  theory.  When 
the  patient  looks  down,  the  upper  eyelid  does  not  immediately 
follow  the  eyeball,  allowing  the  white  sclerotic  to  be  seen  between 
the  lid  and  the  cornea  (von  Graefe's  sign).  A  fine  fibrillary  tremor 
of  the  limbs  is  also  commonly  observed  in  these  cases.  The  patient 
is  always  extremely  nervous,  and  the  pulse-rate  high  ;  any  exertion 
or  excitement  increases  the  irritability  of  the  heart's  action,  and 
may  induce  considerable  respiratory  distress.  Left  to  itself,  the 
disease  in  some  cases  tends  to  improve,  but  in  others  it  may  progress 
to  a  fatal  issue  from  asthenia  or  cardiac  complications. 

Treatment  consists  in  freeing  the  patient,  if  possible,  from  all 
sources  of  irritation  and  worry  by  absolute  rest  in  bed,  whilst 
bromides,  iron,  and  perhaps  iodide  of  potassium,  are  administered 
internally,  attention  being  also  directed  to  correcting  menstrual 
derangements,  or  any  other  abnormalitiss  of  function  or  structure  ; 
thus,  the  cure  of  a  nasal  catarrh  by  cauterizing  the  nasal  mucosa  has 
several  times  led  to  a  rapid  amelioration  of  the  symptoms.  Phos- 
phate of  soda  has  been  found  useful  in  some  cases,  and  Kocher 
speaks  favourably  of  it  when  conjoined  with  suitable  hygienic 
measures.  Thymus  and  suprarenal  extracts  have  sometimes  proved 
beneficial,  as  also  the  blood-serum  or  dried  blood  of  animals  after 
thyroidectomy  (antithyroidin). 

Surgical  treatment  by  removal  of  a  portion  of  the  gland  is  often 
followed  by  excellent  results,  although  the  proceeding  is  not  devoid 
of  serious  risk,  and  should  not  be  lightly  undertaken.  Half  of  the 
gland  has  usually  been  removed,  but  some  surgeons  have  been 
satisfied  with  tying  three  of  the  thyroid  arteries  in  order  to  starve 
the  growth.  General  anaesthesia  is  decidedly  dangerous  in  these 
cases,  and  it  is  better  to  rely  on  local  anaesthesia,  either  of  the 
Schleich  type,  or  by  cocainization  of  the  superficial  cervical  nerve, 
which  can  be  exposed  at  the  posterior  border  of  the  sterno-mastoid 
at  the  level  of  the  thyroid  cartilage ;  2  or  3  drops  of  a  2  per  cent, 
solution  should  be  introduced  within -its  sheath.  Patients  are  also 
very  liable  to  syncope  after  the  operation,  and  occasionally  to  a 
curious  train  of  symptoms  probably  due  to  excessive  absorption  of 
thyroid  secretion.  The  temperature  a  few  hours  after  operation 
rises  suddenly  to  104°  or  105°,  the  pulse-rate  is  greatly  accelerated, 
and  the  patient  becomes  delirious  and  finally  comatose,  dying  in  that 
state  in  about  forty-eight  hours.  The  wound  should  be  at  once 
opened  up,  and  probably  a  considerable  quantity  of  a  thin  glairy 
fluid  will  be  found  within  it ;  this  should  be  soaked  up  by  repeatedly 


QTO  A  MANUAL  OF  SURGERY 

packing  the  wound  with  dry  sterile  wool,  or  a  drainage-tube  may  be 
inserted.  In  the  cases  that  recover,  a  gradual  improvement  usually 
shows  itself,  but  the  full  benefit  of  the  operation  is  rarely  gained  under 
six  or  twelve  months,  and  even  then  the  exophthalmos  often  persists. 

Complete  bilateral  excision .  of  the  cervical  chain  of  sympathetic 
ganglia  has  also  been  employed  in  this  condition,  and  apparently  with 
good  effects ;  the  mortality  is  decidedly  less  than  in  thyroidectomy. 

Malignant  Disease  of  the  Thyroid  Body  is  more  frequently  cancerous 
in  nature  than  sarcomatous,  usually  taking  the  form  of  an  adenoid 
cancer,  and  almost  always  preceded  by  some  variety  of  simple  goitre. 
The  tumour  grows  rapidly,  infiltrating  the  surrounding  parts,  and 
causing  enlargement  of  the  lymphatic  glands,  and  secondary  deposits 
in  the  viscera  and  elsewhere.  The  trachea  is  severely  compressed, 
and  in  some  cases  perforated ;  the  main  vessels  are  frequently  sur- 
rounded by  the  growth,  and  not  merely  displaced  as  in  the  simple 
variety.  Myxoedema  may  ensue  as  a  late  complication,  owing  to 
the  total  destruction  of  the  glandular  substance.  Treatment  by 
extirpation  can  only  be  undertaken  in  the  early  stages. 

Acute  Goitre  is  but  rarely  met  with,  corisisting  of  a  rapid  enlarge- 
ment of  the  thyroid  body,  which  attains  a  considerable  size  in  the 
course  of  a  few  days  or  weeks.  It  affects  young  subjects,  and  is 
generally  fatal  from  asphyxia  due  to  pressure  on  the  trachea  or  spasm 
of  the  glottis.  Removal  of  one  lobe  under  local  anaesthesia  is  the 
only  treatment  that  holds  out  any  prospect  of  cure. 

Inflammation  of  the  Thyroid  Body,  or  acute  thyroiditis,  occasionally 
supervenes  as  a  complication  of  an  ordinary  goitre.  It  is  almost 
always  infective  in  nature,  the  cocci  reaching  it  from  without,  as 
from  tapping  cysts  or  from  a  punctured  wound,  or  from  within  the 
body  in  a  pyaemic  'ernbolus,  suppuration  being  usually  induced ;  it 
sometimes  occurs  as  a  sequela  of  the  acute  specific  fevers,  or  may 
follow  a  blow.  The  gland  becomes  enlarged,  hot,  and  tender  ;  fever 
and  rigors  follow,  and  the  presence  of  pus  is  indicated  by  superficial 
oedema  and  fluctuation.  The  early  treatment  consists  in  the  applica- 
tion of  fomentations  and  perhaps  leeches,  or  in  the  use  of  an  ice 
compress.  The  patient  is  kept  in  bed,  purged,  and  carefully  dieted. 
Under  such  a  regime,  resolution  may  occur  ;  but  if,  as  happens  more 
frequently,  pus  forms,  free  incisions  should  be  made. 

Accessory  Thyroids  sometimes  develop  above  or  below  the 
isthmus,  or  are  closely  attached  to  one  of  the  lateral  lobes.  They 
may  be  connected  with  the  thyroid  body,  moving  up  and  down 
with  it  on  deglutition  ;  or  they  may  be  independent  of  it,  occurring 
in  any  part  of  the  thyro-glossal  duct,  and  even  in  the  base  of  the 
tongue,  in  that  situation,  resembling  a  dermoid  cyst.  If  trouble- 
some, they  should  be  removed  and  subjected  to  microscopic 
examination,  as  their  structure  varies,  and  there  is  a  possibility  of 
recurrence. 

Myxcedema  (or  cachexia  strumipriva)  is  a  curious  condition,  which,  as  already 
mentioned,  supervenes  when  the  thyroid  body  is  '  totally  removed,  or  so 
•■bsolutely  disorganized  or  infiltrated   by  a  new  growth  as  to  be  functionless. 


SURGERY  OF  THE  NECK  911 

Although  it  is  possible  that  we  have  still  much  to  learn  of  the  duties  of  this 
organ,  yet  it  is  known  that  the  elimination,  if  not  the  development,  of  mucin  in 
the  body  is  controlled  by  it,  and  that  its  absence  leads  to  an  accumulation  of 
this  substance  in  the  blood  and  tissues.  The  condition  and  appearance  of  the 
individual  are  very  characteristic.  The  face  is  puffy,  waxy  white,  and  expression- 
less, with  perhaps  a  hectic  flush  over  the  malar  eminences  ;  the  tongue  is 
enlarged  ;  the  limbs  become  thickened  and  clumsy  by  an  increase  in  bulk  of  the 
soft  tissues  ;  there  is  often  a  puffy  mass  occupying  the  supraclavicular  fossa, 
which,  however,  does  not  pit  on  pressure.  The  mental  faculties  are  dulled,  and 
all  intellectual  processes  are  slow  ;  the  temperature  is  subnormal ,  and  the  heart's 
action  weakened.  Left  to  itself,  death  will  supervene  from  asthenia  sooner  or 
later;  should  the  case  be  treated  by  thyroid  gland  or  extract  (half  a  gland,  raw 
or  lightly  cooked,  twice  a  week,  or  a  5-grain  tabloid  once  or  twice  a  day),  the 
symptoms  soon  disappear,  and  the  change  from  the  dufl,  heavy  condition  of 
myxoedema  to  one  of  normal  health  of  mind  and  body  js  almost  miraculous. 

Similar  treatment  should  be  employed  for  myxoedematous  cretins,  who  often 
start  growing. rapidly  as  soon  as  treatment  commences. 

The  Parathyroid  G-lands  are  small  ovoid  bodies,  usually  four  in 
number,  situated  behind  the  thyroid  gland,  and  generally  near  the 
termination  of  the  inferior  thyroid  artery.  Microscopically  they 
consist  of  columns  of  epithelial  cells  with  large  nuclei,  embedded  in 
a  rich  capillary  stroma.  Spaces  are  often  found  in  them  containing 
a  colloid  material,  which  is  not  considered  identical  with  that  found 
in  the  thyroid  vesicles.  Their  function  is  not  definitely  known,  but 
their  complete  removal  in  animals  causes  acute  convulsive  attacks, 
together  with  the  condition  known  as  tetany,  and  death  in  a  few  days 
from  coma.  The  tetany  formerly  ascribed  to  removal  of  the  thyroid 
body  is  in  reality  due  to  disease,  absence  or  removal  of  the  para- 
thyroids. It  is  also  considered  possible  that  the  changes  in  the 
thyroid  body  in  Graves'  disease  are  in  some  way  due  to  lesions  in 
the  parathyroids,  but  the  exact  relationship  is  not  yet  certain. 

The  Thymus  G-land  is  an  occasional  source  of  trouble  in  that  it 
persists  and  becomes  enlarged  instead  of  disappearing.  Normally 
it  reaches  its  greatest  dimensions  about  the  age  of  two  years,  and 
then  gradually  wastes  so  that  by  puberty  it  is  represented  by  a  mass 
of  fatty  tissue,  with  perhaps  a  few  remnants  of  the  original  organ. 
Its  persistence,  and  still  more  its  enlargement,  are  indicated  by 
fulness  of  the  root  of  the  neck,  dulness  over  the  sternum,  perhaps  by 
evidences  of  mediastinal  pressure  on  the  large  veins,  and  certainly 
by  increasing  dyspnoea.  A  thymic  asthma,  partaking  of  the  nature 
of  laryngismus  stridulus,  has  been  described  ;  but  more  important  is 
the  association  of  an  enlarged  thymus  with  generalized  lymphatic 
hyperplasia,  and  a  large  spleen  in  the  condition  known  as  status 
lymphaticus  (g.v.),  which  may  be  the  cause  of  sudden  death  under 
anaesthetics.  The  thymus  is  also  enlarged  in  some  cases  of  Graves' 
disease.  Tracheotomy  is  useless  in  the  treatment  of  the  somewhat 
severe  dyspnoea  sometimes  present,  and  operative  interference  for 
the  removal  of  the  enlarged  gland  has  been  undertaken  with  success 
in  some  cases.  Lymphadenoma  and  lymphosarcoma  have  also  been 
known  to  affect  this  organ. 


CHAPTER  XXXII. 
SUEQERY  OF  THE  AIR  PASSAGES,  LUNGS,  AND  CHEST. 

Examination  of  the  Upper  Air-Passages. 

Before  the  student  can  understand  affections  of  this  region,  it  is 
absolutely  essential  for  him  to  master  the  use  of  the  laryngoscope. 
This  consists  of  a  circular  mirror  set  at  an  angle  on  the  end  of 
a  metal  stem,  which  is  inserted  into  the  patient's  widely-opened 
mouth  in  such  a  way  that  it  rests  against,  and  slightly  elevates,  the 
soft  palate.  A  beam  of  light  is  thrown  into  the  mouth,  either  from 
an  electric  head-lamp  on  the  surgeon's  forehead,  or  reflected  by  a 
frontal  mirror  from  a  suitable  source  of  illumination.  The  patient's 
tongue,  held  with  a  towel,  is  drawn  well  forwards  so  as  to  enable  the 
light  to  reach  the  larynx,  the  image  of  which  is  seen  in  the  mirror. 
Considerable  practice  is  needed  in  order  to  attain  any  facility  in  the 
use  of  this  instrument,  as  also  to  be  able  to  recognise  normal  from 
abnormal  structures.  The  use  of  cocaine  to  anaesthetize  the  fauces 
is  in  many  cases  indispensable.  It  must  be  remembered  that  the 
image  is  always  inverted,  so  that  anterior  portion  of  the  larynx 
appears  behind,  but  there  is  no  reversal  of  the  sides. 

A  new  appliance  has  been  recently  employed  to  see  the  interior 
of  the  air-passages  in  the  form  of  Killians  bronchoscope  (Fig.  416). 
This  consists  of  a  straight  tube,  which  can  be  introduced  through  the 
upper  air-passages  thoroughly  cocainized  (upper  bronchoscopy),  or 
through  a  tracheotomy  incision  (lower  bronchoscopy),  and  can  then 
be  carried  down  to  the  bifurcation  of  the  trachea.  Smaller  tubes 
slipped  down  inside  the  outer  allow  the  bronchi  to  be  examined. 
The  interior  is  illuminated  either  directly  or  by  reflection  from 
a  mirror.  By  this  means  foreign  bodies  have  been  extracted  from 
a  bronchus  on  many  occasions.  A  similar  contrivance  has  been 
employed  by  Killian  for  the  oesophagus,  and  is  decidedly  useful. 

Foreign  Bodies  in  the  Air-Passages. 

Any  part  of  the  respiratory  tract  may  be  partially  or  completely 
obstructed  by  the  presence  of  some  foreign  body,  the  effect  of  which 
may  be  of  greater  or  less  gravity  according  to  the  situation,  character, 
and  size  of  the  intruding  substance. 

gi2 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       913 

1.  In  the  Nasal  Passages,  see  p,  829. 

2.  Obstruction  occurring  at  the  pharyngeal  entrance  to  the  larynx 

is  usually  due  to  attempts  to  bolt  large  masses  of  food,  which, 
becoming  impacted,  may  cause  immediate  death.  A  person,  eating 
a  meal  voraciously,  turns  black  in  the  face  and  falls  off  his  chair 
dead.  A  similar  result  has  followed  such  a  foolish  act  as  attempting 
to  swallow  a  billiard  ball.  If  the  obstruction  is  not  complete,  as 
when  a  plate  of  false  teeth  becomes  impacted,  great  dyspnoea 
is  caused,  and  absolute  inability  to  swallow,  the  symptoms  rapidly 
increasing  owing  to  oedema  of  the  submucous  tissue  of  the  glottis. 
Accidents  of  a  similar  nature  may  occur  during  chloroform  narcosis, 


1^ 


Fig.  416.— Killian's  Bronchoscope  in  Position. 

The  patient  is  generally  anaesthetized,  and  lies  on  his  back  with  the  head  thrown 
over  the  end  of  the  table.  After  introduction  of  the  main  tube  down  the 
trachea,  extension  tubes  can  be  inserted  to  explore  the  bronchi ;  one  of  the 
latter  is  shown  in  the  above  sketch  reaching  down  to  the  bifurcation  of  the 
trachea 

an  epileptic  fit,  or  drunkenness,  some  such  substance  as  a  plate  of 
teeth  being  dislodged  from  the  mouth,  or  a  mass  of  food  being 
vomited,  and  blocking  the  entrance  to  the  larynx.  The  Treatment 
must  be  very  prompt,  since  there  is  no  time  to  lose.  The  mouth 
should  be  forced  open  by  the  handle  of  a  fork,  or  anything  suitable 
that  happens  to  be  near,  and  the  finger  rapidly  swept  round  the 
pharynx  so  as  to  dislodge  the  foreign  body.  Failing  this,  laryngotomy 
must  be  performed  at  once,  and  artificial  respiration,  if  necessary, 
instituted.  In  less  urgent  cases  there  is  time  to  remove  the  substance 
from  the  mouth  with  the  assistance  of  a  frontal  rnirror  and  suitable 
forceps. 

58 


914  A  MANUAL  OF  SURGERY 

3.  In  the  Larynx. — A  foreign  body  enters  the  larynx  by  inhalation 
during  a  deep  inspiratory  effort,  when  the  glottis  is  widely  open. 
Anything  large  is  likely  to  be  stopped  above  the  larynx,  and  hence 
the  type  of  foreign  body  found  in  this  region  consists  of  small 
coins,  buttons,  nutshells,  or  a  small  tooth-plate.  It  may  cause  total 
obstruction  and  immediate  death,  or  may  enter  one  of  the  ventricles, 
and  only  produce  partial  obstruction,  as  evidenced  by  a  sudden  sense 
of  suffocation,  urgent  dyspnoea,  and  a  violent  attack  of  coughing, 
attended,  perhaps,  by  vomiting,  such  as  occurs  when  anything  is  said  to 
have  '  gone  down  the  wrong  way.'  The  voice  becomes  croupy  and 
hoarse,  respirations  are  stridulous,  and  any  movement  of  the  patient 
may  for  some  time  bring  on  a  spasmodic  fit  of  dyspnoea.  After  a  while 
the  obstruction,  which  is  at  first  partial,  m.ay  become  complete  from 
oedema  of  the  glottis,  whilst  perichondritis  and  ulceration  or  necrosis 
of  the  cartilages  may  be  induced.  Laryngoscopic  examination 
should  reveal  the  situation  of  the  intruding  body.  The  Treatment 
consists  in  attempting  to  remove  it  through  the  mouth  with  suitably 
curved  forceps  guided  by  a  laryngoscope  (endo-laryngeal  method) ; 
or,  failing  that,  a  laryngotomy  is  performed,  and  the  body  dislodged 
if  possible  from  below.  Should  this  not  be  successful,  thyrotomy 
(p.  920)  must  be  undertaken. 

4.  In  the  Trachea. — To  lodge  in  this  situation  a  foreign  body  must 
be  small  enough  to  pass  through  the  rima  glottidis,  and  not  too 
heavy,  otherwise  it  drops  into  one  of  the  bronchi ;  it  may  become 
impacted,  if  it  has  jagged  edges,  but  is  not  uncommonly  free.  It 
may  remain  in  one  spot,  only  moving  when  the  patient  alters  his 
position  or  coughs,  and  then  the  longer  it  stays,  the  less  moveable  it 
is,  owing  to  its  becoming  embedded  in  mucus. 

The  Symptoms  may  be  described  as  those  of  obstruction,  irritation, 
and  inflammation.  During  the  passage  of  the  body  through  the 
larynx,  the  patient  suffers  from  a  severe  attack  of  spasmodic  dyspnoea 
and  coughing,  which  may  last  for  some  time.  Later  on  similar 
attacks  may  be  induced  by  the  foreign  body  being  coughed  up 
against  the  lower  aspect  of  the  vocal  cords,  and  death  has  even 
resulted  from  its  impaction  in  the  larynx  brought  about  in  this  way. 
The  irritation  of  the  unusual  occupant  of  the  trachea  produces 
tracheitis,  with  frothy  expectoration  and  spasmodic  cough ;  the  lower 
it  lies,  the  less  the  irritation,  the  mucous  membrane  being  apparently 
less  sensitive  as  it  descends  from  the  larynx.  Treatment  consists  in 
the  introduction  of  a  Killian's  bronchoscope  so  that  the  foreign  body 
may  be  seen,  and  by  suitable  forceps  secured  and  removed.  If  such 
appliances  are  not  available,  a  low  tracheotomy  must  be  performed, 
with  a  good-sized  opening,  and  it  may  be  possible  to  reach  and 
remove  the  foreign  body  ;  or  the  patient  may  be  inverted  and  the 
back  well  concussed  in  order  to  dislodge  it.  '  Failing  this,  the  wound 
in  the  trachea  must  be  left  widely  open,  by  inserting  a  wire  stitch 
through  each  side  of  the  incision  and  tying  the  ends  behind  the  neck ; 
very  probably  the  body  will  be  expelled  through  it  during  an  attack 
of  coughing. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       915 

5.  To  become  impacted  in  a  Bronchus,  the  foreign  body  must  be 
sufficiently  small  to  pass  through  the  rima  glottidis,  and  heavy  and 
smooth  enough  to  allow  of  its  dropping  down  the  trachea ;  the  most 
common  articles  met  with  are  buttons,  pebbles,  slate  pencils,  a  pin, 
an  O'Dwyer's  tube,  or  the  inner  cannula  of  a  tracheotomy-tube.  The 
right  bronchus  usually  becomes  obstructed,  the  reason  for  this:  being 
that,  although  the  left  bronchus  is  more  in  a  direct  line  with  the 
trachea,  yet  the  right  is  the  larger,  the  septum  between  them  lying 
to  the  left  of  the  middle  line.  A  series  of  symptoms  similar  to  those 
already  described  manifests  itself,  viz.,  obstruction,  irritation,  and  in- 
flammation. The  obstruction  is  twofold :  immediate,  as  a  result  of 
the  passage  of  the  intruder  through  the  glottis,  a  condition  due  more 
to  spasm  than  to  mechanical  ■  causes ;  and  late,  as  a  sequence  of  its 
lodgment  in  the  bronchus.  Even  if  the  obstruction  is  at  first  partial, 
it  soon  becomes  complete  from  swelling  of  the  mucous  membrane  ; 
for  a  time  it  is  more  or  less  valvular  in  character,  allowing  exit  to  air 
during  expiration,  but  absolutely  preventing  its  entrance.  Collapse 
of  that  portion  of  the  lung  supplied  by  the  affected  bronchus  is  thus 
induced,  as  indicated  by  dulness  and  the  absence  of  breath-sounds. 
Irritation  and  inflammation  soon  follow,  resulting  in  bronchitis,  the 
formation  of  a  bronchiectasis,  and  peri-bronchial  pneumonia ;  suppura- 
tion ensues,  and  the  foreign  body  may  be  expelled  sooner  or  later 
with  a  sudden  gush  of  pus  during  a  fit  of  coughing.  Thus,  in  one 
case*  a  beech -mast  was  inhaled  in  November,  181 2,  and  was 
not  extruded  till  May,  1822,  the  patient  having  in  the  meantime 
developed  all  the  symptoms  of  a  bronchiectasis.  Sometimes  the 
abscess  may  extend  through  the  lung  substance  to  the  pleura,  setting 
up  a  localized  empyema,  through  which,  when  opened,  the  article  is 
expelled.  In  other  cases  the  lung  becomes  riddled  with  abscesses, 
and  the  patient  dies  of  exhaustion. 

Treatment.  —  The  position  of  the  foreign  body  must  be,  if 
possible,  ascertained  by  careful  examination  of  the  lungs,  which 
may  reveal  a  certain  amount  of  collapse,  whilst  radiography  may 
also  be  useful,  and  Killian's  bronchoscope  may  permit  it  to  be  seen. 
A  skilled  laryngologist  will  probably  be  required  to  introduce  this 
instrument  through  the  mouth,  but  in  his  absence  any  surgeon  could 
pass  it  through  an  incision  in  the  trachea.  The  patient  is  advisably 
anaesthetized,  and  lies  on  the  back  with  his  head  hanging  over  the 
end  of  the  table.  Fine  tubes  can  be  passed  through  the  main 
cannula  so  as  to  enter  the  smaller  bronchi. f 

In  the  absence  of  this  appliance  a  low  and  extensive  tracheotomy 
is  performed,  and  the  bronchi  are  examined  by  a  long  bullet  probe, 
suitably  curved.  The  foreign  body  may  thus  be  felt,  and  its  removal 
accomplished  by  a  delicate  pair  of  forceps,  a  loop  of  wire,  or  a  coin- 
catcher.  Should  it  be  impossible  to  remove  it,  the  tracheotomy 
wound  is  left  open  for  a  time  in  the  hope  that  inflammatory  disturb- 

*  Mr.  William  Rose,  senior,  Lancet,  August,  1843. 

t  For  the  employment  of  this  method  in  the  removal  of  a  pin,  see  St.  Clnir 
Thomson,  Lancet,  May  7,  igio. 


9i6  A  MANUAL  OF  SURGERY 

ance  may  loosen  it,  and  it  may  be  coughed  up.  Abscess  of  the  lung, 
and  localized  empyema,  are  dealt  with  by  incision,  and  it  is  possible 
that  the  foreign  body  may  be  removed  by  this  means  through  the 
thoracic  parietes.  In  several  instances  the  chest  has  been  opened- 
successfully  in  the  early  stages,  and  a  foreign  body  removed  by  direct 
incision  into  the  bronchus. 


Injuries  of  tlie  Larynx. 

Several  conditions  arising  from  traumatism  of  the  upper  air- 
passages  have  been  already  described — e.g.,  fracture  of  the  hyoid 
bone  (p.  490),  and  incised  wounds,  as  in  cut  throat  (p.  900). 

Occasionally  the  thyroid  or  other  cartilages  may  be  injured  or 
fractured  by  direct  violence,  as  in  garrotting,  causing  local  pain  and 
haemorrhage,  and  possibly  some  obstruction  to  the  respiration.  As 
a  rule,  no  treatment  is  required  beyond  keeping  the  patient  quiet, 
but  should  symptoms  of  dyspnoea  arise,  intubation  or  tracheotomy 
must  be  undertaken. 

Diseases  of  the  Larynx. 

The  study  of  laryngeal  diseases  can  only  be  briefly  referred  to  here,  since  it  is 
now  so  extensive  as  to  require  special  textbooks. 

Acute  and  Chronic  Laryngitis  are  conditions  of  but  slight  surgical  interest. 
The  acute  affection  arises  from  cold  or  over-exertion  of  the  vocal  apparatus,  and 
is  characterized  by  aphonia  (loss  of  voice)  and  cough.  Locally,  the  vocal  cords 
are  seen  to  be  hyperaemic  and  swollen.  The  Treatment  is  rather  medical  than 
surgical,  although  in  children  intubation  or  tracheotomy  may  be  sometimes 
required. 

Diphtheritic  Inflammation  of  the  Lar3aix  is  usually  met  with  as  an  extension  of 
a  similar  affection  of  the  fauces.  It  gives  rise  to  severe  dyspnoea  from  obstruc- 
tion, and,  if  the  condition  does  not  yield  to  the  injection  of  the  diphtheritic  anti- 
toxin, will  probably  require  intubation  or  tracheotomy. 

Acute  (Edematous  Laryngitis,  or  oedema  of  the  glottis,  is  a  condition  of  con- 
siderable surgical  importance.  Causes.— {a)  It  is  either  secondary  to  some  other 
laryngeal  affection,  such  as  acute  catarrhal  laryngitis,  acute  perichondritis,  or 
more  rarely  to  some  chronic  affection,  such  as  syphilis  or  carcinoma ;  or 
(b)  it  may  extend  from  inflammatory  conditions  of  neighbouring  tissues,  such  as 
the  root  of  the  tongue,  or  the  submaxillary  region — e.g.,  in  celluhtis  or  Ludwig's 
angina  ;  or  it  may  be  secondary  to  a  retropharyngeal  abscess,  (c)  It  is  also  not 
unfrequently  seen  in  children  from  drinking  scalding  water,  as  from  the  spout 
of  a  kettle,  or  sometimes  in  adults  from  swallowing  corrosives,  (d)  It  may  result 
from  the  presence  of  a  foreign  body,  (e)  It  has  also  been  known  to  occur  as  part 
of  the  general  anasarca  of  chronic  Bright's  disease.  Characters. — The  folds  of 
mucous  membrane  extending  on  either  side  of  the  epiglottis  both  to  the  root 
of  the  tongue  and  backwards  to  the  arytenoid  cartilages  become  swollen  and 
oedematous  from  a  serous  effusion  into  the  submucous  tissue  (Fig.  417).  The 
same  condition  also  involves  the  interarytenoid  fold  and  the  false  vocal  cords 
(superior  thyro-arytenoid  folds),  extending  down  as  far  as  the  true  cords.  The 
process  is  checked  at  this  level  owing  to  the  absence  of  submucous  tissue,  the 
vocal  cords  consisting  of  elastic  fibres  covered  merely  with  a  layer  or  two  of 
squamous  epithelium.  The  epiglottis  becomes  folded  laterally  upon  itself  as  a 
leaf,  leaving  only  a  valve-like  chink  which  permits  of  expiration,  although 
considerably  checking  inspiration.  The  Symptoms  produced  by  this  condition  are 
those  of  mechanical  dyspnoea,  to  which  not  unfrequently  spasm  of  the  glottis  is 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS.  AND  CHEST       917 


superadded,  and  this  is  sometimes  of  sufficient  intensity  to  destroy  the  patient's  life. 
There  may  be  also  some  difficulty  in  swallowing,  owing  to  associated  oedema  of  the 
pharynx  and  oesophagus,  and  some  degree  of  febrile  disturbance.  The  diagnosis  is 
made,  either  by  passing  the  finger  into  the  pharynx,  when  the  rigid,  swollen  epi- 
glottis can  be  felt,  or  by  laryngoscopic  examination,  when  the  slit-like  opening  of 
the  glottis,  bounded  below  and  behind  by  thickened  oedematous  folds  of  mucous 
membrane,  can  be  seen.  Treatment  consists  in  scarification  of  the  swollen  tissues 
below  and  behind  the  epiglottis,  which  can  be  effected  after  spraying  the  parts 
with  cocaine  either  by  the  finger-nail  or  with  a  suitable  knife  guided  by  a  laryngo- 
scope. The  usual  result  is  a  rapid  diminution  of  the  oedema,  and  additional 
relief  may  be  gained  by  inhaling  steam  arising  from  hot  water,  to  which  some 
tinct,  benzoini  co.  has  been  added. 
Fomentations  or  ice  compresses  applif  d 
externally  are  also  useful,  especially 
the  latter.  In  more  severe  cases,  and 
especially  in  children,  intubation  may 
be  necessary,  or  the  air-passages  ma  / 
be  opened  below  the  obstruction,  laryn- 
gotomy  sufficing  in  adults,  but  a  hig!i 
tracheotomy  being  needed  in  children. 
Syphilitic  Diseases  of  the  Larynx. — 
In  the  secondary  stage,  mucous  tubercles 
or  superficial  ulcers  occasionally  form 
in  the  neighbourhood  of  the  vocal  cords, 
concurrently  with  the  rash  on  the  skin, 
and  the  formation  of  condylomata  and 
mucous  tubercles  elsewhere.  These  arc 
most  likely  to  occur  in  costermongers 
or  those  who  have  to  speak  loudly,  and 
may  then  lead  to  a  good  deal  of  thicken- 
ing of  the  cords.  Apart  from  such 
cases,  it  rarely  causes  much  trouble 
beyond  a  little  hoarseness.  No  special 
treatment  is  required,  although  pos- 
sibly the  parts,  if  ulcerated,  may  be 
brushed  over  with  a  solution  of  per- 
chloride  of  mercury.  In  the  tertiary 
period,  difi"use  gummatous  infiltration 
or  localized  gummata  may  develop, 
giving  rise  to  destructive  ulceration, 
which  especially  affects  the  epiglottis 
and  aryteno-epiglottidean  folds,  and 
may  spread  backwards  and  involve  the 
whole  glottis  (Fig.  418).  Inflammation 
of  the  perichondrium  is  likely  to  follow, 
leading  to  necrosis  of  the  cartilages.  The  base  of  the  tongue  is  seen  to  be  en 
Hoarseness  and  dyspnoea  are  the  chief       larged  and  swollen,  and  the  aryteno 


Fig.  417. — CEdema  of  Glottis  from 
Behind.  (College  of  Surgeons' 
Museum.) 


epiglottidean  folds  are  oedematous,  so 
that  the  entrance  to  the  larynx  is 
represented  by  a  mere  chink. 


symptoms  of  this  affection,  whilst  con- 
siderable obstruction  may  be  caused 
subsequently  by  cicatrization  and  laryn- 
geal stenosis.     Treatment  consists  in  the 

administration  of  iodide  of  potassium  and  mercury,  whilst  ulcers  may  be  sprayed 
with  perchloride  of  mercury  solution,  or  dusted  over  with  calomel  or  iodoform. 
Should  urgent  dyspnoea  arise,  tracheotomy  must  be  undertaken. 

Tuberculous  Laryngitis  (Fig.  419)  is  occasionally  a  primary  manifestation,  but 
is  much  more  frequently  secondary  to  phthisis,  arising  from  infection  of  the 
mucous  membrane  owing  to.  the  constant  passage  over  it  of  the  sputum.  It 
usually  commences  at  the  posterior  part  of  the  larynx  in  the  neighbourhood  of 
the  arytenoid  cartilages,  as  a  submucous  infiltration,  which  breaks  down,  and 
leads  to  typical  tuberculous  ulcers,  similar  to  those  occurring  in  other  viscera 
(p.  173).     Considerable  destruction  of  tissue  ensues,  involving  the  whole  circum- 


918 


A  MANUAL  OF  SURGERY 


ference  of  the  larynx,  and  even  leading  to  perichondritis  and  necrosis  of  the 
cartilages.  Hoarseness,  dough,  pain  on  swallowing,  and  perhaps  a  certain 
amount  of  dyspnoea,  in  a  patient  suffering  from  phthisis,  are  the  chief  symptoms 
arising  from  this  affection,  the  prognosis  of  which  is  always  of  a  grave  nature. 
The  anaemic  condition  of  the  mucous  membrane  is  an  important  diagnostic  sig:.i 
in  the  early  stages.  Treatment.— As  for  other  tuberculous  affections,  constitutional 
treatment  is  now  mainly  relied  on,  and  for  choice  in  a  sanatorium,  whilst  absolute 
silence  is  insisted  on.  Occasionally  local  treatment  is  undertaken  by  the  laryn- 
gologist  in  the  form  of  topical  applications  of  lactic  acid,  and  the  removal  of 
papillary  outgrowths  or  of  the  epiglottis.  The  earlier  recognition  of  pulmonary 
tuberculosis  and  its  more  effective  treatment  is,  however,  reducing  the  number  ol 
cases  of  the  laryngeal  affection. 


Fig.  418  — GuMMATOUo  Disease  of 
THE  Larynx.     (Tillmanns.) 

Small  gummata  are  seen  invading 
the  mucous  membrane  of  the 
epiglottis  and  front  of  the  larynx. 


Fig.  419. — Tuberculous  Disease 
OF  the  Larynx,  with  Exten- 
sive Ulceration  in  Front  and 
Behind.     (Tillmanns.) 

a,  b,  c.  Remains  of  the  epiglottis. 


Paralysis  of  the  Larynx  is  observed  in  a  variety  of  conditions,  but  is  only  of 
surgical  interest  when  arising  from  injury  or  division  of,  or  pressure  upon,  the 
recurrent  laryngeal  nerve.  It  may  follow  the  removal  of  a  goitrous  tumour  or  of 
tuberculous  glands,  but  is  most  commonly  seen  in  connection  with  aneurisms  of 
the  innominate  or  aorta,  or  tumours  in  the  same  neighbourhood — eg.,  cancer  of 
the  oesophagus,  the  actual  pressure  in  the  latter  case  be.ng  probably  exercised 
by  secondarily  enlarged  lymphatic  glands.  Paralysis  from  the  above  causes  is 
generally  unilateral,  but  if  due  to  cancer  both  sides  may  be  involved.  The  effect 
of  complete  paralysis  of  one  recurrent  laryngeal  is  to  produce  total  immobil  ty  on 
the  affected  side  of  the  vocal  cord,  which  lies  in  what  is  known  as  the  '  cadaveric 
position  ' — i.e.,  midway  between  that  in  which  it  is  placed  during  phonation  and 
during  inspiration.  Not  uncommonly  the  paralysis  is  incomplete,  and  then 
merely  affects  the  abductor  muscle  (the  crico-arytenoideus  posticus).  The 
Symptoms  arising  from  unilateral  recurrent  paralysis  are  often  slight,  the  voice 
being  usually  but  little  modified,  owing  to  the  healthy  cord  being  capable  of 
passing  across  the  middle  line.  If,  however,  both  sides  are  completely  paralyzed, 
absolute  aphonia,  without  dyspnoea,  results  ;  but  if  only  the  abductors  are  in- 
volved, the  voice  may  be  unimpaired,  although  severe  dyspnoea  is  often  present, 
and  this  may  prove  fatal  unless  tracheotomy  is  promptly  performed. 

Papilloma  of  the  Larynx  (Fig.  420)  occurs  in  the  form  of  wart-like  masses, 
usually  growing  from  the  true  vocal  cords,  and  giving  ri^e  to  considerable 
hoarseness  and  perhaps  some  dyspnoea.  They  are  recognised  on  laryngosoopic 
examination,  and  may  be  removed  successfully  by  laryngeal  forceps,  after  the 
parts  have  been  efficiently  cocainized.  It  is  recommended  by  some  authorit  es 
to  destroy  the  growth  with  a  galvano-cautery,  but  there  is  always  a  certain 
liability  to  recur. 

Epithelioma  Laryngis  occurs  in  patients  over  forty,  originating  as  a  papillary 
overgrowth,  usually  near  the  base  of  the  epiglottis,  or  from  the  true  or  false 
cords  (Fig.  421).  The  tumour  gradually  spreads,  boih  superficially  and  deeply, 
and  may  invade  the  cartilages,  giving  rise  to  necrosis.  At  a  later  stage  it  extends 
beyond  the  limits  of  the  larynx,  attacking  the  base  of  the  tongue,  oeeophagus. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       919 

and  even  the  lateral  walls  of  the  pharynx.  As  long  as  the  disease  is  strictly 
limited  to  the  larynx  (intrinsic),  the  growth  is  often  unilateral,  causing  hoarse- 
ness and  aphonia,  together  with  an  irritable  cough  and  the  expectoration  of 
blood-stained  muco-pus,  which  may  be  horribly  offensive  ;  it  is  associated  with 
but  little  tendency  to  affection  of  lymphatic  glands.  When,  hov/ever,  the 
growth  has  extended  to  surrounding  structures  (extrinsic),  lymphatic  enlargement 
follows,  and  the  disease  runs  its  usual  course,  destroying  life  by  dyspnoea  and 
exhaustion.  Pain  is  often  a  most  distressing  symptom,  being  referred  either  to 
the  larynx  or  pharynx,  or,  according  to  Ziemssen,  not  unfrequently  to  the  ear. 
Treatme7it. — In  the  early  stages  it  is  possible  that  thyrotomy  and  efficient  curetting 
and  cauterization  may  suffice  to  bring  about  a  cure.  Later  on,  removal  of_  one 
or  both  halves  of  the  larynx,  together  with  the  affected  glands,  will  be  required, 


Fig.  420. — PapIllgmata  of  the 
Larynx,  springing  from  the 
Right  Vocal  Cord.      (Till- 

MANNS.) 


Fig.  421. — Epithelioma  of  the  Larynx, 

INVOLVING     the    RiGHT    VoCAL    CoRD 

AND  Base  of  the  Epiglottis.     (Till- 

MANNS.) 


and  the  operation  may  even  include  parts  of  the  tongue  and  pharyngeal  wall. 
Where,  however,  the  disease  has  spread  extensively,  its  total  extirpation  is  rarely 
practicable,  and  all  that  can  be  done  is  to  treat  symptoms  as  they  arise,  and 
perform  tracheotomy  when  necessary. 

Acute  and  Chronic  Perichondritis  are  affections  of  the  perichondrium,  usually 
ending  in  the  formation  of  an  abscess  and  in  necrosis  of  the  cartilage  involved. 
The  acute  V3x\eiy  is  pyogenic,  and  due  to  traumatism  or  to  auto-infection,  following 
acute  fevers,  such  as  typhoid.  The  patient  complains  of  severe  pain  and  tender- 
ness over  the  larynx,  with  fever,  dysphagia,  and  hoarseness.  Dyspnoea  results 
from  swelling  of  the  mucous  membrane,  and  oedema  of  the  glottis  may  follow. 
An  abscess  may  point  internally  or  externally,  and  on  opening  it  the  cartilage 
will  usually  be  felt  bare  and  perhaps  necrosed.  Treatment  in  the  early  stages 
consists  in  fomentations  ;  but  when  the  affection  is  producing  dyspnoea,  and  an 
external  swelling  is  present,  it  is  well  to  cut  down  on  the  cartilages  from  outside. 
Should  this  fail  to  relieve  the  dyspnoea,  a  tracheotomy  will  be  required.  The 
chronic  variety  is  more  often  due  to  tubercle,  syphilis,  or  carcinoma :  in  it  an 
abscess  forms  more  slowly  and  with  less  constitutional  disturbance,  but  necrosis 
ensues  none  the  less.  When  the  abscess  points  externally,  it  should  be  opened 
from  outside,  but  sometimes  in  these  cases  it  is  possible  to  deal  with  it  from 
within.  When  a  well-marked  sequestrum  is  present,  it  must  be  removed  by  an 
external  incision,  and  if  need  be  a  thyrotomy  must  be  undertaken.  Distortion  or 
stenosis  of  the  larynx  is  not  an  unusual  sequela,  possibly  necessitating  the  perpetual 
use  of  a  tracheotomy-tube. 

Operations  upon  the  Air-Passages. 

I.  Subhyoid  Pharyngotomy  was  devised  by  Malgaigne,  in  order  to 
provide  access  to  the  upper  parts  of  the  larynx  in  the  treatment  of 
foreign  bodies  or  tuberculous  disease.  A  transverse  incision  is  made 
through  the  thyro-hyoid  space,  the  pharynx  is  opened,  and  the  epi- 


920 


A  MANUAL  OF  SURGERY 


glottis  detached  from  the  base  of  the  tongue  (Fig.  422,  I.).     It  is  a 
proceeding  that  is  seldom  undertaken,  and  scarcely  necessary. 

A  much  more  satisfactory  procedure  is  Trans-hyoid  Pharyngotomy,* 
in  which  the  hyoid  bone  is  divided  in  the  middle  line  through  a 
vertical  incision  extending  from  the  symphysis  menti  to  the  thyroid 
cartilage.  The  pharynx  can  then  be  opened  either  above  or  below 
the  level  of  the  h3^oid  bone,  and  the  back  of  the  tongue,  the  posterior 
wall  of  the  pharynx,  or  the  upper  part  of  the  lar}mx  freely  exposed. 

A  preliminary  tracheotomy  is,  of  course, 
necessary.  We  have  utilized  this  opera- 
tion both  for  the  removal  of  an  epithe- 
lioma of  the  epiglottis  and  back  of  the 
tongue,  and  for  enucleating  a  sarcoma 
of  the  posterior  pharyngeal  wall,  and 
were  much  pleased  with  the  approach 
given  to  these  parts. 

2.  Thyrotomy  (Fig.  422,  II.)  consists 
in  a  vertical  section  of  the  thyroid  car- 
tilage, and  may  be  required  for  the  re- 
moval of  foreign  bodies  or  tumours,  or 
for  the  radical  treatment  of  laryngeal 
tuberculosis  or  cancer.  Tracheotomy 
is  performed  as  a  prelim.inary  measure, 
and  the  trachea  plugged  around  the 
tube.  An  incision  is  then  made  in  the 
middle  line  of  the  neck,  extending  from 
the  hyoid  bone  to  the  cricoid  cartilage. 
The  crico-thyroid  ligament  is  clearly 
defined  and  severed  transversely,  and 
the  th)'^roid  cartilage  accurately  divided 
by  a  knife,  cutting-pliers,  or  fine  saw. 
The  lateral  halves  are  separated,  and 
the  intralaryngeal  portion  of  the  opera- 
tion proceeded  with.  When  closing 
the  wound,  the  greatest  care  must  be 
taken  to  bring  the  sides  together  in 
such  a  way  that  the  vocal  cords  are 
exactly  opposite  each  other,  or  phona- 
tion  will  be  considerably  impaired.  This 
is  best  ensured  by  making  a  horizontal  nick  across  the  front  of  the 
cartilage  before  dividing  it. 

3.  Extirpation  of  the  Larynx  (Laryngectomy)  is  always  a  serious 
operation,  which  is  never  undertaken  except  for  malignant  disease. 
Accordmg  to  the  site  of  the  tumour,  the  removal  may  be  partial  or 
complete  ;  for  a  growth  strictly  limited  to  one  side,  extirpation  of  that 
half  will  suffice,  and  admirable  results  have  followed  such  treatment, 
distmct  speech  remaining  ;  but  if  the  whole  larynx  is  removed, 
although  the  patient  is  subsequently  able  to  whisper,  phonation  is 
*  See  Revue  de  Chinirgie,  May,  igoo. 


Fig.  422. — Operations  on  the 
Air-Passages. 

r.,  Subhyoid  pharyngotomy ; 
II.,  thyrotomy;  III.,  laryn- 
gotomy  ;  IV. ,  cricotomy  ;  V. , 
high  tracheotomy;  VI.,  low 
tracheotomy;  H.,  hyoid  bone; 
Thy.,  thyroid  cartilage;  Cr.,' 
cricoid  ;  G.Th..  thyroid  body' 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       921 

impossible  without  mechanical  assistance,  whilst  if  the  disease  has 
extended  beyond  the  limits  of  the  larynx,  operative  interference  is 
rarely  successful. 

Operation  for  Complete  Extirpation. — An  incision  is  made  in  the 
middle  line  of  the  neck  from  the  hyoid  bone  to  below  the  cricoid 
cartilage.  The  soft  parts  are  stripped  from  the  lateral  aspects  of  the 
thyroid  cartilage  with  raspatories,  the  sterno-hyoid,  sterno-thyroid, 
and  thyro-hyoid  muscles  being  divided  at  their  insertions,  and  the 
isthmus  of  the  thyroid  body  being  divided  between  ligatures  if 
necessary.  The  crico-tracheal  membrane  is  then  cut  through,  or  the 
trachea  itself  is  divided  on  the  slant,  and  either  fixed  in  the  lower 
angle  of  the  wound,  or  a  fresh  incision  is  made  a  little  lower  down, 
and  through  this  it  is  drawn  and  stitched  flush  to  the  skin.  At  this 
stage  it  is  often  wise  to  divide  the  thyroid  cartilage  longitudinally,  so 
as  to  ascertain  exactly  the  extent  of  the  disease.  If  it  is  limited  to 
the  larynx,  removal  is  perhaps  best  effected  from  below  upwards, 
a  transverse  incision  at  the  level  of  the  hyoid  bone,  and  extending 
between  the  two  sterno-mastoid  muscles,  being  required  to  facilitate 
this  proceeding.  The  connections  of  the  constrictor  muscles  to  the 
cricoid  and  thyroid  cartilages  are  severed  by  scissors,  and  the 
larynx  can  now  be  drawn  forwards  and  separated  from  the  anterior 
pharyngeal  wall,  which  must  be  left  intact  if  possible.  The  thyro- 
hyoid membrane  and  base  of  the  epiglottis  are  cut  through,  and  the 
final  steps  of  the  operation  consist  in  clearing  the  superior  cornua  of 
the  thyroid  and  dividing  the  lateral  thyro-hyoid  ligaments.  The 
operation  is  not  particularly  difficult  or  dangerous,  provided  that  the 
surgeon  keeps  close  to  the  larynx,  and  that  the  disease  does  not 
extend  beyond  its  limits.  When  other  structures  such  as  the  base  of 
the  tongue  have  been  invaded,  these  steps  must  be  modified  so  as  to 
secure,  if  possible,  complete  removal  of  the  disease.  The  upper 
portion  of  the  oesophagus  has  even  been  included  in  the  scope  of  the 
operation.*  Finally,  the  rent  in  the  mucous  membrane  of  the 
pharynx  is  closed  by  sutures,  the  divided  muscles  are  drawn 
together,  and  the  incisions  in  the  skin  closed  ;  if  this  be  practicable, 
healing  by  first  intention  may  follow,  the  air-passages  being  thereby 
entirely  separated  from  the  pharynx.  Of  course,  phonation  is  lost 
completely,  but  the  patient  can  whisper,  and  by  means  of  suitable 
apparatus  this  can  be  magnified  and  utilized  so  as  to  be  of  service. 
In  not  a  few  cases,  however,  it  is  impossible  to  close  the  wound 
completely,  and  then  it  must  be  packed  and  allowed  to  heal  by 
granulation. 

If  the  oesophagus  is  encroached  on  in  the  operation,  it  is  some- 
times feasible  to  restore  continuity  between  the  pharjnix  and  the 
lower  end  by  means  of  a  flap  of  skin  turned  in,  or  the  wound  is 
allowed  to  granulate,  and  a  rubber  funnel  passed  so  as  to  prevent 
cicatricial  contraction,  and  to  allow  the  passage  of  food.  In  other 
cases  a  communication  can  be  established  between  a  pharyngeal  fistula 

*  Arthur  Evans,  Transactions  of  the  Royal  Society  of  Medicine,  Clinical  Section, 
vol.  iii. ,  p.  44,  and  vol.  iv.,  p.  142. 


922  A  MANUAL  OF  SURGERY 

above  and  a  gastrostomy  wound  below,  and  food  can  be  carried  into  the 
stomach  through  an  external  rubber  cesophagus  worn  under  the  clothes. 
If  the  disease  is  limited  to  one  half  of  the  larynx,  the  thyroid 
cartilage  is  cleft  in  the  middle  line,  and  the  operation  confined  to  the 
affected  side. 

4.  Laryngotomy  is  rarely  undertaken  except  for  the  relief  of  dyspnoea 
arising  from  some  sudden  obstruction  to  the  respiration,  and  is  thus 
to  be  looked  on  as  ait  operation  of  urgency.  It  is  required  in  cases 
where  the  entrance  to  the  larynx  is  obstructed  by  a  foreign  body,  for 
spasm  of  the  glottis,  or  for  accumulations  of  blood  in  the  neighbour- 
hood of  the  larynx  during  an  operation.  It  is  readily  performed  by 
making  a  vertical  incision  over  the  situation  of  the  crico-thyroid 
membrane,  which  is  then  divided  transversely  along  the  upper  border 
of  the  cricoid  cartilage  (Fig.  422,  III.),  the  sterno-hyoid  muscles 
being,  if  necessary,  drawn  aside,  and  a  tube  inserted.  Possibly  the 
small  crico-thyroid  artery  arising  from  the  superior  thyroid  may 
require  a  ligature.  In  cases  of  great  urgency,  a  simple  transverse 
incision  may  be  made  with  a  penknife,  and  the  larynx  opened,  the 
margins  of  the  wound  being  held  aside  by  a  hairpin,  or  by  the  handle 
of  a  scalpel  turned  edgeways,  whilst  a  toothpick  will  serve  temporarily 
as  a  cannula.  Whenever  there  is  time  to  operate  deliberately,  a  high 
tracheotomy  is  the  better  practice,  since  a  tube  inserted  throiagh  the 
crico-thyroid  space  gives  rise  to  considerable  irritation,  and  the  voice 
may  be  subsequently  impaired  by  the  contraction  of  the  cicatrix.  A 
special  laryngotomy  -  tube  is  required,  the  lumen  of  which  is  not 
circular,  but  oval  and  flattened  from  above  downwards. 

In  children,  where  there  is  but  little  space,  the  proceeding  may  be 
modified  by  division  of  the  cricoid  cartilage,  and  even  of  the  first 
ring  of  the  trachea,  constituting  what  is  known  as  cricotomy  or  laryngo- 
tvacheotomy  (Fig.  422,  IV.). 

5.  Tracheotomy. — -The  trachea  usually  consists  of  from  sixteen 
to  twenty  rings,  of  which  six  or  seven  are  situated  above  the  sternum. 
The  isthmus  of  the  thyroid  body  generally  covers  the  third  and  fourth 
rings,  and  the  trachea  may  be  opened  either  above  or  below  it,  or  even 
sometimes  behind,  the  isthmus  being,  if  necessary,  divided.  Trache- 
otomy is  required  in  any  condition  in  which  there  is  serious  obstruction 
to  the  respiration — e.g.,  various  forms  of  laryngitis,  and  especially  for 
oedema  of  the  larynx  or  diphtheria ;  for  stenosis,  tumours,  and  some 
forms  of  paralysis  of  the  larynx ;  for  the  removal  of  foreign  bodies, 
either  in  the  larynx,  trachea,  or  one  of  the  bronchi ;  or  for  com- 
pression of  the  larynx  or  trachea  by  external  tumours,  such  as  a 
malignant  thyroid  body.  It  is  also  undertaken  as  a  preliminary 
measure  in  operations  on  the  mouth,  tongue,  pharynx,  or  larynx,  in 
which  there  is  any  likelihood  of  asphyxia  or  ,secondary  septic  pneu- 
monia, owing  to  the  entrance  of  blood  or  septic  discharges  into  the 
air-passages.  As  a  general  rule,  the  high  operation  ^that  is,  above 
the  isthmus  of  the  thyroid  body)  is  to  be  preferred,  but  under  special 
circumstances  it  may  be  advisable  to  open  the  trachea  lower  down. 
The  risk  attaching  to  the  high  operation  is  considerably  less  than  to 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       923 

the  low,  but  the  opening  is  made  nearer  to  any  disease  which  may 
exist  in  the  larynx.  For  the  removal  of  foreign  bodies  from  the 
bronchi  or  trachea,  the  low  operation  should  always  be  employed. 

The  high  operation  (Fig.  422,  V.)  is  performed  as  follows :  The 
patient  is  placed  on  the  back,  with  a  sandbag  or  pillow  beneath  the 
neck,  so  as  to  throw  the  head  backwards  and  put  the  structures  on 
the  stretch,  and  with  the  shoulders  somewhat  raised.  Anaesthesia 
may  be  induced  by  chloroform,  but  it  is  unnecessary,  and  indeed 
unwise,  to  push  the  anaesthetic,  since  it  is  only  needed  for  the 
division  of  the  skin  ;  where  the  dyspnoea  is  considerable,  it  is  better 
to  employ  local  anaesthesia  by  the  infiltration  method  (q.v.).  The 
head  is  held  exactly  in  the  middle  line,  and  the  surgeon  feels  for, 
and  identifies,  the  cricoid  cartilage.  The  incision  extends  from  this 
structure  downwards  for  about  i^  inches.  The  superficial  fascia  is 
divided,  and  the  interval  between  the  sterno-hyoid  muscles  made  out, 
so  as  to  enable  them  to  be  separated  one  from  the  other.  The  edges 
of  the  wound  are  drawn  aside  by  blunt  hooks,  which  should  both  be 
held  by  one  assistant,  so  as  to  insure  equable  traction. 

The  isthmus  of  the  thyroid  body  may  now  be  seen,  and,  if  pro- 
jecting unduly  upwards,  should  be  pushed  down  after  the  fascia 
along  its  upper  border  has  been  transversely  incised.  The  trachea 
is  next  clearly  exposed  by  using  the  handle  of  a  scalpel  and  dissecting 
forceps,  and  should  be  fixed  and  steadied  by  inserting  a  sharp  hook 
into  the  lower  border  of  the  cricoid  cartilage.  The  wound  is  freed 
from  blood  as  far  as  possible,  and  the  trachea  opened  by  inserting  the 
point  of  the  scapel  and  dividing  two  of  the  rings  from  below  up- 
wards. A  deep  inspiration  is  usually  taken  at  once,  followed  by  a 
severe  fit  of  coughing,  and  if  the  operation  is  undertaken  for  diphtheria 
the  surgeon  must  be  careful  not  to  let  any  membrane  which  may 
then  be  expelled  enter  his  eyes,  nose,  or  mouth.  The  insertion  of  the 
tube  is  in  many  cases  easy,  in  others  a  matter  of  some  difficulty  ;  a 
good  deal  depends  upon  the  age  of  the  patient,  the  urgency  of  the 
symptoms,  and  the  depth  from  the  surface  at  which  the  trachea  lies. 
Anything  which  suffices  to  separate  the  lips  of  the  tracheal  incision — 
e.g.,  the  handle  of  a  scalpel  introduced  and  turned,  a  couple  of  hooks, 
or  dressing  forceps — will  form  an  efficient  guide  for  this  purpose. 
The  breathing  soon  becomes  quiet  and  regular,  and  the  tube  is 
fixed  in  position  by  tapes  passed  through  lateral  openings  in  the  face- 
plate, and  tied  round  the  neck.  No  dressing  is  required  for  the 
wound  except  a  few  layers  of  gauze  beneath  the  plate. 

Low  tracheotomy  (Fig.  422,  VI.)  is  performed  in  almost  precisely 
the  same  way,  except  that  the  incision  extends  farther  downwards, 
even  reaching  to  the  episternal  notch,  although  the  deeper  part  of 
the  wound  should  never  pass  beyond  a  finger's  breadth  above  the 
sternum,  for  fear  of  opening  that  portion  of  the  cervical  fascia  which 
is  prolonged  downwards  to  the  pericardium,  or  of  wounding  the  left 
innominate  vein.  The  superficial  layers  of  fascia  are  divided,  and 
the  sterno-hyoid  and  sterno-thyroid  muscles  drawn  to  either  side  by 
retractors.     The  inferior  thyroid  veins  then  come  into  view,  and  may 


924 


A  MANUAL  OF  SURGERY 


cause  trouble  if  they  are  distended  with  blood,  as  is  so  frequently  the 
case  in  patients  suffering  from  dyspnoea.  They  must  be  held  aside 
'  by  hooks,  or  divided  between  ligatures,  and  the  deep  layer  of  fascia 
behind  them  incised  so  as  to  expose  the  trachea,  which  is  cleared, 
fixed,  and  opened  in  the  same  way  as  described  above. 

Many  different  forms  of  tracheotomy-tube  have  been  used  from 
time  to  time,  but  the  essential  elements  of  which  it  consists  are  a 
double  cannula,  the  inner  portion  of  which  can  be  readily  removed 
and  cleansed  ;  it  should  always  be  longer  than  the  outer,  in  order 
to  prevent  any  plug  of  mucus  being  left  within  the  outer  tube  on 
removal  of  the  inner.     A  face-plate,  or  some  similar  contrivance, 

is  attached  to  the  outer  cannula, 
in  order  to  fix  and  steady  it. 
One  of  the  best  is  that  kno's^'n 
as  Parker'' s  tube  (Fig.  423),  which 
has  a  handy  introducer,  and  is 
perhaps  of  a  better  shape  than 
most  of  the  others,  following 
more  closely  the  direction  of  the 
trachea.  The  bivalve  tube  is 
another  useful  instrument ;  the 
outer  sheath  consists  of  two 
lateral  portions,  attached  to  a 
single  face-plate,  and  these  can 
be  pressed  together,  and  hence 
with  care  easily  inserted  through 
the  incision  in  the  trachea.  The 
surgeon  must  see  that  both  limbs 
enter  the  trachea,  as  trouble  has 
arisen  from  one  limb  passing  out- 
side, and  the  other  inside,  thus 
hindering  the  introduction  of  the 
inner  tube.  Whatever  variety  of 
tube  is  preferred  by  the  surgeon, 
it  is  essential  to  have  several 
sizes  to  hand,  as  the  calibre  of 
the  trachea  varies  much  in  dif- 
ferent patients.  In  cases  of  preliminary  tracheotomy,  (p.  855),  under- 
taken to  prevent  the  entrance  of  blood  during  operations,  Halm's  tube 
may  be  used  with  advantage  ;  in  this  the  outer  cannula  is  covered 
with  a  layer  of  compressed  sponge  which  swells  up  from  the  ab- 
sorption of  moisture,  and  thus  occludes  the  lumen  of  the  trachea. 
Trendelenburg'' s  tampon  is  recommended  by  some  for  the  same  object ; 
the  outer  tube  is  here  ensheathed  with  a  thin  indiarubber  casing, 
which  can  be  distended  with  air  at  will. 

Difficulties  and  Dangers  of  the  Operation. — Although  the  above 
description  might  lead  the  student  to  suppose  that  tracheotomy  is  an 
easy  operation,  this  is  by  no  means  always  the  case,  partly  owing  to 
the  fact  that  it  frequently  has  to  be  undertaken  in  a  hurry,  with 


Fig.  423. — Parker's  Tracheotomy- 
Tube  AND  Introducer.  (Down 
Brothers.) 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       925 

perhaps  inefficient  assistance,  and  in  a  bad  light,  and  partly  owing  to 
the  intense  vascular  engorgement  of  the  structures  met  with.  A  cool 
head  and  a  steady  hand  are  in  such  cases  of  infinitely  more  value  to 
the  operator  than  the  most  perfect  anatomical  knowledge.  The 
following  are  the  chief  conditions  which  may  lead  to  mistakes  and 
accidents  : 

(i)  The  administration  of  any  general  anaesthetic  is  often  in- 
advisable in  semi-asphyxiated  patients,  since  complete  cessation  of 
respiration  may  be  caused  thereby,  possibly  from  spasm  of  the  glottis, 
Local  anaesthesia  by  the  infiltration  method  should  be  relied  on  in 
such  cases,  and  the  employment  of  /3-eucaine  and  adrenalin  has 
been  most  satisfactory. 

(2)  It  is  not  always  easy  to  find  the  trachea,  especially  in  the  necks  of 
fat  children,  or  where  it  is  hidden  by  an  unduly  large  thyroid  isthmus, 
or  possibly  by  the  projection  of  the  thymus  gland  into  the  neck.  It 
is  here  most  essential  to  remember  the  old  adage.  In  medio  tntissimns 
ibis,  although  occasionally  the  trachea  may  be  displaced  from  the 
middle  line  by  some  external  growth,  and  can  then  only  be  found  by 
careful  exploration  with  the  finger. 

(3)  Hemorrhage  is  generally  troublesome.  It  is  usually  venous  in 
character,  arising  either  from  the  anterior  jugular  vein  or  from  the 
inferior  thyroid  plexus.  If  possible,  it  should  be  controlled  by 
pressure-forceps  before  opening  the  trachea ;  but  this  is  not  absolutely 
necessary  in  urgent  cases,  since  it  usually  ceases  as  soon  as  easy 
respiration  through  the  tube  has  been  established.  The  presence  of 
the  left  innominate  vein  in  front  of  the  trachea  must  not  be  forgotten, 
although  it  but  rarely  reaches  above  the  sternum.  In  about  8  per 
cent,  of  all  subjects  an  arterial  twig  (the  thyroidea  ima)  courses 
upwards  from  the  innominate  artery  along  the  trachea,  to  reach  the 
isthmus  of  the  thyroid  body ;  if  divided,  it  can  be  easily  secured  and 
tied.  Should  much  blood  be  inspired,  it  may  determine  the  occurrence 
of  septic  pneumonia  at  a  later  date. 

(4)  The  possibility  of  the  entrance  of  air  into  veins  must  not  be  over- 
looked, although  it  is  an  uncommon  accident,  since  the  intravenous 
pressure  is  usually  increased. 

(5)  Not  unfrequently  considerable  m.ischief  has  been  done  by  an 
incautious  use  of  the  knife,  especially  if  the  operator  forgets  to  fix  the 
trachea  with  a  sharp  hook  before  opening  it.  The  knife  should  always 
be  entered  with  its  back  towards  the  episternal  notch,  and  the  in- 
cision made  from  below  upwards.  In  a  child  the  trachea  is  small ; 
and  if  it  is  moving  rapidly  up  and  down,  as  happens  in  urgent 
dyspnoea,  or  if  the  child  is  restless,  and  not  completely  under  the 
influence  of  an  anaesthetic,  the  difficulty  is  manifestly  increased. 
Many  accidents  have  happened  from  this  cause — e.g.,  wounds  of  the 
large  veins  or  arteries  of  the  neck,  or  even  of  the  oesophagus  or 
bodies  of  the  vertebrae  ! 

(6)  As  soon  as  the  trachea  is  opened  or  an  attempt  made  to  intro- 
duce the  tube,  a  severe  fit  of  coughing  is  induced,  which  is  sometimes 
so  prolonged  as  to  interfere  with  the  introduction  of  the  tube.   Under 


926  A  MANUAL  OF  SURGERY 

such  circumstances  the  incision  in  the  trachea  may  be  opened  up 
with  a  tracheal  dilator,  or  by  a  pair  of  sinus  forceps,  and  a  few  drops 
of  cocaine  swabbed  over  the  mucous  membrane. 

(7)  The  introduction  of  the  tube  is  a  matter  of  no  difficulty  if  the 
surgeon  takes  the  precaution  of  not  removing  the  hook  until  this  is 
satisfactorily  accomplished.  Many  mistakes  have  followed  the  non- 
observance  of  this  rule  ;  thus,  the  tube  has  missed  the  trachea  alto- 
gether and  passed  into  the  fascial  interspace  in  front,  as  also  to  one 
or  other  side ;  as  before  mentioned,  the  outer  portion  of  a  bivalve  tube 
has  often  been  passed  with  one  limb  within  the  trachea  and  the  other 
outside.  A  very  dense  diphtheritic  membrane  has  also  been  a  cause 
of  difficulty,  in  that,  although  the  tube  has  been  really  passed  into 
the  trachea,  it  has  not  penetrated  the  membrane,  and  thus  has 
hindered  rather  than  helped  the  breathing.  In  all  cases  of  diphtheria 
the  trachea  should  be  freely  opened,  and  the  interior  carefully 
examined  by  separating  the  lips  of  the  incision  before  attempting  to 
insert  the  tube.  In  order  to  prevent  the  downward  passage  of  the 
membrane,  some  surgeons  have  recommended  that  the  lower  portion 
of  the  larynx  should  be  carefully  stuffed  with  antiseptic  gauze  above 
the  tube. 

After-Treatment. — The  patient  is  placed  in  bed,  in  a  room  kept  at 
a  uniformly  warm  temperature  (75°  F.),  the  air  being  moistened 
by  the  steam  issuing  from  one  or  more  bronchitis  kettles,  so  as  to 
make  up  for  the  absence  of  nasal  and  oral  respiration.  Draughts 
are  excluded  by  curtains,  and  nothing  should  be  placed  over  the 
entrance  to  the  tube,  so  that  respiration  may  not  be  hindered,  nor  the 
expectoration  of  mucus,  false  membrane,  etc.,  prevented.  One  of 
the  most  frequent  sources  of  extension  of  diphtheria  to  the  lungs,  or 
of  septic  pneumonia,  is  the  re-inspiration  of  material  which  has  been 
coughed  out  upon  a  portion  of  muslin  or  gauze,  placed  with  excellent 
intentions  over  the  mouth  of  the  tube.  A  nurse  should  be  in  constant 
attendance  on  the  patient,  in  order  to  wipe  away  all  such  material 
as  it  is  expelled. 

The  inner  portion  of  the  tube  is  removed  by  the  nurse,  and  cleaned 
two  or  three  times  a  day,  any  inspissated  mucus  upon  it  being  readily 
removed  by  the  use  of  a  solution  of  bicarbonate  of  soda  (20  grains 
to  I  ounce).  The  outer  tube  is  also  removed  once  a  day  for  cleansing 
purposes,  but  only  by  the  medical  attendant.  Should  the  respiration 
become  impeded  by  a  collection  of  mucus  in  the  trachea,  a  fine 
feather  may  be  passed  down  the  tube  in  order  to  clear  it,  but  never  in 
diphtheritic  cases ;  for  such  a  contingency  special  suction-tubes  have 
been  devised.  Attempts  have  been  made  to  clear  the  passages  by 
applying  the  lips  to  the  tube,  and  removing  the  block  by  suction ; 
such  is,  however,  quite  unjustifiable,  and  several  promising  house- 
surgeons  have  in  this  way  lost  their  lives. 

The  period  for  which  the  tracheotomy-tube  is  kept  in  position 
varies  in  different  cases,  but  its  removal  should  always  be  undertaken 
at  as  early  a  date  as  possible,  for  fear  of  leading  to  impairment  of 
the  voice.     In  order  to  prevent  this,  the  inner  cannula  is  made  with 


SURGERY  OF  THE  AIR-PASSAGES,   LUNGS,  AND  CHEST       927 

a  hole  in  the  upper  end,  so  that  part  of  the  air  may  pass  through  the 
larynx.  If  the  patient  can  then  breathe  comfortably  when  the  finger 
is  placed  over  the  entrance  to  the  tube,  its  presence  is  no  longer 
necessary. 

After-Complications  of  Tracheotomy. — (a)  The  tube  may  give  rise 
to  ulceration  of  the  trachea  if  it  is  not  correctly  shaped.  Thus,  if  too 
much  curved,  it  tends  to  irritate  the  anterior  wall,  and  cases  are 
known  in  which  it  has  caused  death  by  perforation  of  the  left 
innominate  vein.  If  insufficiently  curved,  the  posterior  wall  may 
become  affected,  and  the  oesophagus  laid  open.  In  cases  where  a 
tracheotomy-tube  has  to  be  worn  for  a  long  time,  it  is  advisable  to 
make  use  of  indiarubber  tubes. 

(b)  Various  forms  of  septic  trouble  may  arise  in  the  wound,  lead- 
ing to  cellulitis  and  even  secondary  haemorrhage  ;  this  is  especially 
dangerous  in  the  low  operation,  since  the  inflammation  may  extend 
to  the  mediastinal  tissues.  In  cases  of  diphtheria  the  wound  may 
also  become  affected  with  the  disease. 

(c)  Inflammation  of  the  trachea,  bronchi,  and  lungs  may  result 
either  from  the  entrance  of  cold,  or  unmoistened  air,  or  from  the 
inspiration  of  septic  or  diphtheritic  material. 

{d)  Difficulty  is  sometimes  experienced  in  leaving  off  the  tube, 
owing  to  the  presence  of  granulations  obstructing  the  lumen  of  the 
trachea,  or  to  stenosis  of  the  trachea  or  larynx,  or  even  to  paralysis 
of  the  abductor  muscles,  especially  in  diphtheritic  cases.  The 
trachea  may  also  be  kinked,  and  its  calibre  thus  diminished,  by 
cicatricial  union  of  the  skin  and  mucous  membrane.  The  diagnosis 
of  the  cause  at  work  in  any  particular  case  can  only  be  made  by 
laryngoscopy,  or  careful  examination  of  the  wound  and  upper  portion 
of  the  trachea.  Granulations  may  be  scraped  away  under  an  anaes- 
thetic or  destroyed  by  caustics  ;  stenosis  of  the  larynx  is  overcome 
by  dilatation  with  an  O'Dwyer's  tube ;  stenosis  of  the  trachea  may 
require  excision  of  the  affected  segment,  whilst  laryngeal  paralysis 
must  be  treated  by  the  use  of  electricity. 

(e)  Finally,  it  should  be  remembered  that  if  a  patient  (and  especially 
a  boy)  is  condemned  to  the  perpetual  use  of  a  tracheotomy-tube,  he 
must  be  warned  of  the  possibility  and  danger  of  water  getting  into 
the  trachea  and  his  being  drowned  thereby.  Certainly  one  death  has 
occurred  from  a  boy  bathing  under  these  circumstances ! 

6.  Intubation  of  the  Larynx  is  a  means  of  treating  laryngeal 
obstruction  which  has  been  introduced  in  order  to  obviate  the  risks 
present  in  tracheotomy.  It  consists  in  the  passage  through  the 
mouth  of  a  suitably  curved  tube  into  the  larynx,  by  means  of  a 
specially  contrived  introducer.  The  best  patterns  to  employ  for  the 
purpose  are  those  known  as  O'Dwyer's  tubes  (Fig.  424).  The  lower 
end  of  the  cannula  is  oval,  and  not  circular,  and  passes  between  the 
cords  into  the  larynx,  whilst  the  upper  enlarged  end  lies  over  the 
entrance ;  it  requires  changing  frequently  in  order  to  prevent  erosion 
of  the  mucous  membrane.  It  has  been  used  with  considerable  success 
in  cases  of  oedema  of  the  glottis  and  laryngeal  stenosis,  but  is  scarcely 


928 


A  MANUAL  OF  SURGERY 


to  be  recommended  for  diphtheria,  owing  to  tlie  risk  of  carrying  the 
false  membrane  down  with  it.  The  actual  mortality  in  a  large  series 
of  cases  of  diphtheria  has  been  proved  to  be  much  the  same  as  for 
tracheotomy — viz.,  about  30  per  cent. 


Fig.  424. — O'Dwyer's  Intubation  Apparatus.     (Down  Brothers.) 

The  cannulse  are  seen  below  on  the  right ;  a  hinged  inner  tube  passes  throughout 
the  length  of  each,  and  the  upper  end  of  this  is  screwed  to  the  extremity  of 
the  introducer  seen  in  the  middle  ;  when  it  has  been  inserted  into  the  larynx, 
the  trigger  of  the  introducer  is  drawn,  and  by  this  means  the  inner  tube  is 
loosened  and  can  be  easily  removed,  leaving  the  cannula  in  position.  To 
extract  the  tube,  the  rectangular  forceps  represented  at  the  top  is  utilized ; 
the  point  of  the  forceps  is  inserted  into  the  top  of  the  cannula,  and  then  by 
opening  the  blades  the  cannula  is  fixed  and  can  be  withdrawn.  A  useful 
type  of  unilateral  gag  is  also  represented,  and  a  small  gauge  to  indicate  the 
size  of  cannula  required  at  different  ages. 


Affections  of  the  Ribs  and  Sternum. 

Several  forms  of  Fracture  have  been  already  described  (pp.  490 
and  492). 

Acute  Suppurative  Inflammation  of  these  bones  is  very  unusual. 
Occasionally  an  acute  osteo-myelitis,  running  its  usual  course  to 
necrosis,  occurs  in  children ;  but  the  most  common  cause  is  typhoid 
fever  (p.  575).  The  affection  is  generally  of  a  subacute  type,  and  a 
more  or  less  extensive  carionecrosis  results.  The  special  feature  of 
the  disease  is  the  tendency  of  the  bacilli  to  remain  in  a  latent  condi- 
tion in  the  tissues,  so  that  it  is  difficult  to  ensure  a  perfect  cure  apart 
from  complete  extirpation  of  the  affected  portion  of  bone.  Mere 
scraping  is  rarely  sufficient. 

SypMlitic  Disease  is  more  common  in  the  sternum  than  in  the  ribs. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       929 

The  upper  part  of  the  stevmim  is  that  usually  involved,  and  the 
affection  is  characterized  by  a  formation  of  gummata  in  and  upon 
the  bone,  which  erode  it,  usually  in  a  pitted  fashion,  and  may  cause 
necrosis.  The  usual  treatment  with  iodide  of  potassium  and  mercury 
is  required,  and  sequestra  will  need  to  be  removed.  In  connection 
with  the  vihs,  syphilis  appears  as  a  tertiary  periostitis  or  perichondritis. 
A  fusiform  swelling  is  produced  in  the  course  of  a  few  weeks,  with 
but  little  pain  or  tenderness  ;  it  may  easily  be  mistaken  for  tuberculous 
disease  or  a  ne  ^  growth,  but  the  history  of  the  patient  may  help  one 
to  a  correct  diagnosis,  or  the  administration  of  iodide  of  potassium 
will  clear  it  up. 

Tuberculous  Disease  affects  the  ribs  much  more  frequently  than 
the  sternum.  In  the  ribs,  it  may  arise  primarily  as  an  osteo- 
myelitis, implicating  an  extensive  portion  of  the  medulla ;  but  it 
is  not  unfrequently  secondary  to  tubercle  of  neighbouring  parts, 
e.g.,  the  spine  or  pleura,  and  then  commences  beneath  the  periosteum; 
several  ribs  may  be  involved  at  the  same  time.  The  disease  is  most 
commonly  seen  in  young  people,  and  affects  either  the  middle  of  the 
rib  or  the  costo-chondral  junction.  The  usual  manifestations  of 
tubercle  in  bone  are  seen,  giving  rise  to  expansion  of  the  bone,  or  to 
caries  or  necrosis,  and  suppuration  is  common.  The  abscess  cavity 
may  be  mainly  external  to  the  ribs,  but  is  not  unfrequently  hour- 
glass-shaped, a  narrow  neck  connecting  the  cavities  which  lie  inside 
and  outside  the  chest.  Treatment  in  these  cases  must  be  of  a  radical 
type.  Mere  scraping  and  disinfection  are  often  inefficient,  and 
the  complete  removal  of  an  extensive  portion  of  the  rib  and  of 
the  abscess  cavity  attached  to  it  is  required. 

In  the  sternum  tubercle  runs  its  usual  course,  and  may  present  an 
abscess  which  points  either  in  front  near  the  middle  line,  or  may 
come  forv/ards  from  behind  through  an  intercostal  space.  The  treat- 
ment consists  in  cutting  or  scraping  away  the  abscess  wall,  and  in  deal- ' 
ing  with  the  bone  ;  it  may  be  necessary  to  remove  some  portion  of  it  by 
gouge  or  cutting-pliers  in  order  to  gain  access  to  the  primary  focus. 

Tumours  of  the  ribs  and  sternum  are  usually  chondromata  or 
chondro-sarcomata  ;  perhaps  the  former  are  a  little  more  common  in 
the  ribs,  the  latter  in  the  sternum.  The  patient  complains  of  but 
little  pain,  and  therefore  the  cases  are  usually  late  in  coming  under 
observation.  In  time  the  growth  becomes  adherent  to  the  pleura, 
and  the  lung  itself  may  be  invaded.  In  the  early  stages  it  is  some- 
times possible  td  remove  them,  although  the  lung  is  likely  to  collapse 
in  the  course  of  such  a  procedure. 

Surgical  Affections  of  the  Lungs  and  Pleural  Cavities. 

Non-penetrating  Wounds  of  the  Lungs  result  from  violence  applied 
to  the  chest,  with  or  without  fractures  of  the  ribs,  and  consist  either 
of  laceration  or  contusion. 

Contusion  of  the  Lung  often  follows  some  injury  which  is  not  suffi- 
ciently severe  to  fracture  the  ribs.  The  symptoms  produced  are 
severe  pain   in  the   side,  with  perhaps' temporary  shock  and  sli"-ht 

59 


930  A  MANUAL  OF  SURGERY 

haemoptysis.  Some  traumatic  inflammation  follows,  both  of  the  lung 
and  of  the  pleura,  as  indicated  by  loss  of  resonance  and  possibly  fric- 
tion sounds.  The  treatment  consists  in  keeping  the  patient  quiet  in 
a  warm  room,  at  the  same  time  carefully  regulating  the  bodily  func- 
tions.    Pain  is  often  relieved  by  strapping  the  side  of  the  chest. 

Laceration  of  the  Lung  is  usually  secondary  to  fracture  of  the  ribs, 
especially  if  due  to  direct  violence.  The  severity  of  the  symptoms 
necessarily  varies  with  the  character  and  extent  of  the  injury.  The 
patient  suffers  from  marked  shock  in  bad  cases,  associated  with 
pain  in  the  side  and  dyspnoea.  Evidences  of  hmnorrhage  soon  follow, 
either  in  the  form  of  haemoptysis  or  haemothorax.  If  the  wound  is  a 
small  one,  the  patient  complains  of  an  irritating  cough,  and  brings  up 
a  good  deal  of  blood-stained  frothy  mucus ;  but  if  the  laceration  is 
extensive,  involving  some  of  the  larger  pulmonary  trunks,  a  quantity 
of  pure  blood  may  be  ejected,  even  leading  to  death  from  syncope, 
or  from  asphyxia,  owing  to  the  blood  filling  the  larger  bronchial 
tubes.  Hemothorax  may  also  be  so  excessive  as  to  cause  the  patient's 
death  from  compression  of  the  lung.  It  results  in  a  gradually 
increasing  area  of  dulness  extending  from  below  upwards,  together 
with  loss  of  breath-sounds  and  vocal  fremitus,  coming  on  soon  after 
the  injury  without  signs  of  inflammation. 

Owing  to  the  laceration  of  the  pulmonary  vesicles,  air  tends  to 
escape  either  into  the  pleural  cavity,  giving  rise  to  the  condition 
known  as  pneumothorax,  or  into  the  cellular  tissue  of  the  body,  con- 
stituting surgical  emphysema.  PneumotJwrax  is  always  associated 
with  more  or  less  collapse  of  the  lung,  and,  if  complete  or  produced 
suddenly,  is  almost  certain  to  lead  to  considerable  interference  with 
respiration,  and  possibly  to  severe  dyspnoea,  or  even  orthopnoea.  A 
slight  degree  of  pneumothorax,  or  a  complete  one,  if  produced  slowly, 
and  if  the  other  lung  is  healthy  and  no  strain  is  thrown  upon  it,  has  but 
little  functional  result.  The  air  which  finds  its  way  into  the  pleura 
in  connection  with  a  ruptured  lung,  having  been  filtered  through  the 
pulmonary  alveoli,  is  free  from  organisms,  and  hence  does  not  cause 
suppuration  or  putrefaction  of  the  blood-clot  present,  unless  bronchitis 
or  some  other  suppurative  condition  has  existed  previously.  The 
physical  signs  of  pneumothorax  consist  in  a  high-pitched  tympanitic 
note  on  percussion,  and  on  auscultation  amphoric  breathing  and 
possibly  metallic  tinkling.  As  soon  as  the  wound  in  the  lung 
commences  to  heal,  the  amphoric  sounds  disappear,  the  effused  air 
is  absorbed,  and  the  lung  gradually  expands — a  process  which  may 
take  four  or  five  days.  If  blood  is  also  present  in  the  thorax,  a 
condition  of  haemopneumothorax  is  produced,  recognised  by  a 
splashing  or  succussion  sound  heard  on  shaking  the  patient.  Surgical 
Emphysema  almost  always  indicates  a  wound  of  both  pulmonary  and 
parietal  layers  of  the  pleura,  which  are  slightly  separated  by  air, 
constituting  a  localized  pneumothorax.  At  each  inspiration  a  fresh 
amount  of  air  enters  this  cavity,  and  is  expelled  into  the  areolar 
tissues  through  the  parietal  wound  at  each  expiration,  being  forced 
perhaps  to  a  considerable  distance  from  the  spot  where  it  commences^ 


SURGERY  OF  THE  AIR.PASSAGES,  LUNGS,  AND  CHEST       931 

or  even  spreading  over  the  whole  body.  It  is  of  no  serious  signifi- 
cance, unless  extensive,  disappearing  rapidly  after  the  wound  in  the 
lung  has  commenced  to  heal,  thus  occluding  the  opened  pulmonary 
alveoli.  It  is  recognised  by  the  parts  becoming  swollen  and  puffy, 
and  giving  a  sensation  of  fine  crackling  crepitus  when  the  hand  is 
pressed  over  them.  Occasionally  emphysema  may  arise  as  an 
interstitial  condition,  when  the  parietal  pleura  has  not  been  injured, 
the  air  escaping  from  the  alveoli  along  the  interalveolar  connective 
tissue  into  the  root  of  the  lung,  and  then  appearing  first  at  the  lower 
part  of  the  neck.     This  is  often  a  condition  of  grave  import. 

Such  are  the  ordinary  phenomena  observed  in  the  early  stages  of 
a  ruptured  lung.  The  effects  subsequently  produced  consist  in  a 
localized  traumatic  pleuro-pneumonia,  associated  with  slight  elevation 
of  the  temperature,  possibly  rusty  sputum,  and  often  severe  dyspnoea. 
In  the  worst  cases  death  may  result  from  asphyxia. 

Penetrating  Wounds  of  the  Lung,  due  to  direct  injury  and  often 
associated  with  fracture  of  the  ribs,  are  followed  by  very  similar 
effects.  The  story  is  modified,  however,  by  the  fact  that  the  external 
wound  in  the  chest  wall  allows  of  the  exit  of  blood,  arising  either  from 
an  intercostal  artery,  the  internal  mammary,  or  from  the  wounded  lung, 
whilst  it  also  permits  the  entrance  of  septic  organisms  with  the  air 
into  the  pleural  cavity,  and  thus  may  change  the  character  of  the 
resulting  pleuro-pneumonia  from  a  simple  to  an  infective  inflamma- 
tion. Empyema  is  consequently  a  frequent  sequela,  whilst  the 
inflammation  of  the  lung  may  be  of  a  spreading  nature,  possibly 
terminating  in  suppuration  or  gangrene.  Surgical  emphysema  is 
also  induced  by  air  being  sucked  into  the  wound  during  inspiration, 
and  failing  to  escape  during  expiration,  owing  to  the  lips  of  the 
wound  falling  together.  This  condition  may  ensue  even  when  the 
lung  itself  has  not  been  damaged. 

Treatment. — When  the  rupture  of  the  lung  is  due  to  a  subcuta- 
neous injury,  the  patient  should  be  kept  quiet  in  a  warm  room,  and 
the  side  strapped.  The  compression  of  the  chest  wall  must  some- 
times be  omitted  in  patients  where  the  irregular  ends  of  fractured 
ribs,  broken  by  direct  violence,  are  driven  inwards,  for  fear  of 
increasing  the  mischief  in  the  lung. 

Persistent  haemoptysis  must  be  treated  by  keeping  the  patient  abso- 
lutely quiet,  and  allowing  him  to  suck  ice  continually.  Ergotin  may 
be  injected  hypodermically,  or  a  mixture  of  ergot,  opium,  and  sul- 
phuric acid  administered  ;  the  opium  is  especially  needed  when  great 
restlessness  and  irritability  are  present.  Stimulants  are  necessarily 
contra-indicated,  for  fear  of  again  starting  the  bleeding.  Haemothorax 
rarely  needs  special  treatment,  since  the  blood  soon  clots  and  is 
readily  absorbed  ;  but  occasionally  it  may  be  so  abundant  as  to  com- 
press the  lung  and  lead  to  dyspnoea,  and  under  these  circumstances 
it  may  be  necessary  to  aspirate  the  chest,  or  if  that  fail  (as  is  not 
unlikely)  to  open  up  the  pleural  cavity  and  remove  it.  Such  must 
never  be  undertaken  until  sufficient  time  has  elapsed  to  permit  of 
thrombosis  in  the  wounded  vessels.     Decomposition  of  the  blood  in 


932  A  MANUAL  OF  SURGERY 

the  pleural  cavity  occasionally  happens  even  in  non-penetrating 
injuries,  the  bacteria  reaching  it  either  from  the  blood  or  from  the 
torn  bronchi ;  the  suppuration  and  fever  thereby  induced  necessitate 
the  opening  and  drainage  of  the  pleural  sac. 

Simple  pneumothorax  seldom  requires  surgical  treatment,  since  the 
imprisoned  air  is  quickly  absorbed,  and  the  lung  re-expands  ;  should 
this  not  occur,  and  if  severe  dyspnoea  is  present,  it  may  be  advisable 
to  remove  the  air  by  aspiration.  This  may  sometimes  fail,  or  the  air 
may  re-collect,  and  then  the  chest  wall  must  be  opened  so  as  to  give 
exit  to  the  air.  It  is  impossible  for  the  lung  to  re-expand  against  the 
pressure  of  air  confined  in  the  chest ;  when  an  opening  is  made,  the 
air  can  be  driven  out  by  a  vigorous  expiratory  movement,  such  as 
coughing,  which  also  forces  air  from  the  healthy  lung  into  the 
wounded  one  when  the  glottis  is  closed. 

Temporary  dyspnoea  may  be  overcome  by  the  inhalation  of  oxygen ; 
but  when  of  a  more  decided  character,  and  not  due  to  any  condition 
which  can  be  removed,  the  essential  treatment  is  to  diminish  the 
blood-pressure,  and  thus  decrease  the  amount  of  blood  carried  to  the 
uninjured  lung,  so  as  to  enable  it  to  cope  with  the  work  of  blood- 
aeration.  This  may  be  accomplished  by  administering  antimonial 
wine  (lo  to  15  minims  every  four  or  six  hours)  combined  with  full 
doses  of  liquor  ammoniac  acetatis ;  but  in  urgent  cases,  where  the 
patient  is  becoming  cyanosed,  and  life  is  threatened  by  asphyxia, 
venesection  must  be  adopted.  The  blood  is  withdrawn  from  the 
arm  rapidly  and  freely,  and  as  it  flows  the  dyspnoea  passes  off. 
This  may  be  repeated  once  or  twice  in  addition  to  the  use  of  the 
medicine  before  the  full  effect  is  obtained  and  respiration  becomes 
unembarrassed. 

The  treatment  oi penetrating  wounds  of  the  thorax,  involving  the  lung, 
is  always  a  matter  of  considerable  difficulty.  The  skin  around  the 
opening  is  carefully  purified  and  shaved,  if  necessary,  and  a  limited 
exploration  of  the  wound  is  permissible,  so  as  to  determine  whether 
portions  of  the  clothing  have  been  carried  in,  or  a  rib  comminuted  ; 
all  such  loose  fragments  must  be  removed,  as  also  any  penetrating 
foreign  body,  such  as  a  bullet,  if  readily  accessible.  The  greatest 
gentleness  must,  however,  be  employed,  and  no  attempt  made  to  pass 
a  probe  into  the  pleural  cavity,  since  it  is  easy  to  dislodge  clots  lying 
in  the  pulmonary  tissues,  and  thereby  restart  the  bleeding.  If  the 
wound  itself  needs  sterilizing,  it  is  perhaps  best  to  touch  it  over  with 
pure  carbolic  acid  or  tincture  of  iodine  rather  than  to  irrigate  it,  and 
then  a  dry  antiseptic  dressing  is  applied  without  drainage. 

Immediate  operative  interference  is  only  required  under  two  con- 
ditions, viz.,  for  haemorrhage  and  for  hernia  of  the  lung. 

Hamovrhage  after  a  penetrating  wound  of  the  chest  wall  may  be 
derived  either  from  a  vessel  in  the  parietes  (intercostal  or  internal 
mammary),  or  from  the  lung  itself.  The  recognition  of  the  source  of 
the  bleeding  is  not  always  easy,  but  it  is  probably  of  parietal  origin 
(a)  if  it  is  unaccompanied  by  haemoptysis  ;  (b)  if  it  increases  obviously 
at  each  systole  ;  and  (c)  if  it  can  be  controlled  by  digital  compression. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       933 

The  treatment  of  bleeding  from  the  internal  mammary  and  intercostal 
vessels  has  been  already  indicated  (p.  295). 

Pulmonary  haemorrhage  is  not  so  readily  controlled,  and  various 
plans  have  been  recommended.  Probably  the  best  method  consists 
in  keeping  the  patient  absolutely  quiet  in  the  horizontal  position, 
applying  cold  to  the  side,  and  giving  haemostatics,  as  indicated  above 
for  non-penetrating  wounds.  The  effect  of  this  will  be  to  cause  the 
blood  in  the  pleural  cavity  to  clot,  and  this  acts  as  a  tampon  to  the 
affected  viscus ;  firmly  plugging  the  external  wound  may  limit  the 
loss  of  blood  and  determine  coagulation  more  quickly.  In  bad  cases 
the  haemorrhage  may  cease  only  when  the  patient  is  in  a  condition  of 
profound  collapse  ;  intravenous  or  hypodermic  infusion  of  hot  saline 
solution  may  then  suffice  to  tide  over  the  period  of  danger  and  lead 
to  a  successful  result. 

The  question  of  opening  the  thorax  by  turning  up  a  large  flap  of 
the  chest  wall  (including  portions  of  several  ribs)  so  as  to  deal  directly 
with  the  injured  lung  has  been  raised  of  recent  years,  and  several 
cases  in  which  it  has  been  undertaken  have  been  recorded.  Further 
experience  will  probably  decide  that  such  a  procedure  is  quite 
unjustifiable  except  in  very  unusual  circumstances. 

The  later  treatment  of  these  cases  is  much  the  same  as  for  simple 
non-penetrating  injuries.  Should  symptoms  of  septic  pleurisy  follow, 
the  wound  must  be  freely  opened,  a  portion  of  rib  being  excised,  if 
necessary,  and  the  cavity  washed  out  and  drained,  as  for  empyema. 

Hernia  of  the  Lung,  or  pneumocele,  is  a  rare  condition  in  which  a 
portion  of  the  lung  protrudes  through  an  opening  in  the  thoracic 
parietes  beneath  the  uninjured  skin.  It  may  occur  suddenly,  as  the 
immediate  consequence  of  a  laceration  of  the  intercostal  muscles  and 
pleura,  or  more  gradually,  being  then  due  to  the  yielding  of  a  cicatrix. 
It  is  most  usually  seen  about  the  fifth  intercostal  space,  but  has  been 
known  to  occur  in  the  root  of  the  neck  from  a  lesion  in  the  dome  of 
the  pleura.  It  is  recognised  by  the  appearance  of  a  rounded  swelling, 
increasing  in  size  on  coughing  or  making  expiratory  efforts,  and 
possibly  disappearing  entirely  on  holding  the  breath.  It  imparts  a 
crepitant  feeling  to  the  fingers  when  compressed,  and  on  ausculta- 
tion a  loud  vesicular  murmur  is  heard.  As  a  rule,  no  treatment  is 
advisable  in  this  condition  beyond  the  application  of  a  pad  or  truss. 

A  similar  condition,  arising  as  a  complication  of  an  open  wound, 
is  termed  a  Prolapse  of  the  lung.  An  attempt  should  always  be  made 
to  return  the  protruded  viscus,  and  to  prevent  its  recurrence  by 
suturing  the  aperture  through  which  it  has  escaped.  If  left  unre- 
duced, it  is  very  likely  to  become  gangrenous  from  strangulation,  and 
should  then  be  removed  by  the  application  of  a  ligature,  the  wound 
being  subsequently  closed. 

Empyema,  or  suppuration  within  the  pleural  cavity,  results  not  only 
from  traumatism,  but  also  as  a  sequela  of  a  simple  pleurisy,  or  as  a 
complication  of  various  affections  of  the  lungs,  whilst  a  basal  empyema 
is  not  an  uncommon  result  of  intra-abdominal  suppuration.  Bacterio- 
logical research  has  demonstrated  that  in  children  more  than  half  of 


934 


A  MANUAL  OF  SURGERY 


the  cases  are  due  to  the  pneumococcus,  either  alone  or  less  often  in 
conjunction  with  streptococci,  whilst  in  adults  the  streptococcus  is 
the  commonest  organism.  A  description  of  the  physical  signs  and 
symptoms  belongs  rather  to  the  physician  than  to  the  surgeon.  It 
will  suffice  to  mention  here  that  in  a  total  empyema  the  affected 
side  of  the  chest  does  not  move  on  respiration,  whilst  the  intercostal 
spaces  may  bulge  ;  on  percussion  the  side  is  dull,  except  perhaps 
immediately  below  the  clavicle,  where  tympanitic  resonance  (Skodaic) 
may  be  elicited.  On  auscultation  breath-sounds  are  absent,  except  in 
the  vertebral  groove,  where  bronchial  breathing  may  be  heard.  The 
loss  of  vocal  fremitus  is  also  an  important  sign.  A  certain  amount  of 
fever  and  dyspnoea  is  usually  present  in  cases  of  empyema  ;  leucocy- 
tosis  is  well  marked,  and  the  heart  and  other  viscera  may  be  displaced. 
Left  to  itself,  an  empyema  slowly  finds  its  way  to  the  surface,  and 
perhaps  most  commonly  bursts  through  the  fifth  or  sixth  costal  inter- 
space in  front,  though  sometimes  through  the  second,  owing  to  the 
perforating  vessels  being  larger  here  than  elsewhere.  An  extrathoracic 
abscess  of  some  size  may  develop,  and  the  opening  in  the  skin  may 
not  correspond  to  that  in  the  chest  wall.  Occasionally  a  localized 
empyema  is  met  with,  giving  rise  to  similar  effects,  but  on  a  smaller 
scale.  When  situated  on  the  left  side  in  close  proximity  to  the  peri- 
cardium, the  movements  of  the  heart  may  be  transmitted  through  the 
fluid  to  the  surface,  causing  a  pulsation  which  can  be  seen  or  felt 
{pulsating  empyema). 

In  the  early  stages  the  pleura  is  but  little  altered  in  structure, 
although  a  certain  amount  of  lymph  may  be  deposited  on  it ;  in  old- 
standing  chronic  cases  it  becomes  very  dense  and  firm,  owing  to  a 
development  of  fibro-cicatricial  tissue,  whilst  the  surface  is  converted 
into  a  layer  of  granulation  tissue,  similar  to  that  found  in  all  chronic 
abscesses.  The  lung  collapses  and  retreats  backwards  towards  the 
spine  ;  at  first  its  alveolar  texture  remains  unaltered,  and  the  early 
removal  of  the  exudation  enables  it  to  re-expand,  as  a  result  of  the 
atmospheric  pressure.  In  chronic  cases,  however,  there  are  two 
hindrances  to  this  expansion,  viz.,  the  density  of  the  thickened 
visceral  pleura,  which  resists  the  atmospheric  pressure,  and  the 
infiltration  and  sclerosis  of  the  lung  tissue  itself.  Under  these 
circumstances,  even  when  the  exudation  is  entirely  removed,  the 
lung  may  remain  collapsed,  and  Nature  then  attempts  in  several 
ways  to  remedy  the  mischief  and  obliterate  the  pleural  cavity  : 
{a)  The  opposite  lung  undergoes  expansion  and  hypertrophy,  and 
together  with  the  heart  projects  over  to  the  opposite  side  ;  (b)  the 
abdominal  viscera  and  diaphragm  are  displaced  upwards;  {c)  the 
chest  wall  falls  in,  and  the  spine  becomes  laterally  curved,  with  its 
convexity  to  the  sound  side ;  and  {d)  there  is  an  exuberant  growth  of 
granulation  tissue  from  the  surface  of  the  pleura.  In  a  certain  pro- 
portion of  cases  these  structural  changes  suffice  to  determine  a  cure, 
but  in  others  a  cavity  still  remains,  lined  with  thickened  pyogenic 
membrane,  and  discharging  pus  or  serum,  according  to  whether  or 
not  sepsis  is  present.  Under  these  circumstances  extensive  operative 
interference  is  necessary. 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST       935 

The  Diagnosis  of  empyema  is  readily  made  by  attention  to  the 
physical  signs,  and  confirmation  of  such  an  opinion  can  be  obtained 
by  puncture  with  a  sterilized  exploring  syringe.  A  medium-sized 
needle  should  always  be  employed  for  this  purpose,  and  it  is  well 
to  insert  it  along  the  top  of  a  rib  after  drawing  the  skin  up  or  down, 
so  that  on  removal  a  valvular  puncture  results.  The  character 
of  the  organisms  contained  in  the  sample  of  pus  thus  withdrawn 
should,  if  possible,  be  ascertained,  since  it  has  been  proved  that  the 
Prognosis  depends  much  on  this  point.  Thus,  an  empyema  due  to 
the  presence  of  pneumococci,  presumably  following  a  pneumonia, 
usually  runs  a  mild  course,  and  is  sometimes  cured  by  aspiration 
alone  ;  one  due  to  the  ordinary  pyogenic  cocci  is  more  acute,  and 
requires  drainage  with  or  without  resection  of  a  piece  of  rib.  The 
presence  of  tubercle  bacilli  renders  the  outlook  much  more  serious, 
whilst  the  addition  of  a  mixed  inflection  to  any  of  the  above  aggra- 
vates the  process  and  much  impedes  a  cure.  The  virulence  and 
number  of  the  organisms  present,  and  the  resisting  power  of  the 
patient  as  indicated  by  the  opsonic  index  have  also  to  be  considered 
in  estimating  the  prognosis.  The  chronicity  or  not  of  the  affection 
is  also  a  most  important  element,  since  the  later  the  treatment  com- 
mences, the  denser  are  the  adhesions  which  bind  down  the  lung, 
and  the  less  the  chance  of  its  re-expansion.  The  character  of  the 
pus  varies  with  the  organisms  present ;  with  pneumococci,  the  pus 
is  usually  yellow,  creamy  and  laudable,  whilst  there  is  usually  an 
abundant  production  of  fibrinous  false-membranes  ;  when  of  strepto- 
coccal origin,  the  pus  is  often  thin  and  oily. 

Treatment  therefore  should  never  be  delayed  ;  the  earlier  it  is 
undertaken,  the  better  the  results. 

Aspiration  may  be  adopted  in  the  first  instance,  but  is  generally 
to  be  regarded  as  of  an  exploratory  nature,  though  a  cure  will 
occasionally  follow  when  the  empyema  is  of  pneumonic  origin.  It  is, 
however,  sometimes  of  value  in  order  to  relieve  for  a  time  the 
pressure  on  the  other  lung  and  the  resulting  dyspnoea,  and  thus 
allow  of  the  administration  of  an  anaesthetic  for  the  more  serious 
subsequent  operation. 

Drainage  of  the  pleural  cavity  through  an  external  incision  is  the 
treatment  almost  invariably  necessary,  and  as  a  matter  of  mechanical 
convenience  it  is  usually  advisable  to  resect  a  portion  of  a  rib  in 
order  that  the  drainage-tube  may  not  suffer  compression  ;  especially 
is  this  the  case  in  children.  The  best  site  for  opening  a  complete 
empyema  has  been  much  discussed,  and  it  is  probable  that  subsequent 
drainage  is  facilitated  by  making  the  opening  well  back — e.g.,  in  the 
ninth  space  just  external  to  the  scapular  line.  Possibly  in  children 
with  a  pneumococcal  empyema,  which  is  not  likely  to  need  lengthy 
drainage,  a  more  convenient  site  may  be  selected  in  the  fifth  or  sixth 
interspace,  just  behind  the  mid-axillary  line  ;  apart  from  these  cases, 
an  incision  here  is  usually  ineffective,  and  will  require  a  subsequent 
counter-opening  farther  back.  An  incision  is  made  along  the  course 
of  a  rib  about  i|  inches  in  length,  and  the  periosteum  stripped  up 
from  both  the  superficial  and  deep  aspects  of  the  bone,  so  as  to  enable 


936  A  MANUAL  OF  SURGERY 

a  curved  raspatory  to  be  passed  beneath  it ;  at  least  i  inch  of  the  rib 
is  then  cut  away  with  bone  pliers.  The  parietal  pleura  is  opened 
sufficiently  to  enable  the  finger  to  be  introduced  and  the  cavity 
explored,  as  also  to  allow  of  the  removal  of  flaky  masses  of  fibri::. 
A  large  drainage-tube  is  inserted,  just  long  enough  to  enter  the 
pleural  cavity,  but  not  to  project  into  it ;  the  tube  is  carefully  stitched 
in,  and  the  wound  immediately  covered,  so  as  to  prevent  as  far  as 
possible  the  entrance  of  unfiltered  air.  Care  must  be  taken  both  at 
the  operation  and  at  the  subsequent  dressings,  to  prevent  the  tube 
being  sucked  into  the  thorax,  a  well-known  but  easily  preventable 
accident. 

Formerly  it  was  considered  desirable  to  wash  out  the  pus,  but 
it  has  now  been  demonstrated  that  this  is  unnecessary  and  occa- 
sionally dangerous.  Several  cases  of  sudden  death  have  followed 
this  practice,  probably  due  to  reflex  irritation  of  the  vagus.  In 
chronic  cases,  where  sepsis  has  been  admitted,  irrigation  is  often 
beneficial,  but  the  following  points  must  be  attended  to :  (i.)  The 
fluid  employed  must  be  sterile  and  unirritating ;  (ii.)  it  must  be  at 
the  temperature  of  the  body,  neither  too  hot  nor  too  cold  ;  (iii.)  it 
must  not  be  injected  with  such  force  as  to  impinge  against  the 
pleura  or  against  the  upper  surface  of  the  diaphragm ;  and  (iv.)  free 
exit  must  be  given  to  it,  so  as  to  prevent  tension  from  accumulation 
within  the  pleural  cavity. 

If  such  treatment  is  undertaken  early,  the  lung  may  be  expected 
to  expand  quickly,  the  discharge  steadily  diminishing,  and  the 
wound  healing  without  delay ;  but  this  does  not  always  occur,  and 
then  a  fistula  persists,  leading  into  a  cavity  lined  with  a  thick 
pyogenic  membrane,  discharging  a  variable  amount  of  pus.  The 
best  means  of  obtaining  a  cure  in  these  cases  consists  in  removal  of 
the  rigid  external  wall,  as  by  Estlander's  operation,  which  is  character- 
ized by  the  excision  of  portions  of  ribs  comprising  the  outer  wall  of 
the  cavity.  It  is  usually  carried  out  through  a  vertical  incision  in  the 
axillary  line,  the  ribs  being  freed  from  their  periosteal  connections  ; 
the  amount  excised  necessarily  varies  according  to  circumstances, 
and  is  in  some  cases  very  extensive.  The  fistulous  track  is  enlarged, 
and  the  interior  of  the  pleura  carefully  curetted  and  washed  out,  so 
as  to  remove  all  necrotic  and  degenerating  tissue ;  the  parietes  are 
then  allowed  to  fall  back  into  contact,  if  possible,  with  the  deeper 
layer,  a  drainage-tube  is  inserted,  and  the  side  firmly  bandaged. 
A  modification  of  this  proceeding  is  known  as  Schede's  operation, 
in  which  not  only  are  the  ribs  removed,  but  also  the  intervening 
tissues,  so  that  the  subcutaneous  or  muscular  structures  in  the  flaps 
are  laid  down  upon  the  prepared  -surface  of  the  deeper  layer  of  the 
pleura. 

Necessarily,  either  of  these  methods  of  treatment  is  associated 
with  considerable  deformity,  and  also  with  a  terrible  weakening  of 
the  side,  and  plans  have  been  suggested  to  obviate  this  by  removing 
portions  of  a  number  of  ribs  before  and  behind,  so  as  to  leave  the 
intervening  segment  free  to  collapse  without  totally  destroying  the 


SURGERY  OF  THE  AIR-PASSAGES.  LUNGS,  AND  CHEST       937 

osseous  thoracic  boundary.  Another  proceeding  that  has  been 
recently  practised  with  occasional  success  is  the  stripping-  of  the 
thickened  pleura  away  from  the  collapsed  lung,  so  as  to  enable  it  to 
expand  once  more  (pulmonary  decortication).  Obviously  such  a 
procedure  could  only  be  of  value  when  the  compression  of  the  lung 
has  not  been  followed  by  sclerosis  ;  whilst  infection  of  the  pulmonary 
tissue  has  resulted  in  grave  inflammatory  disturbance  and  even  death. 
It  is  more  than  doubtful  whether  this  proceeding  is  ever  justifiable. 

Considerable  assistance  in  gaining  re-expansion  of  a  collapsed 
lung  may  be  obtained  by  making  the  patient  undertake  forced  ex- 
piratory efforts  against  resistance — e.g.,  by  learning  to  play  some 
wind  instrument. 

Pneumotomy,  or  incision  of  the  lung,  has  been  undertaken  for  not 
a  few  pulmonary  lesions,  and  the  results  obtained  have  been  rather 
variable,  i.  For  tuhercidoiis  cavities  it  is  of  little  use.  They  are 
usually  situated  at  the  apex  of  the  lung  and  drain  well ;  the  original 
disease  is  not  removed  ;  and  the  general  health  is  frequently  so 
impaired  that  the  shock  of  the  operation  hastens  the  inevitably  fatal 
issue.  Hence  it  is  only  required  for  a  cavity  located  in  the  lower  half 
of  the  lung,  which  drains  badly,  and  the  difficulty  of  diagnosing  such 
a  condition  is  considerable.  2.  For  bronchiectases  pneumotomy, 
though  prima  facie  desirable,  has  given  but  little  benefit,  since 
it  is  uncommon  for  only  one  dilatation  of  the  bronchus  to  exist.  In 
suitable  cases,  however,  where  there  is  a  good  deal  of  foetid  secre- 
tion, whicti  is  with  difficulty  expelled,  it  may  be  useful.  3.  Gangrene 
of  the  lang  and  pulmonary  abscess  usually  follows  acute  septic 
pneumonia  in  debilitated  individuals.  The  expectoration  is  abun- 
dant and  exiremely  offensive.  The  localization  is  made  partly 
with  the  stethoscope,  but  mainly  with  the  exploring  needle.  The 
gangrenous  area  is  often  near  the  base  of  the  lung.  Operation  is 
frequently  successful.  Of  course,  the  pulmonary  abscesses  of 
pyaemia,  being  multiple,  are  not  suited  to  operative  treatment.  4.  In 
hydatid  disease  of  the  lung,  incision  and  drainage  have  so  considerably 
reduced  the  mortality  that  this  method  of  treatment  should  alone  be 
adopted. 

As  to  the  technique  of  the  operation,  the  first  thing  is  to  locate  the 
mischief,  and  this  is  effected  partly  by  a  careful  attention  to  the 
physical  signs,  partly  by  the  use  of  an  exploring  needle  or  syringe. 
An  incision  is  then  made,  and  a  portion  of  one  or  more  ribs  removed. 
If  the  lung  is  adherent  to  the  thoracic  walls,  and  shows  no  signs  of 
retracting,  the  operation  may  be  continued  ;  but  if  no  adhesions  are 
present,  it  may  be  well  to  pack  the  wound  with  gauze  for  a  day  or 
two,  so  as  to  determine  their  formation  and  thus  shut  off  the  pleural 
cavity.  The  lung  itself  may  be  punctured  with  sinus  forceps  intro- 
duced along  an  exploring  needle,  and  then  opened,  or  may  be  incised 
with  a  cautery.  The  abscess  or  other  cavity  is  thus  emptied  of  its 
secretion,  and  a  drainage-tube  inserted.  As  a  general  rule  it  is 
unwise  to  scrape  or  irrigate  it,  for  fear  of  a  communication  existing 
with  any  of  the  larger  bronchi. 


938  A  MANUAL  OF  SURGERY 

Pneumectomy,  or  excision  of  a  portion  of  the  lung,  has  been 
attempted  in  a  few  cases  of  tuberculous  disease  limited  to  the  apex  ; 
the  operation  is,  however,  quite  unjustifiable,  since,  if  the  affection 
is  localized  to  the  apex,  it  can  often  be  cured  by  hygienic  measures, 
whilst  if  it  is  more  diffuse  it  cannot  be  extirpated.  Primary  malig- 
nant tumours  of  the  lung,  moreover,  are  usually  central,  and  the 
diagnosis  can  rarely  be  made  early  enough  to  warrant  an  attempt  at 
removal.  The  only  conditions  under  which  it  is  justifiable  to  excise 
portions  of  lungs  are  :  (a)  when  a  hernial  protrusion  has  become 
strangled  through  a  small  opening,  and  cannot  be  reduced ;  and 
(&)  when  malignant  disease  of  a  rib  has  invaded  the  superficial 
portion.  In  the  former  case,  the  base  of  the  protrusion  is  transfixed 
and  ligatured  prior  to  being  cut  away  ;  in  the  latter  the  disease  is 
snipped  away  with  scissors,  and  bleeding  stayed  by  cautery,  ligature, 
or  plugging. 

Wounds  of  the  Heart. 

Wounds  of  the  Heart  and  great  vessels  are  so  usually  fatal,  either 
immediately  or  within  a  few  hours,  that  it  is  unnecessary  to  discuss 
them  in  any  great  detail.  They  may  be  divided  into  two  classes,  the 
non-penetrating  and  the  penetrating.  The  former  are  due  to  crushes 
of  the  chest  wall,  and  fragments  of  the  overlying  bones  may  be 
driven  into  the  heart  substance ;  it  is  unusual  for  any  surgical  treat- 
ment to  be  practicable  in  such  cases.  Penetrating  wounds  (go  per 
cent,  of  the  whole)  have  of  late  years  been  brought  within  the  range 
of  surgical  art,  and  a  number  of  successful  cases  of  cardiac  suture 
have  been  reported.  The  right  ventricle  is  most  often  injured  ;  the 
left  auricle  least  frequently.  Wounds  of  the  auricles  are  more 
dangerous  than  those  of  the  ventricles,  as  the  thicker  and  more 
muscular  walls  of  the  latter  may  suffice  to  check  the  bleeding.  The 
outlook  depends  largely  on  the  nature  of  the  wound,  those  due  to 
small  penetrating  bodies,  such  as  stilettos,  etc.,  being  the  most  favour- 
able. The  patient  may  die  from  immediate  cessation  of  the  heart's 
action  ;  or  from  intra-pericardial  pressure  of  blood  ;  or  from  haemor- 
rhage, internal  or  external,  according  to  whether  or  not  the  blood  can 
escape.  If  the  patient  does  not  die  at  once,  he  suffers  from  intense 
shock  and  prostration,  combined  with  a  weak  and  turbulent  action  of 
the  heart,  great  pain  in  the  chest,  and  dyspnoea,  whilst  the  pulse  is 
scarcely  to  be  felt.  Purulent  pericarditis  is  likely  to  ensue.  Treatment. 
-^The  patient  must  be  kept  absolutely  quiet  and  with  the  head  low 
until  it  is  decided  whether  or  not  operative  interference  is  justifiable. 
If  the  case  is  to  be  left,  the  external  wound  is  purified,  but  no  attempt 
made  to  explore  it  with  finger  or  probe  for  fear  of  dislodging  clots. 
If  operation  is  attempted,  an  anaesthetic  is  carefully  administered  so 
as  to  avoid  struggling,  and  a  suitable  incision  made  in  the  chest  wall; 
possibly  the  best  plan  is  to  turn  up  a  trap-door  flap  consisting  of 
parts  of  the  fourth  and  fifth  ribs  or  their  cartilages.  The  pericardium 
is  freely  opened,  and  the  cardiac  wound  gently  explored.  It  has 
been  found  possible  to  stay  a  sudden  gush  of  blood  by  introducing 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHEST 


939 


one  or  more  fingers  into  the  ventricle.  Deep  sutures  are  then 
inserted  through  the  muscular  substance,  for  choice,  during  the 
diastole,  and  tied ;  branches  of  the  coronary  artery  may  require 
ligature.  It  must  not  be  forgotten  that  cases  have  been  reported  in 
which  a  wound  of  the  heart  has  healed  spontaneously,  and  the  patient 
survived  for  years. 

Effusion  into  the  Pericardium,  whether  serous  or  purulent,  may 
require  surgical  treatment  in  order  to  relieve  symptoms  of  cardiac 
failure,  due  to  the  pressure  of  the  exudate.  The  sac  when  distended 
pushes  aside  the  pleurae  and  lungs,  and  also  is  enlarged  upwards, 
carrying  up  the  base  of  the  heart  and  rotating  the  apex  forwards  to  a 
slight  degree.  The  bare  interpleural  area  of  the  pericardium  is 
therefore  increased,  and  the  cavity  may  be  tapped  by  trocar  and 
cannula,  or  by  aspirator  either  close  to  the  left  border  of  the  sternum 
in  the  fifth  interspace,  or  i-|-  inches  from  the  left  margin  of  that  bone 
through  the  fourth  or  fifth  interspace,  so  as  to  avoid  the  internal 
mammary  trunk,  which  courses  down  about  half  an  inch  from  the 
border.  It  may  also  be  reached  with  safety  from  the  right  side 
of  the  sternum  in  certain  cases. 

For  suppurative  pericarditis  incision  and  drainage  are  necessary. 
This  may  be  readily  accomplished  by  removing  the  fourth  or  fifth 
-  costal  cartilage,  thereby  exposing  the  pericardium,  which  is  opened, 
washed  out,  and  a  drainage-tube  inserted.  Care  must  be  taken 
to  prevent  infection  of  the  mediastinal  tissues,  and  this  can  sometimes 
be  accomplished  by  stitching  the  pericardium  to  the  parietes  before 
opening  it.  Possibly  better  drainage  is  provided  by  operating  through 
the  costo-sternal  angle  (Allingham).  An  incision  is  made  through 
the  left  rectus  abdominis,  reaching  up  between  the  xiphoid  and  the 
seventh  costal  cartilage,  the  latter  being,  if  necessary,  removed. 
The  peritoneum  is  depressed  ;  the  interval  between  the  sternal  and 
costal  attachments  of  the  diaphragm  is  opened  up  ;  and  the  lowest 
part  of  the  pericardium  is  thereby  exposed,  and  can  be  easily 
drained.     The  patient  is  propped  up  in  bed. 

Cardiolysis  is  an  operation  for  the  removal  of  a  portion  of  the 
chest  wall,  lying  in  front  of  the  heart,  with  the  object  of  replacing 
the  comparatively  unyielding  thoracic  wall  by  a  soft,  pliable  covering. 
It  has  been  performed  in  cases  of  adherent  mediastino-pericarditis  to 
relieve  the  fixation  of  the  heart  to  the  chest  wall,  with  its  consequent 
mechanical  disadvantage ;  and  also  for  cases  of  valvular  disease  with 
great  hypertrophy. 

The  parts  usually  removed  have  been  the  third,  fourth,  and  fifth 
left  costal  cartilages,  with  or  without  a  piece  of  the  sternum,  and  the 
ends  of  the  corresponding  ribs.  It  is  desirable  to  remove  the 
perichondrium,  but  in  cases  of  adhesive  inflammation  this  may  be 
almost  impossible  without  wounding  the  underlying  structures. 


940  A  MANUAL  OF  SURGERY 


Asphyxia. 

Asphyxia,  or  Apnoea,  is  the  term  applied  to  indicate  the  condition  arising  from 
interference  with  or  stoppage  of  the  respiratory  act.     If  this  has  not  proceeded 
to  any  great  extent  it  is  termed  Dyspnoea  ;  when,  however,  the  obstruction  is  so 
marked  that  the  patient  is  obliged  to  maintain  the  upright  sitting  position,  the. 
term  Orthopnoea  is  applied  to  it. 
.   The  Causes  of  asphyxia  may  be  classified  as  follows  : 

1.  Conditions  arising  from  the  presence  of  abnormal  contents  within  the  air- 
passages — e.g.,  foreign  bodies  ;  blood-clot  or  pus  from  the  bursting  of  an  aneurism 
or  abscess;  serum,  as  in  oedema  of  the  lung;  mucus  or  muco-pus,  as  in 
bronchitis  ;  the  consolidated  exudation  in  pneumonia ;  diphtheritic  membrane ; 
or  irrespirable  gases — e.g.,  nitrogen,  hydrogen,  carbonic  acid  gas,  etc.,  as  in 
suffocation.  Death  by  drowning  usually  arises  from  a  similar  cause,  viz.,  the 
replacement  of  air  by  water  in  the  respiratory  passages. 

2.  Causes  arising  in  the  walls  of  the  air-passages,  such  as  diminution  of  their 
lumen  from  inflammatory  congestion,  as  in  oedema  of  the  glottis  ;  cicatricial 
stenosis  ;  the  presence  of  new  growths,  or  the  displacement  of  parts,  as  in  cut 
throat ;  or  the  falling  back  of  the  root  of  the  tongue  after  partial  excision  of  that 
organ. 

3.  Extrinsic  causes,  or  those  arising  outside  the  air-passages — e.g.,  in  the  neck ; 
strangling,  hanging,  garrotting,  etc. ;  the  presence  of  tumours,  such  a  5  goitres  or 
aneurisms  ;  a  retropharyngeal  abscess  or  tumour;  and.  under  exceptional  circum- 
stances, displacement  backwards  of  the  sternal  end  of  the  clavicle.  Within  the 
thonix  gradually  increasing  obstruction  to  the  respiration  may  be  caused  by  the 
presence  of  tumours,  aneurisms,  or  effusion  into  the  pericardium  or  pleur.a. 

4.  Nervous  causes — e.g.,  paralysis  or  spasm  of  the  larynx,  and  paralysis  of  the 
diaphragm,  either  from  peripheral  lesions,  such  as  the  pressure  of  aneurisms  or 
tumours  on  the  nerve  trunks,  or  from  central  causes,  such  as  a  lesion  in  the 
upper  part  of  the  spinal  cord  or  medulla.  It  may  also  arise  from  paralysis  of  the 
respiratory  centre,  as  from  an  overdose  of  chloroform. 

5.  In  many  forms  of  cardiac  disease  the  lungs  may  become  engorged  with 
stagnant  blood,  leading  gradually  to  dyspnoea,  orthopnoea,  and  finally  asphyxia, 
owing  to  the  increasing  difficult)'  in  eliminating  the  excessive  accumulation  of 
carbonic  acid. 

The  Treatment  of  the  different  conditions  giving  rise  to  asphyxia  cannot  here 
be  dealt  with  in  extcnso,  but  merely  the  general  plan  of  treatment  indicated. 
A  rapid  examination  is  at  once  made,  to  ascertain,  if  possible,  the  cause  of  the 
mischief,  and  whether  its  onset  has  been  gradual  or  sudden.  If  it  has  been 
gradually  developing,  it  is  not  uncommonly  due  to  some  thoracic  condition  which 
cannot  be  relieved  ;  if,  however,  its  onset  has  been  sudden,  and  not  the  result  of 
any  evident  lesion,  the  neck  and  chest  should  be  bared,  and  examined  for  signs 
of  traumatism,  the  mouth  opened,  the  tongue  drawn  forwards,  and  the  glottis 
examined  with  the  finger  to  see  that  the  passages  are  clear.  The  patient  should, 
if  necessary,  be  removed  into  fresh  air,  and  artificial  respiration  at  once  com- 
menced. Breathing  can  sometimes  be  excited  by  alternately  dashing  hot  and 
cold  water  over  the  thorax,  whilst  electric  stimulation  of  the  phrenic  nerve  may 
also  be  undertaken,  one  electrode  being  placed  over  the  neck  and  the  other  on 
the  epigastrium.  The  administration  of  oxygen  instead  of  air  is  useful  during 
the  earlier  stages,  whilst  if  the  condition  is  due  to  cardiac  disease  with  distension 
of  the  right  side  of  the  heart,  venesection  holds  out  the  best  hope  of  relief. 
Obstruction  within  the  larynx  needs  tracheotomy  or  intubation,  as  also  other 
conditions  associated  with  pressure  on  the  trachea. 

Artificial  Respiration  is  required  in  a  variety  of  surgical  conditions,  and  can 
be  undertaken  by  what  is  known  as  Sylvester's  method.  In  this  the  patient  lies 
on  his  back,  with  a  pillow  beneath  the  shoulders,  the  mouth  opened,  and  the 
tongue  drawn  forwards.  The  arms  are  then  grasped  just  above  the  elbows  and 
drawn  upwards  above  the  patient's  head,  so  as  to  expand  the  chest  through  ihe 
action  of  the  great  pectoral  muscles.     This  position  is  maintained  for  about  two 


SURGERY  OF  THE  AIR.PASSAGES,  LUNGS,  AND  CHEST        941 

seconds,  and  then  the  arms  are  lowered  to  the  side,  and  pressed  firmly  aa^ainst 
the  ribs,  so  as  to  determine  a  forcible  expiratory  act.  At  the  end  of  about  two 
seconds  more  the  arms  are  again  elevated,  and  the  same  cycle  passed  through. 
This  should  be  repeated  about  fifteen  times  a  minute,  and  the  operator  must  bs 
careful  not  to  use  too  great  violence,  or  to  hurry  over  it  unnecessarily,  as  harm 
rather  than  good  thereby  results. 

Another  less  satisfactory  method  consists  in  alternately  compressing  the  lower 
part  of  the  thorax  and  abdomen  with  the  hands,  so  as  to  drive  out  a  certain 
amount  of  air,  and  then  by  suddenly  relieving  the  pressure  the  elastic  expansion 
of  the  chest  walls  draws  in  a  fresh  supply. 

In  the  Treatment  of  the  Apparently  Drowned  the  air-passages  must 
be  cleared  as  quickly  as  possible.  During  the  struggles  of  the 
drowning  man  water  enters  the  trachea  and  is  churned  up  with 
mucus,  saliva,  and  perhaps  blood  into  a  froth  which  does  not  easily 
escape,   but    must    be  slowly  squeezed    out   by   the  application   of 


hiG.  425. — Treatment  of  the  Apparently  Drowned — Movement  No.  i. 

pressure  to  the  back,  whilst  the  patient  is  lying  face  down.  At  the 
same  time  artificial  respiration  must  be  maintained,  and  it  is  obvious 
that  Sylvester's  method  is  not  an  ideal  plan  under  these  circum- 
stances. Dr.  R.  L.  Bowles  has  elaborated  a  procedure  for  these 
cases  which  admirably  suits  their  requirements,  and  we  have  much 
pleasure  in  quoting  his  instructions  verbatim,  and  introducing  the 
illustrations  which  he  has  kindly  placed  at  our  disposal : 

'  Treat  the  patient  at  once  and  on  the  spot.  Undo  any  tight 
clothing.  Kneel  and  place  the  patient  on  the  right  side  and  quickly 
wipe  out  the  rhouth  and  throat. 

'  If  there  are  no  signs  of  breathing,  spread  a  handkerchief  on  the 
ground  where  the  patient's  mouth  will  come,  and  carry  out 

Movement  No.-  i. — Turn  the  patient  flat  on  the  stomach,  and  at 
once  with  widespread  hands  press  gently  but  firmly  for  three  or 
four  seconds  on  the  back  of  the  ribs  on  both  sides  to  squeeze  out  the 
froth,  fluid,  or  foul  air  (Fig.  425).     Then  suddenly  remove  the  hands 


942 


A  MANUAL  OF  SURGERY 


to  allow  the  entrance  of  air  by  the  natural  recoil  of  the  ribs,  and 
proceed  to 

'Movement  No.  2.— With  the  right  hand  grasp  the  patient's  left 


Fig.   426. — Treatment  of  the  Apparently  Drowned — Movement  No.  2. 


Fig.   427. — Treatment  of  the  Apparently  Drowned — Movement  No.  3. 

shoulder ;  with  the  left  hand  take  his  left  wrist,  place  it  against  his 
hip,  and  roll  him  towards  you  on  to  his  right  side  (Fig.  426).  This 
movement  should  take  about  two  seconds. 

'  Repeat  first  and  second  movements  in  succession  for  ten  minutes 


SURGERY  OF  THE  AIR-PASSAGES,  LUNGS,  AND  CHESl        94-, 

or  more  (if  necessary),  when  some  of  the  froth  or  fluid  will  have 
drained  away  from  the  lungs,  and  then  proceed  to 

'  Movement  No.  3. — Each  time  the  patient  is  rolled  from  the 
stomach  on  to  the  right  side,  take  hold  of  the  left  or  uppermost  arm 
and  raise  it  above  the  head  in  a  line  with  the  body.  This  movement 
expands  the  chest  still  more  and  allows  air  to  enter  the  upper  left 
lung  (Fig.  427).  Then  bring  the  arm  down  to  the  side,  roll  the 
patient  on  to  the  stomach,  and  begin  again  at  movement  No.  i,  and 
continue  each  movement  in  succession  as  before,  for  an  hour  or 
until  signs  of  natural  breathing  begin. 

'  Always  turn  the  patient  on  to  the  right  side,  never  on  the  left, 
and  under  no  circumstances  on  the  back.  From  time  to  time  wipe 
away  froth  from  the  mouth  and  nose. 

'  The  neck  should  be  kept  fairly  straight  and  the  chin  away  from 
the  breast-bone ;  the  head  may  then  be  left  to  take  care  of  itself, 
and  the  face  will  take  no  harm,  as  it  will  remain  chiefly  on  its  side, 
and  yet  perfect  drainage  will  be  insured.' 


CHAPTER  XXXIII. 


DISEASES  OF  THE  BREAST. 

Congenital  Malformations  of  the  breast  are  much  more  common  than 
is  generally  supposed.     One  or  more  accessory  breasts  {polymastia)  or  • 
_  nipples  are  found  either  below 

the  normal  one  or  just  above 
it ;  sometimes  they  have  been 
found  in  the  axilla,  on  the 
outer  side  of  the  thigh,  or 
other  unusual  situations.  They 
are  often  of  a  most  rudimen- 
tary nature,  but  in  a  few  cases 
have  secreted  milk.  Very 
rarely  the  breasts  are  entirely 
absent  (amazia).  Occasionally 
the  male  breast  becomes  en- 
larged to  the  ordinary  size  of  a 
virgin's  breast  {gynecomastia) ; 
the  organ  is  usually  function- 
less,  since  the  overgrowth 
mainly  affects  the  stroma,  al- 
though lactation  has  been 
known  to  occur.  The  condi- 
tion may  be  associated  with 
imperfect  or  irregular  develop- 
ment of  the  sexual  organs. 

Diffuse  Hypertrophy  of  the 
breast  (Fig.  428)  consists  of  a 
general  enlargement  of  the 
organ,  both  gland  substance 
and  interstitial  tissue  partici- 
pating in  the  process,  and  hence 
the  breast  becomes  firm  and 
indurated.  It  may  be  uni-  or 
bi-lateral,  perhaps  more  fre- 
quently the  latter,  and  generally  occurs  in  adolescents.  The 
size  varies  considerably,  but  the  breasts  may  become  enormous, 
hanging  down  by  their  weight,  and  perhaps  to  such  an  extent  as  to 
rest  on  the  knees  of  the  patient  when  sitting.     They  are  usually  pain- 

944 


Fig.  428. — Diffuse  Hypertrophy  of  the 
Breasts. 

It  occurred  in  a  girl  aged  sixteen  and  a  half 
years,  and  both  organs  had  to  be  re- 
moved. The  left  breast  weighed  g\  lbs., 
the  right  breast  9  lbs. 


DISEASES  OF  THE  BREAST 


945 


less,  although  sometimes  neuralgia  is  noticed.  Functionally  they  are 
useless,  as  even  if  the  patient  becomes  pregnant,  secretion  of  milk 
but  rarely  occurs.  No  cause  can  be  assigned  for  the  overgrowth,  and 
the  only  treatment  is  amputation,  when  the  increased  size  is  causing 
discomfort. 

Affections  of  the  Nipple. 

Fissures  of  the  Nipple  (cracked  nipples)  seldom  occur  apart  from 
lactation,  and  may  usually  be  traced  to  a  want  of  care  and  cleanliness 
on  the  part  of  the  mother,  associated  with  a  tender  condition  of  the 
skin,  which  might  have  been  prevented  by  bathing  the  parts  during 
the  later  weeks  of  preg- 
nancy with  spirit,  so  as  to 
harden  them.  The  actual 
lesion  is  brought  about  by 
leaving  the  nipples  wet 
after  nursing.  The  super- 
ficial layers  of  epithelium 
become  macerated,  and  arc 
easily  rubbed  off,  thus  ex- 
posing the  more  delicate 
and  sensitive  deeper  parts, 
which  are  irritated  and  in- 
flamed by  the  repeated  acts 
of  suction.  As  a  result, 
nursing  becomes  painful, 
and  if  persisted  in,  the 
wound  may  be  infected,  the 
inflammation  spreading  to 
the  breast  substance  along 
the  ducts  or  lymphatics,  or 
extending  along  the  super- 
ficial lymphatics  to  the 
axillary  glands. 

Treatment.  —  The  best 
way  to  prevent  the  occurrence  of  cracks  is  to  bathe  the  nipples  with 
some  dilute  antiseptic,  such  as  boric  acid  lotion,  immediately  after 
nursing,  and  then  to  dry  them  thoroughly.  If  at  all  tender,  a  little 
powdered  boric  acid  and  starch  may  be  dusted  over  them  in  the 
intervals.  When  a  fissure  has  formed,  it  should  be  dressed  with 
cooling  or  antiseptic  lotions — e.g.,  lotio  plumbi  or  lotio  acidi  borici. 
Sometimes  more  stimulating  applications  are  required,  such  as  a 
solution  of  sulphate  of  copper,  or  even  of  nitrate  of  silver.  It  is  also 
recommended  to  paint  the  sore  with,  equal  parts  of  glycerine  and 
sulphurous  acid. 

Eczema  of  the  Nipple  may  be  of  a  simple  nature,  needing  nothing 
but  ordinary  treatment,  or  it  may  take  on  special  features,  being  then 
known  as  Paget's  Disease  (dermatitis  maligna),  a  condition  really  due  to 
a  carcinomatous  development  in  the  skin.    It  is  seen,  but  very  rarely, 

60 


Fig.  429. — Chancre  of  the  Nipple.  (From 
Photograph  and  Sketch  lent  by  Pro- 
fessor RusHTON  Parker,  of  Liverpool.) 


946  A  MANUAL  OF  SURGERY 

in  parts  other  than  the  breast.  It  presents  a  smooth,  red,  raw.surface, 
discharging  a  yellowish  viscid  fluid,  and  may  occasionally  rpread 
widely  beyond  the  areola.  It  is  almost  invariably  fcllow^.^;l  by  a 
cancerous  tumour  in  the  breast,  which  may  resemble  either  ;.  -^uct 
cancer  or  an  ordinary  scirrhus.  No  local  treatment  ih  <-^  -y 
avail,  and  the  disease,  when  once  recognised  with  certainty^.'.:  best 
treated  by  removal  of  the  breast  and  axillary  glands. 

Abscess  of  the  Areola  is  not  uncommon  in  young  girls  about  the  age 
of  puberty,  arising  in  the  sebaceous  follicles,  and  requiring  no  special 
notice. 

Chancre  of  the  Nipple  (Fig.  429)  is  rarely  seen  in  the  mothers  of 
syphiHtic  children  (Colles's  law,  p.  161),  but  much  more  commonly  in 
wet-nurses.  It  usually  presents  as  a  shallow  ulcerated  surface  with  a 
well-marked,  raised,  and  indurated  border.  Not  uncommonly  the 
condition  is  symmetrical. 

Primary  Tumours  of  the  Nipple  are  met  with,  such  as  papilloma, 
sebaceous  cysts,  and  occasionally  epithelioma. 

Inflammatory  Affections  of  the  Breast. 

Acute  Mastitis  is  most  often  observed  in  puerperal  women,  owing  to 
the  sudden  estabUshment  of  function  in  the  breast  after  the  birth  of 
a  child,  and  to  its  maintained  activity  during  lactation.  It  usually 
results  from  a  sore  or  cracked  nipple,  through  which  pyogenic 
organisms  find  their  way  into  the  lymphatics  or  acini  of  the  breast 
substance.  In  the  former  case  the  inflammation  is  mainly  interstitial 
in  character,  the  pus  diffusing  itself  widely  between  the  lobules ;  in 
the  latter  the  pus  is  primarily  intra-alveolar.  Simple  obstruction  to 
one  or  more  of  the  ducts  from  inflammation  of  the  nipple,  without  any 
external  wound,  also  determines  an  attack  of  mastitis,  which  is 
frequently  non-suppurative  in  character.  In  non-puerperal  women 
acute  mastitis  may  result  from  injury,  or  may  be  pyasmic  in  origin. 
Occasionally  a  metastatfc  inflammation  of  the  breast  occurs  after 
the  disappearance  of  the  parotid  swelling  in  mumps ;  whilst  in  girls 
about  the  age  of  puberty  a  subacute  inflammation,  involving  both 
the  breast  and  areola,  and  even  terminating  in  suppuration,  has  been 
observed.  In  newly-born  infants  a  similar  inflammation,  sometimes 
running  on  to  suppuration,  has  been  seen,  possibly  resulting  from  an 
infection  of  the  gland  ducts  during  birth  with  cocci  from  the  maternal 
passages.  A  slight  enlargement,  with  congestion  of  the  breasts,  often 
occurs  after  birth,  and  may  be  due  to,  or  is  certainly  aggravated  by, 
the  foolish  habit  followed  by  ignorant  midwives  of  pulling  or  forcibly 
squeezing  them  in  order  'to  break  the  nipple-strings.' 

Signs  and  Symptoms. — An  inflamed  breast  is  characterized  by  the 
organ  becoming  swollen,  acutely  painful,  and  tender.  The  gland 
lobules  are  felt  to  be  enlarged  and  indurated,  whilst  if  lactation  is  pro- 
gressing, the  secretion  is  to  some  extent  impaired  ;  but  owing  to  the 
inabiUty  of  the  mother  to  allow  the  child  to  relieve  the  organ,  on 
account  of  the  pain  produced  thereby,  considerable  tension  results 


DISEASES  OF  THE  BREAST  947 

from  accumulation  of  milk.  If  suppuration  follows,  the  skin  over  the 
breast  becomes  red  and  cedematous,  and,  according  to  the  situation  of 
the  yx^6,  tkree  different  forms  of  acute  abscess  of  the  breast  are 
d-^.'/jribed  ;  {a)  Supramanimayy  abscess  is  the  term  applied  to  a  collection 
c.  ••■us  m  the  subcutaneous  tissues  or  beneath  the  nipple  ;  it  is  often 
unoeii:_iected  with  the  organ,  or  may  originate  in  the  superficial  lobules. 
It  does  not  burrow  deeply,  and  comes  readily  to  the  surface,  {b)  An 
intvaniammayy  abscess  is  the  most  common  variety,  the  pus  developing 
within,  and  distending  the  lobules,  or  infiltrating  the  cellular  tissue 
around  them  ;  it  is  usually  diffused  widely  throughout  the  organ,  and 
may  point  at  several  spots.  When  very  acute,  or  in  debilitated 
women,  especially  if  it  has  been  allov/ed  to  progress  without  treat- 
ment, the  inflammatory  process  may  actually  determine  gangrene  of 
the  glandular  tissue,  {c)  A  submammary  abscess  forms  in  the  cellular 
tissue  beneath  the  breast.  It  may  spread  from  the  deep  lobules,  but 
more  frequently  results  from  disease  of  some  of  the  adjacent  ribs  or 
cartilages,  or  starts  as  a  cellulitis.  In  these  cases  the  breast  is 
pushed  forwards,  and  becomes  prominent,  floating,  as  it  were,  on  a 
bed  of  pus.  The  abscess  usually  points  at  the  periphery  of  the  organ, 
perhaps  in  several  places,  but  most  commonly  at  the  lower  and  outer 
quadrant. 

Inflammation  of  the  breast  occurs  in  women  who  are  anaemic  and 
weakly.  Even  the  simple  forms  are  associated  with  fever  and  malaise, 
and  these  become  exaggerated  if  suppuration  ensues,  owing  partly  to 
the  pain,  and  partly  to  the  absorption  of  toxins. 

The  Treatment  of  simple  acute  mastitis  consists,  in  the  first  place, 
in  supporting  the  inflamed  gland  by  means  of  a  sling  or  bandage,  and 
in  binding  the  arm  to  the  side,  so  as  to  keep  at  rest  the  pectoral  muscle, 
on  which  it  lies.  F'omentations  are  then  applied,  and  any  tension  due 
to  retained  secretion  is  relieved  by  the  breast- pump.  The  bowels  are 
opened,  and  the  patient  placed  on  a  light  and  nourishing  diet,  whilst 
stimulants  and  tonics,  such  as  iron  and  quinine,  may  be  judiciously 
administered. 

As  soon  as  the  acute  stage  has  passed,  friction  with  warm  oil,  or 
the  inunction  of  a  belladonna  ointment,  is  advisable. 

When  suppuration  is  threatening,  the  breast  may  be  poulticed 
until  fluctuation  is  detected ;  but  under  no  circumstances  must  the 
abscess  be  allowed  to  burst  into  the  poultice,  and  thus  become  septic. 
If  such  a  practice  is  permitted,  chronic  suppuration  ensues,  and  the 
breast  may  become  riddled  with  sinuses.  The  most  rigid  asepsis 
must  be  maintained  in  these  cases,  and  as  soon  as  pus  is  evidently 
present,  an  incision  should  be  made  to  permit  of  its  escape.  In  the 
supramammavy  variety  it  matters  little  in  which  direction  the  cut  is 
made,  since  the  pus  is  always  superficial  to  the  breast  tissue.  In  the 
true  intramammavy  abscess  the  incisions  should  radiate  from  the  nipple. 
One  or  more  may  be  needed,  and  these  should  be  made  with  a  free 
hand,  so  as  to  aflow  of  the  insertion  of  the  finger,  and  the  opening  up 
of  any  pockets  or  lobules  which  are  distended  with  matter.  A 
large  drainage-tube  is  inserted  for  a  time,  and  gradually  shortened 


948  A  MANUAL  OF  SURGERY 

day  by  day,  until  its  entire  removal  is  permissible.  When  the  chief 
incisions  are  needed  above  the  nipple,  it  is  often  wise  to  make  a 
counter-opening  in  the  lower  half  of  the  breast,  and  generally  on  tlie 
outer  side,  to  permit  of  more  efficient  drainage.  With  such  treat- 
ment the  best  of  results  may  be  attained,  and  it  is  interesting  to  note 
how  quickly  the  contour  of  the  breast  is  restored,  but  how  slight  is 
the  permanent  injury  inflicted  on  the  parts.  The  submammary  abscess 
is  best  opened  towards  the  lower  and  outer  side,  but  also  at  any  spot 
where  pus  points. 

If  septic  sinuses  persist  after  an  abscess  has  burst,  their  orifices 
should  be  enlarged,  and  their  walls  thoroughly  scraped  and  dis- 
infected ;  deep  cavities  should  be  efficiently  drained  and  packed  with 
gauze,  so  as  to  insure  the  wounds  healing  by  granulation ;  the  arm 
must  also  be  kept  to  the  side. 

Clironic  Mastitis  occurs  in  two  forms — one,  a  localized  affection 
of  one  segment  of  the  breast  (chronic  lobar  mastitis),  the  other 
involving  the  smaller  lobules  and  interstitial  tissue  (chronic  lobular 
or  interstitial  mastitis). 

1.  Chronic  Lobar  Mastitis  is  by  no  means  unfrequent  as  a  result  of 
imperfect  involution  of  the  organs  at  the  cessation  of  lactation,  but 
may  arise  from  blows  or  squeezes,  and  especially  in  young  women  ; 
it  may  also  follow  a  subacute  or  acute  attack,  which  has  not  ended 
in  suppuration.  It  is  characterized  by  an  enlargement  of  one  or 
more  lobes  of  the  organ,  which  are  usually  tender,  and  often  exces- 
sively painful,  the  pain  being  of  a  neuralgic  character,  and  increased 
during  menstruation.  The  condition  is  of  comparatively  little  impor- 
tance, but  may  give  rise  to  a  great  deal  of  anxiety  and  worry.  All 
that  is  necessary  in  the  shape  of  Treatment  is  to  support  the  part  and 
keep  the  arm  at  rest  in  a  sling,  whilst  an  ointment  containing  bella- 
donna, or  a  belladonna  plaster,  may  be  applied. 

2.  Clironic  Lobular  or  Interstitial  Mastitis  is  an  affection  which 
occurs  not  unfrequently  in  women  with  small  or  atrophic  breasts,  who 
have  passed,  or  are  near  to,  the  climacteric.  It  is. also  met  with  at 
an  earlier  age  in  unmarried  women,  involving  the  whole  of  one  or 
both  breasts,  or  limited  in  its  development  to  a  portion  of  one  breast, 
and  then  being  sometimes  mistaken  for  a  malignant  tumour. 
Pathologically,  it  is  characterized  by  diff'use  overgrowth  of  the 
connective  tissue,  which  becomes  thickened  and  perhaps  sclerosed. 
This  is  associated  with  Vs^ell-marked  epithelial  proliferation,  so 
that  sometimes  in  the  earlier  stages  the  acini  are  filled  with  a  thick 
cheesy  or  grumous  material  which  can  be  squeezed  out  in  thread- 
like masses,  often  of  a  dirty  brown  or  greenish-yellow  colour.  Cysts 
are  formed  in  the  gland  tissue,  partly  by  liquefaction  of  this  pro- 
liferated epithelium,  partly  by  exudation  into  the  acini  of  serous 
fluid,  which  is  unable  to  find  an  exit  owing  to  the  pressure  of  the 
interstitial  growth.  Such  are  known  as  '  involution  cysts,'  and  the 
fluid  contained  therein  is  usually  clear  and  limpid  ;  but  may  be 
brown  and  turbid,  from  admixture  of  blood  ;  intracystic  growths  are 
not  present.     As  a  rule,  many  of  these  cysts  are  scattered  widely 


DISEASES  OF  THE  BREAST  949 

through  the  breast  substance,  but  they  are  small  and  insignificant ; 
occasionally  one  or  more  of  them  become  notably  enlarged,  and 
simulate  a  tumour,  especially  when  covered  in  by  a  mass  of  thickened 
glandular  tissue. 
.  Clinical  History. — The  condition  often  passes  unnoticed  in  the 
early  stages,  until  a  distinct  lump  has  formed,  which  is  nodular  and 
indurated  to  the  touch,  and  often  very  painful.  The  breast  may  be 
somewhat  enlarged,  and  there  is,  perhaps,  some  retraction  of  the 
nipple,  owing  to  contraction  of  the  interstitial  tissue  ;  but  this  is  by 
no  means  an  essential  feature.  A  scanty  serous  discharge  from  the 
nipple  is  sometimes  noticed.  The  skin  seldom  becomes  adherent  to 
the  swelling,  whilst  the  lymphatic  glands  in  the  axilla  may  be  enlarged 
and  tender,  but  they  are  never  hard.  On  careful  examination  of  the 
breast,  the  affection  is  rarely  found  to  be  limited  to  one  particular 
region,  for  although  a  distinct  enlargement  of  one  portion  may  be 
present,  yet  the  whole  organ  feels  more  or  less  '  lumpy,'  and  not 
unfrequently  the  other  breast  participates  in  the  same  change. 
Small,  rounded,  elastic  spots  can  often  be  detected,  and  indicate 
the  presence  of  cysts.  There  may  be  but  little  pain,  although  this 
is  sometimes  one  of  the  most  marked  features  of  the  case ;  it  is  of  a 
neuralgic  type,  and  usually  increased  at  the  menstrual  periods. 

If  left  to  run  its  course,  the  disease  may  remain  much  in  the  same 
condition  for  many  years,  and  even  in  time  disappears ;  but  more 
frequently  it  slowly  progresses,  and  then  results  in  one  of  three  con- 
ditions :  (a)  General  atrophy,  the  breast  becoming  shrunken,  hard,  and 
nodular,  (h)  More  frequently  general  cystic  disease  follows,  a  condition 
in  which  the  organ  becomes  transformed  into  a  number  of  cysts  held 
together  by  dense  connective  tissue,  {c)  There  is  some  question 
as  to  whether  or  not  cancer  is  a  sequela  of  this  disease ;  there  is 
abundant  evidence  to  prove  that  any  continued  source  of  irritation 
in  an  organ  like  the  breast  renders  an  individual  with  a  cancerous 
inheritance  more  liable  to  its  development,  especially  if  it  commences 
at  or  about  the  climacteric. 

The  Diagnosis  is  sometimes  easy,  but  the  condition  often  simulates 
somewhat  closely  a  scirrhous  tumour.  The  chief  points  of  distinction, 
however,  lie  in  the  facts  (i.)  that  the  whole  breast  is  more  or  less 
involved;  (ii.)  that  the  opposite  organ  is  very  often  similarly  affected; 
(iii.)  that  enlargement  of  the  axillary  glands  is  less  common  than  in 
scirrhus,  and  even  if  enlarged  they  are  not  hard,  as  in  the  latter 
disease  ;  (iv.)  that  the  skin  is  usually  free  from  the  mass ;  (v.)  that 
the  tumour  is  never  adherent  to  the  pectoral  facia,  nor  is  it  of  the 
stony  hardness  of  a  scirrhus ;  and  (vi.)  that  it  is  often  more  dis- 
seminated and  less  defined  than  a  cancerous  growth,  (vii.)  More- 
over, on  careful  palpation  with  the  flat  of  the  hand,  it  is  often 
impossible  to  make  out  any  distinct  lump,  the  so-called  tumour 
merging  into  the  surrounding  tissues;  this  never  occurs  in  scirrhus, 
the  growth  always  being  easily  detected  with  the  flat  of  the  hand. 
Small  cysts  can  also  be  felt  as  localized  elastic  spots  in  the  inflam- 
matory mass.      Of  course  it  is  possible  for  the  two  conditions  to 


550  A  MANUAL  OF  SURGERY 

co-exist,  and  in  doubtful  cases  an  exploratory  incision,  and  microscopic 
examination  of  a  portion  of  the  tissue,  can  alone  be  depended  on. 

Treatment. — In  the  early  stages,  and  especially  in  the  younger 
patients,  friction  with  some  sedative  application  containing  bella- 
donna may  be  used  at  the  same  time  that  the  breast  is  supported, 
and  freed  from  the  irritation  of  badly-fitting  stays.  Firm  and  equable 
pressure,  as  by  strapping,  is  also  useful  in  some  cases,  whilst  iodides 
may  be  administered.  If  a  definite  tumour  is  present,  or  if  many 
cysts  can  be  detected,  and  especially  if  the  patient  is  anxious  and 
worried  about  herself,  it  is  wise  to  remove  the  affected  portion,  or 
even  better  to  excise  the  whole  breast,  especially  when  there  is 
a  family  history  of  malignant  disease. 

Localized  or  Encysted  Ckronic  Abscess  is  usually  associated  with 
pregnancy,  and  is  characterized  by  the  formation  of  an  indurated 
mass  in  the  breast  substance,  which  slowly  softens,  giving  rise  to  a 
sense  of  fluctuation,  although  when  the  abscess  walls  are  very  thick, 
as  is  often  the  case,  it  may  be  exceedingly  difficult  to  detect  this. 
Retraction  of  the  nipple  is  not  uncommonly  present,  and  the  axillary 
glands  may  be  enlarged.  The  condition  has  frequently  been  mis- 
taken for  a  tumour,  but  is  recognised  from  it  by  its  incorporation 
with  the  breast  substance,  by  its  lack  of  definition,  and  by  the  fact 
that  on  careful  examination  elasticity  can  be  felt  at  its  centre,  which 
is  almost  always  less  resistant  than  the  margin,  whereas  the  opposite 
is  the  case  with  a  tumour.  In  cases  of  doubt  the  insertion  of  a 
grooved  needle  or  an  exploratory  incision  will  settle  the  diagnosis. 
Sometimes  chronic  abscesses  of  the  breast  are  of  a  tuberculous  nature. 

Treatment  consists  in  opening  the  abscess  cavity,  scraping  out  its 
interior,  disinfecting  with  pure  carbolic  acid,  if  tuberculous,  and 
draining  or  stuffing  it. 

Diffuse  Tuberculous  Disease  of  the  breast  is  not  very  uncommon. 
Scattered  nodules  of  caseous  material  are  developed  in  the  inter- 
acinous  tissue,  which  break  down  into  pus,  and  come  to  the  surface  at 
various  spots.  The  breast  may  thus  become  riddled  with  sinuses 
discharging  caseous  pus.  It  may  be  associated  with  tuberculous 
disease  of  the  lungs,  whilst  a  like  affection  may  arise  secondarily  in 
the  axillary  glands ;  possibly  in  some  cases  the  primary  trouble  lies 
in  the  glands,  the  breast  being  subsequently  involved. 

Treatment  should  be  carried  out,  if  possible,  by  incision,  scraping, 
and  purification  of  the  cavities ;  but  if  the  tuberculous  foci  are 
multiple,  it  is  wiser  to  amputate  the  breast. 

Occasionally  a  chronic  tuberculous  submammary  abscess  forms  as  a 
result  of  a  similar  affection  of  the  ribs  or  costal  cartilages.  It 
develops  slowly,  pushing  the  breast  forwards,  and  is  easily  recognised, 
although  the  causative  lesion  can  only  be  ascertained  by  exploration. 
It  must  be  opened  thoroughly,  and  its  wall  scraped  and  disinfected, 
whilst  attention  is  also  directed  towards  the  affected  bone. 

Syphilitic  Diseases  of  the  Breast. — As  already  pointed  out,  a 
primary  sore  may  be  met  with  on  the  nipple;  secondary  mucous 
tubercles,  or  condylom.ata,  are  found  in  a  similar  situation  or  beneath 


DISEASES  OF  THE  BREAST  951 

a  pendulous  breast,  whilst  superficial  and  deep  gummata  have  in  rare 
cases  formed  in  the  tertiary  period  of  the  disease. 

Cysts  of  the  Breast. 

When  the  structure  of  the  breast,  its  abundance  of  ducts  and 
alveoli,  and  its  complex  lymphatic  distribution  are  considered,  it  is 
not  surprising  that  many  different  forms  of  cystic  change  are  associated 
therewith.     The  following  are  the  more  important : 

I.  Acinous  or  Retention  Cysts  arise,  as  the  name  suggests,  from 
some  obstruction  to  the  ducts  or  lobules,  whereby  the  secretion 
of  the  organ  is  unable  to  escape.  They  are  met  with  most 
frequently  in  women  during  or  after  the  puerperal  period,  a  milk 
cyst,  or  galadocele,  being  then  produced.  It  usually  results  from 
compression  of  one  or  more  of  the  ducts,  connected  with  a  sore 
nipple,  and  contains  inspissated  milk ;  it  forms  a  rounded  swelling 
and  is  located  near  the  nipple.  The  wall  is  lined  with  cuboidal  or 
columnar  epithelium,  according  to  whether  a  portion  of  the  lobule  or 
the  duct  itself  is  implicated  ;  if,  however,  it  attains  any  great  size, 
the  epithelium  may  become  flat  and  squamous.  This  is  surrounded 
by  a  fibro-cicatricial  layer,  the  thickness  of  which  increases  with  the 
chronicity  of  the  case.  It  is  treated  by  laying  the  part  open, 
removing  the  contents,  and  stuffing  or  draining  the  cavity. 

Similar  glandular  cysts  form,  as  already  described,  in  the  course 
of  chronic  interstitial  mastitis,  and  are  then  known  as  involution  cysts  ; 
in  long-standing  cases,  general  cystic  disease  of  the  breast  may  follow. 

Retention  cysts  have  also  been  described  as  resulting  from  irrita- 
tion of  the  nipple,  as,  for  instance,  when  a  young,  non-pregnant 
woman  constantly  puts  a  baby  to  her  breast ;  it  may  also  occur  apart 
from  such  irritation  in  young  and  vigorous  unmarried  women,  as  an 
expression  of  the  inherent  capacity  of  the  gland  for  functional 
development.  The  organ  becomes  enlarged,  the  epithelium  pro- 
liferates, and  a  thin  serous  fluid  is  secreted,  which  does  not  entirely 
escape,  and  by  its  distension  of  the  lobules  gives  rise  to  what  may  be 
termed  irritation  cysts.  They  may  in  time  undergo  spontaneous 
absorption,  but  Erichsen  describes  a  case  of  this  nature  in  w^hich 
the  swellings  did  not  disappear  until  the  patient  subsequently  became 
pregnant.     Chronic  interstitial  mastitis  may  sometimes  supervene. 

Again,  one  frequently  finds  cystic  dilatation  of  the  ducts  and 
lobules  arising  in  connection  with  certain  tumours  of  the  breast,  such 
as  duct  papilloma,  duct  cancer,  or  cysto-adenoma.  In  the  latter 
cases  haemorrhage  from  the  contained  growth  is  often  seen,  giving 
rise  to  a  blood-stained  discharge  from  the  nipple.  A  scirrhous  growth 
also  occasionally  starts  from  the  wall  of  an  acinous  cyst. 

In  most  of  these  retention  cysts,  discharge  from  the  nipple  occurs 
on  squeezing  the  organ. 

2.  Interacinous  Cysts  develop  in  the  interstitial  tissue  of  the  breast. 

{a)  Serous  Cysts  originate  from  a  dilatation  of  lymph  spaces.  They 
may  be  uni-  or  multi-locular,  perhaps  more  frequently  the  latter.  They 


952  A  MANUAL  OF  SURGERY 

are  lined  by  a  smooth,  shiny  layer  of  endothelium,  and  contain  serum, 
perhaps  blood-stained,  and  in  old-standing  cases  cholesterine  ;  being 
separate  from  the  gland  substance,  they  never  give  rise  to  a  discharge 
from  the  nipple,  and  intracystic  growths  are  unknown.  They  are 
usually  surrounded  by  a  wall  of  connective  tissue  which  may  become 
exceedingly  thick  and  dense.  Occasionally,  however,  they  project 
under  the  skin,  and  if  the  walls  remain  thin,  fluctuation,  and  even 
translucency,  can  be  observed,  leading  to  the  condition  sometimes 
badly  termed  a  hydrocele  of  the  breast. 

The  Diagnosis  of  a  serous  cyst,  if  the  wall  is  thick,  is  often  a 
matter  of  considerable  difficulty,  as  it  resembles  in  many  ways  a 
scirrhus.  It  is  recognised,  however,  by  the  facts  that  the  grow^th 
is  incorporated  with  the  breast  substance,  usually  occurring  near  its 
under  surface ;  that  on  careful  examination  an  elastic  resistance 
is  transmitted  to  the  fingers,  quite  distinct  from  the  stony  hardness  of 
a  scirrhus ;  that  there  is  no  retraction  of  the  nipple  and  no  enlarge- 
ment of  the  axillary  glands,  whilst,  as  a  rule,  the  patient  complains 
of  but  little  pain.  The  diagnosis  in  cases  of  doubt  may  be  readily 
determined  by  inserting  a  grooved  needle,  or  by  an  exploratory 
incision,  which  should  be  made  of  sufficient  depth  to  insure  the 
thorough  division  of  the  mass,  for  fear  that  a  small  cyst  surrounded 
by  walls  of  fibrous  tissue,  half  an  inch,  or  even  an  inch,  in  thickness, 
should  be  mistaken  for  a  solid  tumour. 

Treatment.— Although  it  may  suffice  to  lay  the  cavity  open  and 
drain  it,  it  is  decidedly  wiser  to  remove  it  completely. 

(b)  True  Hydatid  Cysts  are  occasionally  met  with,  manifesting  the 
general  characteristics  described  at  p.  227. 

3.  Cysts  may  also  arise  in  connection  with  cancerous  or  sar- 
comatous tumours,  from  degeneration  of  tissue  in  the  former  case, 
and  from  haemorrhage  into  the  substance  of  the  latter. 

4.  Dermoid  Cysts  are  described  ;  but  it  is  a  little  doubtful  whether 
old  galactoceles  have  not  been  mistaken  for  them. 

Tumours  of  the  Breast. 

In  investigating  any  case  of  tumour  of  the  breast,  the  surgeon 
must  never  arrive  at  a  hasty  conclusion,  but  only  give  an  opinion  as ' 
to  its  nature  after  careful  and  detailed  examination.  Thus,  the  age 
and  previous  history  of  the  patient  should  be  considered,  as  also  the 
family  history.  Simple  tumours  generally  arise  at  an  earlier  date 
than  the  malignant,  whilst  the  sarcomata  usually  affect  younger 
individuals  than  the  carcinomata.  There  can  be  little  doubt,  more- 
over, as  to  the  occasional  tendency  of  tumours  to  run  in  families. 
The  length  of  time  for  which  the  swelling  has  been  observed  should 
be  ascertained,  and  whether  or  not  it  varies  in  size  at  the  menstrual 
periods.  The  general  appearance  of  the  patient  should  be  noted,  as 
also  the  fact  whether  or  not  pain,  local  or  neuralgic,  is  experienced. 
It  is  not  unusual  for  pain  to  be  referred  to  that  part  of  the  shoulder 
supplied  by  the  posterior  division  of  the  second  intercostal  nerve,  the 


DISEASES  OF  THE  BREAST  953 

anterior  branch  of  which  goes  to  the  breast.  A  careful  inspection 
of  the  organ  should  then  be  made,  comparing  it  with  the  opposite 
breast,  so  that  any  signs  of  asymmetry  may  be  noted.  Dimpling  of 
the  skin,  projection  of  the  tumour  or  of  the  whole  gland,  and  the 
situation  and  condition  of  the  nipple,  are  the  chief  points  to  which 
attention  should  be  directed.  Examination  of  the  tumour  with  the 
flat  of  the  hand,  accompanied  by  gentle  pressure  of  the  finger-tips, 
must  then  be  undertaken ;  it  is  not  enough  to  pick  up  the  breast 
substance  between  the  fingers,  as  thereby  false  impressions  are 
obtained.  The  relation  of  the  tumour  to  the  gland,  its  shape,  its 
consistency,  whether  fluctuating  or  not,  and  its  mobiHty  on  super- 
ficial, deep,  and  surrounding  parts,  should  all  be  investigated.  To  this 
end  the  breast  must  also  be  examined  with  the  arm  raised  well  above 
the  head,  so  as  to  put  the  fibres  of  the  pectoralis  major  on  the  stretch ; 
transverse  movement  of  the  organ  across  the  fibres  is  always  possible, 
unless  the  growth  is  fixed  to  the  thoracic  wall;  movement  in  the 
direction  of  the  fibres  is  at  once  limited  if  the  tumour  has  invaded 
the  muscle,  or  even  if  the  overlying  fascia  is  seriously  involved. 
Finally,  the  lymphatic  glands  in  the  axilla  must  be  carefully  examined, 
as  also,  in  suspicious  cases,  the  supraclavicular  glands  and  the 
opposite  breast  and  armpit. 

The  chief  types  of  tumour  met  with  in  the  breast  may  be  arranged 
in  three  groups  :  the  adenomata,  the  sarcomata,  and  the  cancers.  A 
few  otherconditions  have  been  observed,  but  are  so  rare  that  they  need 
no  special  description — e.g.,  lipoma,  fibroma,  chondroma,  and  osteoma. 

Adenoid  Tumours  of  the  Breast. — This  group  includes  the  two 
forms  of  fibro-adenoma  (the  hard  and  the  soft)  and  the  cysto-adenoma. 
All  are  characterized  by  the  existence  of  spaces  lined  with  epithelium, 
which  does  not  extend  beyond  the  basement  membrane.  The  spaces 
may  contain  a  variable  quantity  of  fluid,  and  in  some  cases  intra- 
cystic  growths  are  a  prominent  feature.  The  interstitial  tissue  is 
sometimes  of  a  very  embryonic  type. 

A  pure  Adenoma  is  said  to  occur,  but  is  very  uncommon.  Its 
texture  would  be  identical  with  ordinary  mammary  tissue,  and  its 
characters  with  those  of  a  fibro-adenoma,  except  that  it  is  a  little  softer. 

The  Hard  Fibro-adenoma  (or  Adeno-flbroma)  is  the  most  common 
mammary  tumour  met  with  in  young  people  before  the  age  of  thirty  ; 
it  is  often  attributed  to  a  blow  or  squeeze,  and  doubtless  correctly. 
It  occurs  as  a  more  or  less  rounded  or  oval  mass,  which,  if  placed 
superficially,  moves  freely  in  the  breast  substance,  and,  indeed,  may 
be  described  as  floating  in  it  (Fig.  430) ;  if  situated  deeply,  it  still 
appears  quite  moveable,  but  its  definition  is  less  evident.  Sometimes 
several  such  growths  are  found  in  the  same  breast.  A  fibro-adenoma 
is  usually  firm  and  more  or  less  elastic  in  consistency,  of  slow 
growth,  and  it  may  be  either  painless,  or  in  anaem.ic  and  neurotic 
women  exceedingly  painful,  the  pain  often  increasing  at  the  menstrual 
periods.  There  is  no  concurrent  enlargement  of  the  axillary  glands, 
unless  arising  from  other  causes,  and  no  retraction  of  the  nipple, 
with  which  it  is   entirely  unconnected ;   the  skin  over  it   does  not 


954 


A  MANUAL  OF  SURGERY 


dimple.  The  general  health  is  unimpaired  unless  the  patient  is 
suffering  from  an  associated  anaemia.  On  section  the  tumour  is  of 
a  grayish-white  colour,  becoming  pink  on  exposure  to  the  air.  It  is 
more  or  less  foliated  in  texture,  being  compared  by  Virchow  to  the 
section  of  a  cabbage ;  no  juice  can  be  obtained  on  scraping  the  cut 
surface  with  a  scalpel,  although  on  pressure  some  fluid  of  a  thick 
glutinous  or  mucoid  nature  may  escape.  Microscopically,  the 
tumour  consists  of  imperfectly  developed  glandular  elements,  sur- 
rounded by  a  considerable  amount  of  firm  interstitial  tissue,  but 
ducts  are  never  present.  The  tumour  is  distinctly  encapsuled, 
except  at  the  one  spot,  through  which  vessels  enter,  and  at  which 


^ri? 


Fig.  430. — FiBRO-ADENOMA  Mamm^.     (From  Museum  of  Royal  College 

OF  Surgeons.) 

it  is  connected  with  the  neighbouring  mammary  tissue.  It  is  stated 
that  fibro-adenomata  are  occasionally  converted  into  sarcomata,  thus 
changing  their  type  from  simple  to  malignant ;  the  evidence,  how- 
ever, as  to  this  is  not  conclusive. 

The  Diagnosis  is  readily  made  if  the  above  signs  are  considered. 
An  adenoma  differs  from  chronic  interstitial  mastitis  or  a  serous 
cyst  by  its  exact  definition  and  free  mobility,  whilst  from  malignant 
tumours  it  is  distinguished  by  its  slow  rate  of  growth,  and  its  freedom 
from  adhesions  either  to  the  skin  or  to  surrounding  parts. 

The  Treatment  consists  in  its  removal,  which  is  easily  effected  by 
cutting  down   upon   the  tumour  in  a  direction  radiating   from  the 


DISEASES  OF  THE  BREAST 


955 


nipple,  until  the  capsule  is  reached,  when  the  mass  is  enucleated  from 
its  surroundings  with  a  few  touches  of  the  knife.  When  the  growth 
is  situated  deeply  in  the  upper  half  of  the  breast,  a  crescentic  incision 
may  be  made  along  the  lower  and  outer  border  of  the  organ,  and 
by  burrowing  upwards,  the  breast  can  be  turned  over  sufficiently  to 
permit  the  tumour  to  be  removed  from  the  deep  aspect ;  the  scar 
will  be  subsequently  hidden  (Thomas's  operation). 

The  Soft  Fibro-adenoma  differs  from  the  above  mainly  in  the 
increased  rate  of  growth,  in  its  soft  consistency,  and  in  the  fact  that 
the  interstitial  tissue  is  of  a  more  embryonic  character,  and,  indeed, 
is  often  of  a  mucoid  nature ;  it  is  sometimes  incorrectly  termed  an 
adeno- sarcoma.     It  usually  occurs  in  women  at  a  somewhat  earlier 


Fig.  431. — Cysto-adenoma  Mamm^.     (Museum  of  Royal  College  of 

Surgeons.) 

The  intra-cystic  growths  are  seen  projecting  from  a  large  cyst,  into  which  a 
bristle,  passed  down  the  nipple,  enters.  A  glass  rod  has  also  been  passed 
into  the  cyst  through  a  perforation  in  the  skin. 

period  of  life  than  sarcoma  or  cancer — viz.,  between  the  ages  of 
twenty-five  and  thirty-five.  It  may  consist  from  the  first  of  a 
localized  tumour,  increasing  rapidly  in  size,  or  it  may  possibly 
commence  as  a  hard  fibro-adenoma,  which,  after  remaining  quiet  for 
a  time,  takes  on  a  more  active  development.  It  remains,  however, 
throughout  its  course  strictly  encapsuled,  and  when  large  may  lead 
to  pressure-atrophy  of  the  true  gland  substance.  It  is  soft  and 
elastic  in  consistency,  usually  painless,  and  freely  moveable  on  the 
surrounding  breast  tissue.  The  skin  over  it  remains  healthy, 
although  distended  and  atrophic  when  the  tumour  is  of  large  size  ; 
the  nipple  shows  no  sign  of  retraction  ;  the  axillary  glands  are  not 
involved,  and  there  is  no  systemic  invasion.  On  removal  the  section 
is  similar  to  that  of  a  fibro-adenoma,  but  cysts  are  often  present,  as 
also  areas  of  mucoid  softening,  somewhat  resembling  sago.  It  can  be 
readily  removed  in  its  entirety,  and  does  not  tend  to  recur. 


956  A  MANUAL  OF  SURGERY 

Cysto -adenoma  (Syn. :  Cysto-sarcoma,  Adenocele,  Intracanalicular 
Adenoma,  etc.)  is  a  condition  characterized  by  a  marked  development 
of  intracystic  growths,  consisting  of  newly-formed  fibrous  tissue 
covered  with  epithelium,  within  the  dilated  acini  of  a  newly-formed- 
mass  of  adenomatous  tissue,  or  within  the  smaller  ducts  (Fig.  431). 
It  usually  has  a  definite  capsule,  and  then  the  normal  gland  tissue 
may  be  pressed  aside,  and  perhaps  atrophies.  Several  cysts  are,  as  a 
rule,  present,  and  may  be  of  great  size,  the  intracystic  growths  also 
varying  in  amount.  Sometimes  there  is  only  one  large  cauliflower- 
like  mass  in  a  cyst ;  sometimes  there  are  several  smaller  pedunculated 
growths.  The  epithelium  covering  them  is  cuboidal  or  columnar ; 
they  are  exceedingly  vascular,  and  haemorrhage  into  the  cavity  of  the 
cyst  frequently  occurs,  as  also  a  blood-stained   discharge  fiom  tlic 


Fig.  432. — Cysto-adenoma  MaMm.b.     (From  a  Photograph.) 

nipple.  They  are  due  to  a  proliferation  of  the  interacinous  tissue, 
which  pushes  the  epithelial  wall  of  the  duct  or  acinus  before  it. 
The  tumour  produced  is  irregular  in  outline,  owing  to  the  projection 
of  the  cysts  (Fig.  432) ;  it  is  usually  painless,  and  unaccompanied  by 
enlargement  of  the  axillary  glands  ;  if  of  large  size,  blue  veins  are 
seen  coursing  over  it.  In  the  later  stages  the  capsule  becomes 
adherent  to  the  integument,  and,  finally,  owing  to  the  pressure  of  the 
tumour,  the  skin  may  give  way,  allowing  the  growth  to  protrude. 
This  will  be  followed  by  the  development  of  a  fungating  mass,  which 
bleeds  readily,  and  becomes  extremely  offensive.  With  care  a  probe 
can  be  passed  between  the  intracystic  portion  of  the  growth  and  the 
thinned  and  stretched  skin,  which  has  merely  given  way,  and  is  not 
incorporated  with  it ;  this  fact  is  a  ready  means  of  distinguishing  this 
condition  from  a   fungating   encephaloid    cancer.     The  tumour  is 


DISEASES  OF  THE  BREAST  957 

essentially  benign  in  nature  :  it  is  never  disseminated  generally,  and 
can  be  readily  and  completely  removed,  so  that  there  is  but  little 
tendency  to  recur.  In  the  early  stages  it  is  unnecessary  to  take  away 
the  entire  breast  if  the  tumour  can  be  efficiently  dealt  with  otherwise, 
but  in  the  later  stages  the  whole  organ  should  be  excised. 

Somewhat  similar  in  nature  to  the  above  is  the  condition  known 
a  duct  papilloma.  This  is  characterized  by  the  development  of  a  soft 
polypoid  papillomatous  mass,  generally  of  small  size,  in  the  interior 
of  one  of  the  terminal  galactophorous  ducts,  which  in  consequence 
becomes  dilated.  A  discharge  of  blood-stained  serum  results,  and 
there  is  usually  but  little  tumour  to  be  felt,  although  the  nipple 
may  be  slightly  pushed  forwards  and  rendered  prominent.  It  is  often 
the  precursor  of  a  duct  cancer.  Amputation  of  the  breast  will  in  many 
cases  be  needed,  but  it  may  be  feasible  in  some  to  deal  with  the 
tumour  alone. 

Sarcoma  of  the  Breast  is  not  a  common  disease  (2  to  8  per  cent,  of 
all  mammary  tumours).  It  originates  in  the  connective  tissue  of  the 
organ,  being  deeply  placed  in  its  substance,  or  perhaps  more  fre- 
quently developing  in  the  outer  and  upper  quadrant.  It  is  of  two 
chief  types :  (a)  The  round-celled  sarcoma  forms  a  soft,  somewhat 
elastic  swelling,  which  grows  rapidly,  and  although  often  limited  at 
first  by  a  fibrous  membrane,  the  capsule  sooner  or  later  yields, 
allowing  the  growth  to  become  diffused  through  the  organ.  It 
sometimes  gives  rise  to  secondary  growths  in  the  axillary  glands,  or 
becomes  disseminated  throughout  the  body  by  means  of  the  blood- 
vessels. Cysts  often  occur  in  its  substance,  resulting  either  from 
haemorrhage  or  occasionally  from  the  dilatation  of  an  incorporated 
glandular  alveolus ;  in  the  latter  case  the  cavity  will  be  lined  with 
epithelium.  Myxomatous  changes  are  also  not  unfrequently  observed, 
and  in  the  more  rapidly  growing  recurrent  tumours  the  mass  is  often 
a  true  myxo-sarcoma.  It  usually  occurs  in  women  between  the  ages 
of  thirty  and  forty — i.e.,  somewhat  earlier  than  scirrhus — whilst  its 
rapid  growth  and  the  absence  of  retraction  of  the  nipple  or  dimpling 
of  the  skin  are  useful  diagnostic  features.  Should  pregnancy  follow, 
the  tumour  may  increase  in  size  at  an  alarming  rate.  In  the  infil- 
trating forms  it  is  almost  impossible  to  distinguish  it  from  encephaloid 
cancer,  except  on  microscopic  examination.  (b)  A  spindle -celled 
sarcoma,  or  fibro-sarcoma,  is  also  met  with,  forming  a  rounded  or 
oval  tumour,  more  limited  than  the  above,  and  growing  less  rapidly. 
It  somewhat  simulates  an  adenoma,  but  is  more  closely  connected 
with  the  breast  substance.  The  axillary  glands  are  but  rarely 
involved,  and  the  sarcomatous  nature  is  recognised  by  the  micro- 
scope and  by  the  great  tendency  of  the  growth  to  recur  even  after 
apparently  complete  removal ;  on  account  of  this  latter  feature,  the 
name  of  '  recurrent  fibroid  tumour '  (Paget)  was  formerly  applied 
to  it.  The  recurrences  generally  take  place  at  gradually  diminishing 
intervals,  and  the  tumour  may  then  become  softer  and  more  vascular  ; 
occasionally  the  tendency  to  recur  seems  to  wear  itself  out  after  the 
performance  of  several  operations. 


958  A  MANUAL  OF  SURGERY 

The  Treatment  of  sarcoma  mammge  consists  in  the  removal  of  the 
entire  organ  at  as  early  a  date  as  possible,  together  with  the  axillary 
glands. 

Cancer  of  the  Breast. 

No  organ  of  the  body,  with  the '  exception  of  the  uterus,  is  more 
frequently  the  seat  of  cancer  than  the  female  breast ;  it  also  occurs  in 
the  male  subject,  but  is  about  a  hundred  times  less  common  than  in 
the  other  sex. 

jEtiology. — Cancer  of  the  breast  is  usually  met  with  after  the  age 
of  forty,  although  the  disease  may  occur  at  a  much  earlier  date.  It 
equally  affects  women  who  have  borne  children  and  nulliparae,  and 
the  question  whether  or  not  the  woman  has  nursed  her  children  seems 
to  have  but  little  influence.  The  left  breast  is  more  often  affected 
than  the  right.  It  is  frequently  attributed  to  some  injury,  such  as  a 
blow  or  squeeze  ;  whilst  there  is  little  doubt  that  badly-fitting  stays 
are  responsible  for  a  certain  percentage  of  the  cases.  It  not  un- 
commonly follows  eczema  of  the  nipple,  especially  that  variety  known 
as  Paget's  eczema ;  chronic  interstitial  mastitis  may  also  possibly  be 
an  occasional  precursor  of  this  affection.  The  question  as  to  heredity 
is  one  exceedingly  difficult  to  decide,  and,  although  it  may  be  a  marked 
feature  of  some  cases,  it  is  somewhat  doubtful  whether,  as  a  general 
rule,  it  has  any  considerable  influence. 

Two  distinct  types  of  cancer  are  met  with  in  the  breast — viz., 
the  spheroidal-celled  acinous  cancer  (including  the  acute  form,  and  the 
more  chronic  type  known  as  scirrhus)  and  duct  cancer.  Colloid  de- 
generation of  either  of  the  former  varieties  has  been  observed,  but 
is  very  uncommon. 

I.  Spheroidal- celled  Acinous  Cancer  includes  the  great  majority  of 
cases  ;  the  division  into  scirrhus  and  acute  cancer  depends  clinically 
on  the  rate  of  growth  and  degree  of  hardness,  pathologically  on  the 
greater  or  less  amount  of  fibrous  stroma  present  in  any  particular  case. 

Scirrhus  usually  commences  as  a  hard  circumscribed  mass, 
situated  most  commonly  in  the  upper  and  outer  quadrant  of  the 
organ.  It  is  closely  united  to,  if  not  absolutely  incorporated  with, 
the  breast  substance,  and  on  careful  digital  examination  its  margin 
is  quite  indefinite.  In  the  early  stages  it  is  entirely  distinct  from  the 
skin,  which  moves  freely  over  its  surface ;  but  as  growth  proceeds, 
the  stroma  contracts,  and,  by  dragging  on  the  suspensory  ligaments  of 
Cooper  passing  from  the  glandular  substance  to  the  skin,  the  latter 
structure  becomes  more  or  less  fixed,  and  hence,  on  attempting  to 
move  it  upon  the  tumour,  an  appearance  of  dimpling  results.  At  the 
same  time,  the  whole  breast  is  acted  upon  in  a  similar  manner,  so 
that  the  affected  organ  sometimes  seems  to  be  smaller  than  the  other ; 
and,  since  the  upper  half  of  the  gland  is  usually  affected,  the  nipple 
may  be  drawn  up  so  as  to  lie  at  a  higher  level  than  its  fellow,  as  well 
as  being  retracted  from  the  drag  of  the  growth  on  the  galactophorous 
ducts  (Fig.  433).  The  tumour  itself  is  rarely  of  great  size,  so 
long  as   it  retains  its  scirrhous  nature ;  it  is  sometimes  extremely 


DISEASES  OF  THE  BREAST 


959 


painful  and  tender,  but  not  uncommonly  the  pain  is  intermittent,  and 
of  a  neuralgic  type,  extending  to  the  shoulder,  and  perhaps  only 
elicited  on  manipulation.  As  the  growth  increases  in  size,  it  becomes 
adherent  to  the  pectoral  fascia,  and  may  even  infiltrate  the  underlying 
muscular  substance,  so  that,  on  examination,  with  the  arm  extended 
and  abducted,  it  is  found  that,  although  moveable  across  the  fibres  of 
the  muscles,  the  breast  cannot  be  moved  with  them. 

The   lymphatic  glands   in   the   axilla   soon   become   enlarged,    the 
disease    rarely    lasting    many   months    without    this    complication. 


Fig.  433.^Scirrhus  of  the  Left  Breast.     (From  a  Photograph.) 

The  retraction  of  the  nipple  and  its  elevation  above  the  level  of  the  other  are 

well  seen. 


Those  running  with  the  long  thoracic  vessels  under  cover  of  the 
pectoralis  major  are  first  involved,  and,  as  the  case  progresses,  the 
remaining  axillary  and  subscapular  sets  become  similarly  affected,  and 
even  after  a  time  the  supraclavicular.  When  the  inner  or  deeper  part 
of  the  breast  is  attacked,  the  disease  may  spread  to  the  mediastinal 
glands  along  the  lymphatics,  which  accompany  the  nutrient  vessels 
arising  from  the  internal  mammary  trunk;  and  thus  intrathoracic 
deposits  develop,  which  even  extend  along  the  subpleural  connective 
tissue,  and  affect  the  pleural  cavity  and  lungs.  In  those  cases  where 
the  primary  growth  is  situated  near  the  inner  border  of  the  breast, 
the  free  lymphatic  anastomosis  across  the  middle  line  allows  of  the 
transmission  of  the  disease  to  the  glands  in  the  opposite  axilla,  and 
sometimes  a  similar  affection  of  the  opposite  breast  arises  from  this 
cause. 

The  sTiin   may  be   implicated   in   many  ways,     (a)  The  dimpling 
which  is  met  with  over  the  tumour  in  the  early  stages  has  already 


96o 


A   MANUAL  OF  SURGERY 


been  mentioned.  As  the  case  proceeds,  the  cancer  extends  outwards 
along  the  suspensory  bands  of  fascia,  so  that  the  skin  itself  becomes 
invaded,  feeling  firm  and  brawny,  and  looking  congested  and  purplish 
in  colour,  whilst  a  branny  desquamation  is  usually  present.  A  crack 
or  fissure  at  length  forms,  giving  exit  to  a  little  serous  discharge, 
which  at  first  scabs  over,  but  finally  leaves  an  ulcerated  surface, 
which  slowly  extends,  and  may  attain  considerable  dimensions.  A 
typical  scirrhous  ulcer  is  hollowed  out  and  excavated ;  its  surface,  if 
kept  clean,  is  covered  with  smooth  granulations,  discharging  a  con- 
siderable amount  of  sanious  fluid,  but  if  neglected,  it  becomes  sloughy 
and  offensive ;  it  is  surrounded  by  a  projecting  elevation  of  the 
tumour  substance,  forming  a  sort  of  rampart  around  it.  (b)  Less 
commonly   the   disease   becomes    disseminated    through    the   skin, 

giving  rise  to  a  series 
of  dusky  red  button-like 
masses  of  cancer,  sur- 
rounded by  skin  which  is 
often  apparently  unaffected; 
or  the  whole  cutaneous 
surface  of  the  organ  may 
becomeinfiltrated  and  thick- 
ened, constituting  the  con- 
dition known  as  cancer  en 
cuirasse.  In  the  earlier 
stages  the  skin  is  thickened 
and  firmer  than  usual ;  but 
the  mouths  of  the  sebaceous 
glands  are  enlarged  and 
very  evident,  giving  it  a 
coarse  appearance  like  'pig- 
skin,' or  the  rind  of  an 
orange  (peatt  d'orange  of 
French  authors).  Later 
the  colour  becomes  dusky, 
and  the  skin  so  contracted 
and  indurated  that  it  is  im- 
possible to  pinch  it  up  ;  the 
sebaceous  glands  may  exude  an  abundant  secretion,  which  becomes 
inspissated  on  the  surface  into  crusts  or  scabs,  which  are  inde- 
pendent of  any  ulceration.  This  process  often  extends  widely  beyond 
the  limits  of  the  breast,  invading  the  whole  thoracic  wall,  and 
even  running  over  the  shoulder  to  the  back  of  the  head  or  neck ; 
it  is  due  to  a  diffuse  extension  of  the  disease  along  the  cutaneous 
lymphatics,  and  in  its  most  typical  form  is  slow  in  its  development, 
the  patient  perhaps  living  for  many  years.  Localized  buttons  or 
nodules  of  cancer  are  often  found  scattered  through  the  affected  area, 
(c)  Occasionally  one  meets  with  a  much  more  rapid  form  of  cancerous 
lymphangitis,  in  which  the  skin  becomes  affected  with  what  is 
supposed  to  be  a  '  weeping '  eczema ;  the  surface  is  red,  hot,  and 


Fig.  434. — Lymphatic  CEdema  of  t?ie  Arm 
Secondary  to  Carcinoma  Mamm.^e,  which 
had  recurred  after  operation. 


DISEASES  OF  THE  BREAST  g6i 

infiltrated,  and  on  examining  it  with  a  lens  the  dilated  lymphatics  can 
be  seen  from  which  the  secretion  oozes.  The  process  spreads  widely 
and  rapidly,  and  cancerous  nodules  appear  here  and  there  in  the 
infiltrated  area  ;  the  prognosis  is,  of  course,  very  grave. 

In  the  later  stages,  the  patient  passes  into  a  state  of  cachexia, 
becoming  emaciated  and  exhausted.  Ulcerated  surfaces  of  consider- 
able size  may  exist,  and  the  tumour  is  fixed  to  the  thoracic  wall,  even 
invading  the  ribs.  The  arm  on  the  affected  side  is  swollen  and 
brawny,  owing  to  the  pressure  of  enlarged  glands  on  the  main 
lymphatics  and  veins  of  the  limb,  constituting  a  condition  of  solid 
or  lymphatic  oedema  (Fig.  434).  Severe  neuralgic  pain  of  the  arm 
may  result  from  involvement  of  or  pressure  upon  the  brachial  nerves 
jn  the  supraclavicular  fossa.     Secondary  deposits  also  develop  in  the 


Fig.  435. — Atrophic  Cancer  of  Both  Breasts.     (From  a  Photograph.) 

The  nipples  are  both  retracted,  and  the  skin  around  puckered  and  fixed  to  the 
growth.  On  the  right  side  the  axillary  glands  are  obviously  enlarged.  The 
patient  was  an  old  woman  over  70  years  of  age. 

viscera,  especially  the  pleura,  lungs,  and  liver,  and  may  lead  to 
various  symptoms.  Not  unfrequently  recurrence  takes  place  in  the 
connective  tissue  between  the  rib  cartilages  and  the  pleura,  and 
nodules  of  growth  develop,  which  may  in  time  project  forwards 
through  one  of -the  intercostal  spaces  (usually  the  second).  Deposits 
in  the  bones  (p.  607)  are  also  not  unusual,  the  sternum,  vertebrae,  and 
upper  ends  of  femur  and  humerus  being  perhaps  most  often  affected. 
Severe  pain  is  caused  by  such  lesions,  followed  probably  by 
spontaneous  fracture,  which  may  heal  quite  effectively  or  remain 
ununited.     Finally,  death  from  exhaustion  ends  the  scene. 

Acute  Cancer  is  fortunately  not  common,  and  appears  as  a  some- 
what soft,  rapidly  growing  tumour,  which  quickly  infiltrates  the 
whole  organ,  and  gives  rise  to  secondary  lymphatic  and   visceral 

61  . 


562 


A  MANUAL  OF  SURGERY 


affections  at  a  much  earlier  date  than  scirrhus.  It  does  not  cause 
retraction  of  the  nipple  or  dimpling  of  the  skin,  the  latter  structure 
being  distended,  and  with  blue  veins  coursing  under  it.  The  breast 
becomes  enlarged  and  prominent ;  the  skin  is  stretched  and  gradually 
invaded  by  the  tumour,  and  if  ulceration  follows,  a  foul  fungating 
mass  sooner  or  later  sprouts  up  through  the  opening.  This  variety 
usually  attacks  young  women  under  thirty-five  years  of  age,  and  runs 
a  rapidly  destructive  course,  especially  if  it  occurs  during  pregnancy 
or  lactation,  when  it  is  likely  to  be  mistaken  for  an  acute  mastitis. 

Finally,  in  elderly  women,  a  chronic  form  of  cancer  is  met  with, 
known  as  Atrophic  Scirrhus  (Fig,  435),  in  which  the  disease  lasts  for 
many  years  without  much  definite  extension.  Cases  have  been 
known  to  persist  for  fifteen  or  twenty  years,  the  patient  at  length 
dying  of  some  intercurrent  malady,  although  in  the  great  majority 
dissemination  has  ultimately  occurred.  The  special  characters  are 
due  to  the  excessive  contraction  of  the  stroma,  as  a  result  of  which 
the  cellular  elements  become  crushed,  and  practically  destroyed. 
The  nipple  is  deeply  retracted,  and  the  tumour  and  breast  substance 
in  the  most  marked  cases  are  scarcely  discernible. 

2.  Duct  Cancer  is  a  somewhat  rare  form  of  the  disease,  the  exact 
nature  of  which  is  still  uncertain,  and  there  is  very  little  doubt 
that  several  distinct  types  have  been  described  under  this  name.  It 
is  sometimes  characterized  by  the  development  of  one  or  more  nodules 
of  a  malignant  papillomatous  nature  within  the  dilated  ducts,  and 
usually  situated  not  far  from  the  nipple.  These  growths  are  covered 
with  columnar  epithelium,  and  may,  indeed,  be  looked  upon  as  forms 
of  columnar  cancer.  They  are  exceedingly  vascular,  and  a  blood- 
stained discharge  from  the  nipple  is  usual.  They  always  grow 
slowly,  and  when  situated  near  the  skin  give  rise  to  a  round  dusky 
red  swelling.  The  nipple  is  not  retracted,  and  lymphatic  enlarge- 
ment not  constant.  In  other  cases  the  dilated  alveoli  are  occupied 
by  masses  of  proliferated  epithelial  cells  of  a  spheroidal  type,  which 
arrange  themselves  into  more  or  less  definite  papillomatous  growths, 
whilst  cystic  degeneration  also  occurs.  Either  of  these  varieties 
may  be  associated  with  a  development  of  ordinary  scirrhus  in  some 
other  part  of  the  breast.  The  diagnosis  can  only  be  established  with 
certainty  by  microscopic  examination  after  removal. 

Adeno-carcinoma  is  the  term  given  by  Halstead  to  a  condition  very 
similar  to  the  latter  variety  of  duct  cancer.  The  growth  consists  of 
tubular  spaces  heavily  lined  with  epithelium  ;  it  develops  slowly, 
but  frequently  fungates  through  the  skin,  and  presents  as  a  localized 
pedunculated  growth,  which  readily  bleeds.  The  axillary  glands  are 
usually  free  from  infection,  and  the  prognosis  is  good. 

The  duration  of  cancer  varies  considerably  in  the  different  forms. 
The  encephaloid  type  runs  a  rapid  course,  and  will  probably  destroy 
the  patient's  life  in  six  to  twelve  months.  Duct  cancer  is  very 
slightly  malignant,  whilst  atrophic  scirrhus  is  similarly  slow  in  growth, 
and  in  both  death  may  be  postponed  for  a  considerable  period,  or  is 
often  due  to  some  intercurrent  malady.     Cancer  en  cuirasse  is  variable 


Diseases  of  the  breast  963 

in.  its  course,  being  sometimes  tolerably  rapid,  and  at  others  chronic  ; 
it  cannot  be  cured  by  operation  on  account  of  its  early  and  extensive 
dissemination.  A  circumscribed  scirrhous  tumour  is  stated  to  end 
fatally,  on  an  average,  in  two  or  three  years  if  no  operative  treatment 
is  undertaken,  whilst  removal  of  the  mass  will  probably  add  another 
year  or  eighteen  months  to  the  patient's  life.  These  figures  are, 
however,  derived  from  statistics  of  operations  performed  before  the 
general  adoption  of  the  more  exact  and  extensive  measures  which 
are  now  usually  undertaken,  and  it  is  likely  that  they  underestimate 
considerably  the  benefits  derived  from  such  interference. 
The  Pathological  Anatomy  of  cancer  is  discussed  at  p.  210, 
The  Diagnosis  of  scirrhus  from  chronic  interstitial  mastitis  and  chronic 
abscess  or  cyst  has  been  already  considered  (p.  949).  From  tumours  of 
the  adenoid  type  it  is  easily  distinguished.  The  stony  hardness  of  a 
scirrhus,  its  union  with  the  breast  substance,  its  limited  mobility,  the 
dimpling  of  the  skin,  retraction  of  the  nipple,  and  enlargement  of  the 
axillary  glands,  are  the  chief  local  characteristics  to  be  noted.  Non- 
malignant  tumours  are  more  elastic  to  the  touch,  more  moveable, 
and  usually  quite  circumscribed  in  outline,  whilst  the  skin,  though 
expanded,  does  not  become  adherent ;  the  nipple  is  rarely  retracted, 
and  the  axillary  glands  remain  of  normal  size.  It  is  often  impossible 
to  distinguish  a  cancerous  from  a  sarcomatous  tumour,  except  on  micro- 
scopic examination ;  a  round-celled  sarcoma  closely  resembles  an 
acute  cancer,  although  it  is  usually  more  circumscribed — at  any  rate, 
in  the  early  stages.  A  Jibro -sarcoma  may  sometimes  be  mistaken 
for  scirrhus,  but  it  is  more  defined  in  outline,  does  not  cause  retraction 
of  the  nipple  or  dimpling  of  the  skin,  whilst  lymphatic  enlargement 
is  not  a  constant  accompaniment.  A  cysto-adenoma  presents  no  diffi- 
culty in  diagnosis  if  the  skin  is  entire,  and  the  cysts  prominent ;  but 
when  ulceration  has  taken  place,  and  a  fungating  bleeding  mass 
protrudes,  it  is  not  unlike  the  later  stage  of  an  encephaloid  cancer  or 
fungating  round-celled'  sarcoma.  It  can  be  distinguished,  however, 
by  the  fact  that  a  probe  can  sometimes  be  passed  under  the  skin  for 
some  distance  into  the  cavity  of  the  cyst,  whilst  lymphatic  enlarge- 
ment is  rare.  For  the  diagnosis  of  scirrhus  from  a  tense  single  cyst, 
seep.  952. 

Treatment. — This  necessarily  consists  in  the  removal  of  the  tumour 
by  operation  in  all  cases  where  there  seems  a  reasonable  chance  of 
eradicating  the  disease.  The  only  conditions  that  would  contra- 
indicate  operation  are  extensive  adhesions  to  the  thoracic  walls,  the 
presence  of  visceral  deposits,  and  extensive  diffusion  of  a  rapidly 
growing  acute  cancer  in  a  young  subject.  Atrophic  scirrhus  is  often 
left  alone,  on  the  plea  that  the  prognosis  is  so  favourable  as  to 
render  operation  unnecessary ;  if,  however,  the  patient  is  fairly  strong, 
there  is  no  objection  to  it,  and  it  certainly  seems  wise  to  remove  a 
cancerous  focus,  however  chronic  it  be.  Disease  of  both  breasts, 
although  rendering  the  prognosis  more  grave,  is,  ccBteris  paribus,  no 
hindrance,  since  both  organs  have  been  removed  successfully,  even 
at  one  operation.     Speaking  generally,  rapidly  growing  tumours  in 


964  A  MANUAL  OF  SURGEkY 

vigorous  patients  are  very  unfavourable  cases  to  deal  with,  whilst 
slow  growth  of  the  tumour,  and  definite  limitation  of  its  outline,  are 
favourable  signs. 

In  the  old  days,  only  the  more  prominent  portion  of  the  breast  was 
removed  with  the  tumour,  and  consequently  recurrence  was  so 
extremely  common  that  if  5  or  10  per  cent,  of  the  patients  were  really 
cured,  it  was  thought  to  be  as  much  as  any  surgeon  could  reasonably 
expect.  Since  we  have  learnt  more  of  the  anatomy  of  the  organ  and 
of  the  evolution  of  the  disease  (for  which  we  are  mainly  indebted  to 
Heidenhain  and  Stiles),  more  extensive  proceedings  have  been  under- 
taken, with  a  gradual  amelioration  in  the  results,  so  that  several 
surgeons  have  been  able  to  report  50  to  60  per  cent,  of  their  cases  as 
free  from  recurrence  at  the  end  of  three  years.  It  was  suggested  by 
Volkmann  that  any  case  which  remains  free  from  recurrence  for  three 
years  may  be  claimed  as  a  cure,  but  this  is  now  generally  considered 
too  short  a  period,  since  the  disease  sometimes  reappears  at  a  much 
later  date  (even  nine  or  ten  years). 

The  breast  is  a  much  more  extensive  organ  than  was  formerly 
supposed,  its  lobules  extending  upwards  nearly  as  high  as  the 
clavicle,  outwards  into  the  axilla,  and  for  some  distance  downwards, 
so  that  removal  merely  of  the  prominent  part  of  the  gland  may  leave 
much  behind,  and  thereby  favour  recurrence.  Moreover,  the  deeper 
lymphatics  pass  into  the  fascia  covering  the  pectoralis  major,  and  so 
to  the  axilla  ;  hence,  this  structure  should  always  be  taken  away,  as 
well  as  a  thin  layer  of  the  muscular  fibres,  but  the  wiser  course  is  to 
remove  the  whole  of  the  sternal  portion  of  the  pectoralis  major, 
leaving  only  the  clavicular.  Many  surgeons  also  remove  the 
pectoralis  minor  muscle ;  this  procedure  certainly  favours  the 
axillary  dissection,  and  does  not  seem  to  have  any  harmful  influence 
on  the  subsequent  movements  of  the  arm.  Again,  lymphatics  travel 
along  the  fibrous  bands  reaching  from  the  breast  tissue  to  the  over- 
lying skin,  and  thus  this  latter  must  never 'be  dissected  back  from 
over  the  tumour.  The  nipple  should  under  no  circumstances  be  left 
behind,  since  all  the  interlobular  lymphatics  converge  to  a  plexus 
around  it,  and  thence  pass  to  the  axilla  by  three  or  four  main  trunks. 
The  axilla  itself  should  be  opened  in  every  case,  and  entirely  cleared 
of  its  lymphatic  contents,  since  deposits  in  the  glands  are  often  found 
on  microscopic  examination,  where  no  clinical  evidence  of  their 
presence  had  been  previously  noted.  It  is  also  important  to  remove 
the  breast  and  axillary  tissues  in  one  piece,  so  as  to  avoid  division  of 
the  lymphatics  and  possible  infection  of  the  wound  with  their 
cancerous  contents. 

Operation  for  Cancer. — The  patient  lies  on  the  back,  with  the  head 
directed  towards  the  opposite  side,  and  the  arm  raised  to  a  little 
more  than  a  right  angle,  so  as  to  put  the  pectoralis  on  the  stretch. 
An  aseptic  towel  should  be  wrapped  round  the  head,  so  as  to  keep 
the  hair  out  of  the  way,  and  a  similar  sterilized  towel  may  be  placed 
below  the  chin  on  a  cross-bar,  to  form  a  barrier  between  the 
anaesthetist  with  his  apparatus   and   the   field   of   operation.     The 


DISEASES  OF  THE  BREAST 


965 


axilla  should  be  previously  shaved,  and  the  skin  carefully  purified. 
The  incisions  employed  vary  with  the  size  and  position  of  the 
tumour  ;  the  primary  object  is  to  remove  the  growth  together  with 
the  whole  gland  and  all  its  accessible  lymphatic  connections  ;  the 
question  of  being  able  to  close  the  wound  subsequently  is  quite  a 
secondary  and  minor  consideration.  As  a  rule,  sufficiently  wide 
undercutting  will  allow  very  extensive  wounds  to  be  closed  ;  but 
when  this  is  impossible,  skin-grafting  can  be  adopted,  and  no  lengthy 
convalescence  need  ensue.  Fig.  436  suggests  the  types  of  incision 
that  may  serve  for  the  removal  of  tumours  on  the  outer  and  inner 
sides  of  the  breast  respectively.  Slight  modifications  will  suggest 
themselves  when  the  growth  is  in  other  positions. 


L^^- 


Fig.  436. — Incisions  for  Removal  of  Cancerous  Breast  when  the  Tumour 
IS  Situated  in  the  Upper  and  Outer,  or  in  the  Inner  Segment 
Respectively. 

When  the  incisions  have  been  made,  they  are  deepened,  but  not 
directly  inwards.  The  skin  around  is  dissected  up  so  that  the 
subcutaneous  connective  tissue  may  be  removed  together  with  the 
breast  over  a  wide  area  extending  as  high  as  the  clavicle  above, 
down  to  the  epigastric  notch  below,  and  behind  the  posterior  border 
of  the  axilla  on  the  outer  side.  The  surface  of  the  pectoralis  major 
is  then  exposed  throughout  the  whole  length  of  the  inner  or  upper 
incision,  the  connective  tissue  over  it  being  turned  downwards.  The 
junction  between  the  sternal  and  clavicular  portions  is  defined,  anfl 
opened  up  by  finger  and  knife  throughout  its  whole  length.  The 
insertion  of  the  sternal  portion  is  divided  about  an  inch  from  the 
humerus,  and  then  the  finger  is  introduced  under  its  origin  from  the 
sternum  and  costal  cartilages,  and  this  is  severed  by  the  knife  close 


966  A  MANUAL  OF  SURGERY 

to  the  bone.  Several  perforating  branches  of  the  internal  mammary 
will  be  divided  in  this  procedure,  and  must  be  at  once  secured,  so 
as  to  prevent  their  retraction  through  the  intercostal  spaces.  The 
pectoralis  minor  comes  into  view,  and  is  divided  at  its  costal  attach- 
ments and  also  close  to  the  coracoid  process. 

The  breast  and  underlying  tissues  can  now  be  drawn  downwards  and 
outwards,  thereby  opening  up  the  axilla  freely  ;  the  next  step  consists 
in  thoroughly  clearing  it.  The  main  vessels  are  first  defined  below  the 
lower  border  of  the  pectoralis  minor  close  to  the  outer  angle  of  the 
wound  ;  a  layer  of  fascia  needs  division  in  order  to  accomplish  this. 
The  dissection  is  then  carried  inwards  along  the  vessels  and  nerves, 
which  are  freed  from  fat  and  glands  both  in  front  and  behind,  if 
necessary.  Arterial  and  venous  branches  are  best  secured  by 
ligature  before  division.  If  the  glands  are  closely  adherent  to  the 
vein,  it  is  wise  to  excise  a  portion  of  it  rather  than  to  attempt  to 
peel  them  off.  The  most  careful  search  for  glands  must  be  made  in 
the  apex  of  the  axilla,  and  in  removing  them  every  effort  must  be  used 
not  to  rupture  the  glands  by  careless  handling,  as  thereby  dissemina- 
tion of  cancer  cells  may  occur. 

The  surgeon  nexts  proceeds  to  remove  the  fat  and  fascia  from  the 
serratus  magnus  on  the  inner  side  of  the  wound,  care  being  taken  to 
secure  the  lateral  branches  of  the  intercostal  arteries  as  they  are 
divided,  and  to  protect  the  nerve  of  Bell.  The  subscapularis  is  then 
cleared,  and  possibly  the  subscapular  vessels  may  need  division,  but 
the  subscapular  nerves  must  be  spared.  Not  unfrequently  there  aic 
many  enlarged  lymphatic  glands  in  this  part  of  the  axilla.  When 
this  has  been  effected,  but  little  more  remains  to  be  done  except  to 
free  the  breast,  pectorals,  and  connective  tissue  from  their  external 
attachments,  and  this  is  quickly  accomplished  by  a  few  sweeps  of 
the  knife. 

An  enormous  wound  results,  and  during  the  later  stages  the 
exposed  tissues  must  be  protected  as  far  as  possible  by  covering  them 
with  warm  sterilized  cloths.  Bleeding-points  are  secured,  the  wound 
washed  out  with  hot  sterile  salt  solution,  and  preparations  made  for 
closing  it.  Surrounding  parts  may  need  to  be  extensively  undermined, 
or  even  plastic  proceedings  carried  out  in  order  to  bring  forwards 
redundant  skin  from  the  side  and  back.  As  a  general  rule  the  wound 
can  be  more  or  less  completely  closed  by  the  exercise  of  a  little 
patience  and  ingenuity.  Under  no  circumstances  should  the  upper 
part  of  the  wound  be  left  open,  as  thereby  the  axillary  contents  would 
be  exposed,  and  harmful  cicatrices  might  form.  Should  any  part  be 
left  open,  it  is  probably  wise  to  defer  a  grafting  operation  till  later. 
Deep  tension  stitches  are  often  useful,  and  the  margins  of  the  wound 
are  approximated  by  ordinary  catgut  or  silk  sutures.  Drainage  is 
usually  desirable,  and  the  tube  may  be  placed  through  an  opening 
made  for  it  in  the  posterior  axillary  wall.  A  large  and  efficient  dress- 
ing is  applied  back  and  front  to  receive  the  sero-sanguineous  dis- 
charge, which  is  sure  to  be  abundant.  The  arm  is  left  at  right 
angles  to  the  side  throughout  the  healing  with  the  object  of  prevent- 


DISEASES  OF  THE  BREAST 


967 


ing  the  subsequent  stiffness  and  limitation  of  movement,  which  was 
so  marked  formerly  when  the  arm  was  bandaged  to  the  side.  The 
first  dressing  will  be  required  in  twenty-four  or  forty-eight  hours,  and 
the  drainage-tube  may  then  be  removed.  Healing  should  be  com- 
plete in  from  ten  to  twelve  days. 


Fig.  437. — Method   of    introducing    Silk    Strands   to   act    as    Artificial 

Lymphatics. 

(For  loan  of  these  illustrations  we  are  indebted  to  Mr.  W.  Sampson  Handley.) 


The  immediate  results  of  this  operation  are  exceedingly  satisfactory, 
the  mortality  being  under  5  per  cent.  The  ultimate  results  necessarily 
vary  with  the  period  at  which  the  operation  was  undertaken,  with  the 
extent  and  character  of  the  disease,  and  with  the  thoroughness  aad 
skill  of  the  operator. 

When  the  supraclavicular  glands  are  enlarged,  the  operation  must 
also  include  the  supraclavicular  fossa  in  its  scope,  as  recommended 
by  Halstead  ;  he,  indeed,  goes  so  far  as  to  maintain  that  the  posterior 
triangle  should  be  cleared  of  its  lymphatic  contents  in  all  cases,  whether 
or  not  enlarged  glands  can  be  detected  beforehand,  and  states  that  in  a 
considerable  percentage  cancerous  invasion  will  have  already  occurred. 
The  cervical  incision  is  9.  curved  one,  extending  along  the  posterior 


968  A   MANUAL  OF  SURGERY 

border  of  the  sternb-mastoid,  and  outwards  along  the  clavicle.  This 
flap  is  dissected  up,  and  all  the  fat  and  glands  are  removed  from 
before  backwards,  the  internal  jugular  vein  being  the  starting-point. 
Of  course,  the  greatest  care  is  taken  to  avoid  the  thoracic  duct  or 
right  lymphatic  trunk.  Some  surgeons  have  even  proposed  to  divide 
the  clavicle,  but  this  seems  to  be  a  needless  proceeding.  The  axillary 
and  the  supraclavicular  wounds  can  easily  be  made  continuous  under 
the  clavicle.  In  the  majority  of  cases,  however,  the  cervical  operation 
will  probably  be  secondary,  and  undertaken  for  recurrence 

Local  recurrence  after  operation  is  always  due  to  incomplete  removal 
of  the  growth,  or  to  infection  of  the  wound  during  the  operation.  The 
operator  must  ever  keep  in  mind  that  although  in  a  healthy  organism 
the  implantation  of  cancerous  material  has  apparently  but  little  or  no 
effect,  yet  in  a  cancerous  individual  positive  results  are  only  too 
certainly  obtained.  The  recurrence  appears  either  in  the  neighbour- 
hood of  the  cicatrix,  the  most  usual  situation,  or  in  adjacent  lymphatic 
glands,  in  the  other  breast,  or  in  the  retrocostal  connective  tissue. 
The  progress  is  often  slow,  but  occasionally  the  disease  spreads  more 
rapidly  than  if  no  operation  had  been  undertaken.  Another  attempt 
should  always  be  made  to  remove  the  growth,  if  such  be  feasible. 

Diffuse  cancer  of  the  skin  en  cuirasse  is  not  suitable  for  operative 
treatment,  but  much  may  be  done  by  exposure  to  the  X  rays  (p.  218) 
or  by  radium. 

It  has  been  proposed  to  treat  lymphatic  or  solid  oedema  by  intro- 
ducing subcutaneous  strands  of  carefully  sterilized  silk  from  below 
upwards  into  the  healthy  tissues  so  as  to  act  as  artificial  lymphatics. 
In  the  cases  hitherto  reported  a  considerable  degree  of  improvement 
has  followed.     The  position  of  such  strands  of. silk  is  indicated  in 

Fig-  437- 

Some  years  back  Beatson  of  Glasgow  proposed  to  treat  inoperable 
cases  by  double  oophorectomy  and  the  administration  of  thyroid 
extract.  Many  patients  have  been  dealt  with  in  this  way,  and  the 
results  gained  thus  far  show  that  whilst  a  few  cases  have  been  appar- 
ently cured,  in  a  much  larger  number  no  effect  was  produced,  but 
that  in  quite  an  appreciable  proportion  the  disease  seems  to  have 
been  temporarily  controlled  (perhaps  for  years),  and  the  pain  and 
discomfort  very  definitely  diminished.  The  operation  should  of 
course  only  be  undertaken  in  women  who  have  not  yet  reached 
the  climacteric. 

Amputation  of  the  Breast  for  non-malignant  conditions  is  a  very 
different  operation  to  that  described  above.  The  incisions  usually 
employed  are  crescentic  and  placed  obliquely  ;  they  need  not  include 
much  more  skin  than  that  indicated  by  the  breadth  of  the  areola. 
The  integument  is  dissected  up  from  the  glandular  tissue  on  either 
side,  and  the  organ  freed  from  its  attachments  to  the  pectoral  fascia ; 
the  axilla  is  frequently  not  opened. 


CHAPTER  XXXIV. 

ABDOMINAL  SURGERY. 

General  Remarks  on  Abdominal  Operations.  —  No  branch  of  the 
surgical  art  has  grown  so  rapidly  or  attained  such  importance  as  that 
directed  to  the  abdominal  contents.  Operations  which  formerly  were 
advisably  rare  are  now  of  everyday  occurrence,  and  no  surgeon 
hesitates  to  open  the  peritoneal  cavity  whenever  it  appears  necessary. 
Success  is,  however,  entirely  dependent  on  a  minute  and  careful 
attention  to  details,  which  can  only  result  from  attentive  observation 
and  considerable  experience.  The  peritoneum  carefully  treated  is  a 
good  friend  to  the  surgeon  ;  it  resents,  however,  rough  handling  or 
prolonged  exposure,  and  serious  inflammatory  trouble  may  follow 
slovenly  work,  jeopardizing  the  patient's  life,  or  even,  if  he  live,  giving 
rise  to  such  disabihties  and  discomfort  as  may  impair  his  usefulness. 
In  no  department  of  operative  surgery  is  rapid  and  yet  minutely 
careful  work  so  well  repaid.  The  following  are  a  few  points  which 
may  prove  helpful  to  those  aspiring  to  success  in  this  important 
branch  of  surgery : 

The  patient  should  be  prepared,  when  circumstances  permit,  by 
regulating  the  diet  and  bowels  for  some  days  previously,  and 
thoroughly  cleansing  the  teeth  and  mouth,  so  that  the  intestinal 
canal  may  be  as  free  from  organisms  as  possible  ;  a  course  of 
internal  antiseptics,  such  as  salol,  calomel,  or  /8-naphthol,  may  be 
advisable.  During  the  previous  day  an  effective  purgative  is  given 
— e.g.,  I  ounce  of  castor  oil — and  an  enema  may  be  desirable  in  the 
morning  to  ensure  that  the  lower  gut  is  empty.  The  abdominal  wall 
is  shaved,  as  also  the  pubes,  and  purified  beforehand  in  the  usual 
way,  special  care  being  directed  to  the  umbilicus,  where  dirt  is  very 
liable  to  lodge. 

No  food  should  be  allowed  by  mouth  for  Lhree  or  four  hours,  and 
immediately  before  being  placed  on  the  table  the  bladder  should  be 
emptied,  if  need  be,  by  catheter.  If  the  proceedings  are  likely  to  be 
protracted,  it  is  advisable  to  give  a  rectal  injection  of  warm  saline 
solution,  or  of  beef-tea  and  coffee,  half  an  hour  beforehand,  and 
possibly  a  hypodermic  injection  of  strychnine  (gr.  yw)* 

The  patient  should  be  warmly  wrapped  up  and  protected  from 
cold,  no  unnecessary  exposure  being  allowed.     The  operating  room 

969 


970 


A  MANUAL  OF  SURGERY 


should  be  well  warmed,  and  not  below  70°  F.  ;  a  temperature  of 
80°  F,,  though  trying  for  the  surgeon  and  his  helpers,  is  better  for 
the  patient.  Full  anaesthesia  is  desirable,  so  as  to  diminish  shock, 
but  this  should  be  obtained  with  as  small  a  dose  of  anaesthetic  as 
possible.  Intraperitoneal  operations  are  not  painless,  for  although 
the  visceral  peritoneum  is  not  acutely  sensitive,  yet  the  parietal  layer 
is,  as  well  as  that  included  in  the  mesenteries,  and  any  handling  of 
these  structures  gives  rise  to  pain  and  necessarily  to  increased  shock, 
if  the  patient  is  conscious. 

As  a  general  rule  the  patient  lies  flat  on  the  table,  but  if  the 
operation  involves  the  pelvic  viscera,  the  Trendelenburg  position  is 
often  adopted.  In  it  the  patient  is  placed  with  the  head  con- 
siderably below  the  rest  of  the  body,  which  is  more  or  less  inverted 

(Fig.  438).  The  knees 
are  bent  over  the  end 
of  the  table,  and  help 
to  keep  the  body  in 
position.  The  head- 
piece of  the  table  must 
be  lowered,  or  the  neck 
will  be  bent  forwards 
into  a  position  that 
impedes  respiration. 
The  arms  must  not  be 
kept  above  the  head,  or 
musculo -spiral  paral- 
ysis may  follow  ;  they 
are  best  placed  behind 
the  patient's  back  or 
close  to  the  sides.  This 
position  must  not  be 
adopted  when  it  is  prob- 
able that  the  pelvis  is  occupied  by  a  fluid  inflammatory  exudate, 
nor  in  conditions  where  obstruction  is  present,  and  the  stomach  is 
likely  to  be  filled  with  offensive  material  which  might  gravitate  into 
the  mouth  and  suffocate  the  patient. 

Antiseptics  are  avoided  as  far  as  possible  in  intraperitoneal 
operations ;  after  eflicient  sterilization  of  the  hands  of  the  surgeon 
and  his  assistants  and  of  the  skin  of  the  patient,  nothing  is  employed 
in  the  shape  of  lotion  except  sterilized  salt  solution.  Instruments 
are  boiled  previously  and  counted.  Swabs  are  best  done  up  in 
packets  of  a  dozen,  wrapped  in  gauze  ;  it  is  thus  easy  to  keep 
account  of  the  number  employed.  Gauze  strips  for  packing,  abdo- 
minal cloths,  etc.,  are  dealt  with  in  the  same  way  ;  a  careful  record 
of  the  number  employed  must  be  made.  If  irrigation  of  the 
abdomen  is  required,  warm  salt  solution  is  the  best  lotion  to  use  for 
the  purpose. 

Parietal  Incision. — Formerly,  whenever  practicable,  the  incision 
was  made  in  the  middle  line  through  the  linea  alba,  in  consequence 


Fig.  438. — ^Trendelenburg's  Position  for 
Pelvic  Operations. 


ABDOMINAL  SURGERY  971 

of  the  facts  that  there  is  less  bleeding  in  this  situation,  that  all  parts 
of  the  abdomen  are  easily  accessible  from  it,  and  that  the  wound  is 
more  rapidly  closed.  It  has  been  found,  however,  that  ventral  hernia 
is  a  not  uncommon  sequela,  and  hence,  although  the  median  incision 
is  still  largely  retained  on  account  of  its  convenience,  and  especially 
in  infected  cases  that  need  to  be  drained,  it  has  been  discarded  in 
many  operations,  and  incisions  have  been  planned  going  through  more 
vascular  structures.  Even  in  such  procedures  as  ovariotomy,  where 
the  middle  line  gives  the  best  access,  it  is  wise  to  go  through  the 
rectus  a  little  to  one  side  of  the  centre  rather  than  through  the  linea 
alba  itself.  The  linea  semilunaris,  again,  is  unfavourable  for. an 
incision,  since  the  traction  of  the  muscles  which  are  inserted  into 
its  outer  side  is  so  great  that  hernia  is  likely  to  follow.  On  the 
other  hand,  care  must  be  exercised  not  to  place  the  incisions  too 
near  the  bony  margins  of  the  abdominal  cavity,  or  subsequent  mani- 
pulations may  be  hampered  by  the  rigidity  of  one  side  of  the  wound. 

The  muscles  should  be  cleanly  divided,  and  it  is  wise  to  see  that 
bleeding  is  stopped  before  opening  the  peritoneum.  This  membrane 
can  usually  be  picked  up  by  dissecting  forceps  and  opened  by 
scissors ;  air  rushes  into  the  cavity,  -and  it  is  easy  to  secure  the 
margins  with  Spencer-Wells  forceps,  and  holding  these  well  up  the 
incision  can  be  prolonged  up  or  down  as  far  as  may  be  considered 
necessary. 

Several  ingenious  methods  of  opening  the  abdomen  have  been 
suggested  of  recent  years,  with  the  idea  of  minimizing  the  chances 
of  subsequent  ventral  hernia.  It  must  ever  be  remembered  that  the 
method  of  opening  the  abdomen  is  every  whit  as  important  as  that 
of  closing  the  incision  ;  above  all,  it  is  desirable  that  the  motor 
nerves  of  the  abdominal  parietes  should  be  respected.  McBuvmy's 
muscle-splitting  method  is  frequently  adopted  in  removing  a  quiescent 
appendix  (p.  1056)  ;  it  gives  a  sufficient  approach  when  there  are  no 
adhesions,  and  the  appendix  is  not  displaced  ;  but  should  these  condi- 
tions not  be  present,  or  if  the  patient  is  very  stout,  it  will  prove  most 
inconvenient.  It  may  also  be  used  in  iliac  colotomy.  Lennanders 
trap-door  incision  consists  in  opening  the  sheath  of  the  rectus  in 
front,  displacing  the  muscle  in  or  out,  and  then  making  the  incision 
in  the  posterior  layer  of  the  sheath  and  through  the  peritoneum  so  as 
not  to  correspond  too  closely  with  that  in  front. 

The  intestines  must  be  carefully  guarded  during  the  intraperitoneal 
portion  of  the  operation,  as  if  they  are  unduly  exposed  to  the  air,  the 
endothelial  lining  is  quickly  shed,  and  adhesions  may  form  subse- 
quently, whilst  bacterial  invasion  from  the  gut  is  favoured.  If  they 
have  to  be  withdrawn  from  the  abdomen,  they  should  be  wrapped 
in  cloths  wrung  out  of  warm  salt  solution,  and  it  is  the  assistant's 
duty  either  to  replace  these  from  time  to  time  by  warm  cloths,  or 
better  to  keep  them  moist  and  warm  by  pouring  fresh  salt  solution 
over  them ;  no  unnecessary  handling  of  intestine  is  permitted.  If 
any  infective  focus  is  to  l3e  opened,  or  the  intestine  incised,  the 
surrounding  parts  must  be   carefully  protected   from    infection  by 


972  A  MANUAL  OF  SURGERY 

'walling  off'  the  area  of  operation;  this  is  effected  by  surrounding 
it  with  abdominal  cloths  of  suitable  size  and  material,  or  strips  of 
sterilized  white  gauze,  wrung  out  of  warm  salt  solution,  or  by  placing 
them  in  directions  where  pus  or  other  fluids  might  gravitate.  A 
record  of  these  must  be  kept,  and  it  is  wise  not  to  cut  any  of  them 
into  smaller  pieces.  It  is  undesirable  to  use  dry  gauze  for  this 
purpose,  as  it  is  likely  to  stick  to  the  intestine,  and  its  removal  may 
disturb  the  endothelial  covering. 

Closure  of  the  Wound. — A  careful  toilette  of  the  peritoneum  must 
be  undertaken  before  the  abdomen  is  closed.  All  bleeding  is  stopped 
and  blood-clot  removed  ;  swabs  are  counted,  and,  if  thought  neces- 
sary, the  site  of  operation  cleansed  with  sterilized  salt  solution  at  a 
temperature  of  about  105°  F.  Many  different  methods  of  closing 
the  parietal  incision  have  been  adopted,  but  perhaps  the  best 
consists  in  firstly  securing  the  peritoneum  by  a  continuous  catgut  or 
silk  stitch  ;  then  the  muscular  coats  are  approximated  by  deep 
interrupted  stitches  either  of  purified  silk  or  of  silkworm  gut,  which 
remain  buried ;  and  finally  the  skin  is  united  by  means  of  a  con- 
tinuous suture  of  catgut  or  silk,  which  is  subsequently  removed. 

Drainage  is  not  usually  called  for  in  abdominal  operations.  If  the 
surgeon  is  careful  in  his  manipulations,  and  avoids  measures  which 
are  liable  to  lead  to  subsequent  oozing,  the  peritoneum  may  be 
closed  with  safety.  When  adhesions  likely  to  bleed  have  been 
divided,  or  raw  surfaces  left  such  as  occur  after  enucleating  a  paro- 
varian cyst  from  the  broad  ligament,  some  means  should  be  provided 
whereby  any  considerable  effusion  of  fluid  can  escape,  and  this  can 
often  be  best  effected  by  the  use  of  a  rubber  drainage-tube  or  a 
Keith's  glass  tube,  which  can  be  removed  in  twenty-four  hours. 
Into  the  latter  it  is  perhaps  well  to  introduce  a  strip  of  aseptic 
gauze,  which  will  act  as  a  lamp-wick,  and  along  which,  by  capillary 
action,  the  effusion  finds  its  way  into  the  general  dressing  placed 
over  the  wound. 

On  the  other  hand,  when  an  infected  focus  has  been  opened  and 
needs  to  be  drained — e.g.,  an  acute  appendix  abscess,  surrounding 
parts  must  be  protected  from  spread  of  the  infection,  a.nd  this  is  best 
accomplished  by  the  use  of  a  rubber  drainage-tube,  around  which 
sterile  gauze  is  packed  in  such  a  way  as  to  induce  the  formation  of 
protective  adhesions. 

After -Treatment. — After  the  completion  of  the  operation,  the 
patient  is  replaced  in  bed,  with  the  head  low  ;  but  this  position  need 
not  be  maintained  for  any  length  of  time.  If  restless  and  irritable, 
a  small  dose  of  morphia  may  be  administered,  but  the  less  the  better, 
since  it  induces  intestinal  paresis,  and  this  in  turn  assists  bacterial 
invasion  from  the  gut.  No  food  is  allowed  to  enter  the  stomach 
during  the  day  of  operation,  but  the  patient  may  be  allowed  to  sip 
hot  water.  Thirst  is  relieved  by  the  administration  of  saline 
solution  by  rectum,  either  continuously  or  at  intervals  of  four  or  six 
hours.  The  great  essential  is  to  avoid  vomiting,  and  this  is  best 
accomplished  by  a  complete  temporary  cessation  of  stomach-feeding. 


ABDOMINAL  SURGERY  973 

At  the  end  of  twenty-four  hours,  if  all  is  going  well,  a  little  fluid 
nourishment  is  given,  and  this  is  gradually  increased,  whilst  the 
nutrient  enemata  are  diminished.  Of  course,  special  directions  as  to 
feeding  are  required  when  the  stomach  itself  has  been  incised.  The 
bowels  may  be  opened  by  castor  oil  on  the  third  day  unless  there  is 
any  special  necessity  for  keeping  them  quiet  for  a  longer  period,  and 
the  diet  may  then  be  rapidly  approximated  to  the  normal. 

Not  uncommonly  there  is  a  good  deal  of  discomfort  and  abdominal 
distension  for  the  first  few  days.  This  is  usually  due  to  a  collection 
of  flatus  which  the  patient  is  unable  to  expel.  Relief  is  best  obtained 
by  the  administration  of  a  turpentine  enema  (i  ounce  of  turpentine 
to  I  pint  of  soap  and  water)  which  may  need  to  be  repeated.  If  the 
condition  persists,  and  is  accompanied  by  flatulence  and  vomiting 
{peritonism),  suggesting  the  possible  onset  of  peritonitis,  the  adminis- 
tration of  a  saline  purgative— e.g'.,  20  grains  of  sulphate  of  soda  every 
half-hour — or  five  doses  of  i  grain  each  of  calomel  every  hour,  may 
stop  the  process  by  re-establishing  peristalsis,  removing  bacteria  and 
their  products,  and  lessening  the  vascular  tension.  A  hypodermic 
injection  of  strychnine  may  also  help  these  measures  by  its  direct 
action  on  the  muscular  coat  of  the  intestine.  These  measures  should 
be  assisted  by  enemata  containing  castor  oil  and  olive  oil,  as  well  as 
turpentine. 

Stitch  suppuration  is  a  troublesome  and  irritating  sequela  of  ab- 
dominal operations.  It  may  be  due  to  faulty  technique,  but  occurs 
quite  apart  from  this.  The  most  careful  sterilization  of  suture 
material  will  not  always  prevent  its  occurrence,  and  then  it  must  be 
attributed  either  to  tying  the  suture  too  tightly  and  strangling  the 
tissue  within  its  grasp,  or  to  its  becoming  drawn  too  tight  owing  to 
post-operative  abdominal  distension,  and  to  auto-infection  of  this 
strangled  tissue  or  of  some  collection  of  blood  around  it.  The  trouble 
may  start  early  or  late,  and  its  occurrence  is  not  unfrequently  in- 
dicated by  a  slight  but  persistent  rise  of  temperature  (say,  to  100° 
every  night),  associated,  perhaps,  with  an  increased  rate  of  pulse. 
The  external  wound  may  apparently  heal  perfectly,  and  then  ten  or 
twelve  days  after  the  operation  the  cicatrix  yields,  and  a  quantity  of 
pus  may  escape.  Under  these  circumstances  efficient  drainage  should 
be  arranged,  and  if  need  be  the  exposed  stitches  must  be  removed. 
Of  course  this  process  weakens  the  abdominal  wall,  and  extra  pre- 
cautions must  be  taken  to  prevent  the  formation  of  a  ventral  hernia. 
Intestinal  Sutures. — The  interior  of  the  bowel  is  occupied  by 
material  which,  as  long  as  it  remains  in  its  proper  place,  is  innocuous 
enough ;  but  should  it  find  its  way  into  the  peritoneal  cavity,  an 
acute  and  often  fatal  peritonitis  is  almost  certain  to  follow.  Hence, 
every  union  made  by  the  surgeon  must  be  air-  and  water-tight,  and 
capable  of  accommodating  itself  to  varying  degrees  of  intra-intestinal 
pressure.  It  is  also  essential  that  on  its  peritoneal  aspect  the  line 
of  union  should  present  nothing  but  serous  membrane,  as  otherwise 
adhesions  are  likely  to  form,  and  the  comfortable  action  of  the  bowel 
may  be  subsequently  impaired.  Special  forms  of  stitches  have  there- 
fore been  adopted,  the  more  im.portant  of  which  are  described  below. 


974 


A  MANUAL  OF  SURGERY 


Lemberfs  Suture,  originally  proposed  at  the  end  of  the  eighteenth 
century,  has  for  its  object  the  bringing  of  surfaces  of  peritoneum 
together  without  encroaching  on  the  mucous  membrane  ;  any  stitch 
which  involves  the  whole  thickness  of  the  wall  is  hable  to  be  followed 
by  leakage  of  the  intestinal  contents,  and  possibly  by  peritonitis.  The 
needle  is  passed  at  right  angles  to  the  axis  of  the  wound  through  a 


Fig.  439. — Lembert's  Suture  as  applied  for 
A  Longitudinal  Wound  of  the  Bowel. 

The  stitches  are  carried  well  beyond  the  ex- 
tremities of  the  incision,  so  as  to  obliterate 
the  groove  always  caused  by  this  method  of 
suturing. 


^ry/ 


Fig.  440. — Lembert's  Suture 
seen  in  Section,  to  show 
Character  of  Approxima- 
tion. 

serosa ;  b,  mus- 
c,  mucosa. 


Suture  ;  a, 
cularis  ; 


small  fold  of  the  serous  and  muscular  coats,  going  down  to  the  sub- 
mucosa ;  each  fold  is  placed  about  ^^2  inch  from  the  margins  of  the  in- 
cision (Fig.  439).  On  drawing  up  and  tightening  the  stitch,  the 
margins  of  the  wound  are  tucked  in  (Fig.  440),  and  only  the  serous 
coats   brought   into   apposition.      A   series   of   similar   stitches  are 


Fig 


441. 


Fig.  442. — Halstead's  Mattress  Suture. 


-Czerny-Lembert 
Suture. 

I.,  Stitch  securing  divided  mucous  membrane;  II.,  ordinary  Lembert  suture,  for 
the  serous  coats;  a,  serosa;  b,  muscularis  ;  c,  mucosa. 

inserted  along  the  whole  extent  of  the  wound,  numbering  about  ten 
or  twelve  to  the  inch,  or  it  may  be  carried  on  as  a  continuous  stitch. 
In  closing  a  longitudinal  incision  in  this  way,  a  groove  will  be  formed 
at  either  end  which  must  be  obliterated  by  two  or  three  extra 
sutures.  For  a  small  puncture  the  same  type  of  stitch  is  utilized, 
but  it  may  be  introduced  circularly  around  the  opening  like  a  purse- 
string,  and  by  tightening  it  the  margins  of  the  aperture  are  turned  in 
and  buried  (Fig.  470). 

The  Czerny-Lembert  Suture  is  very  similar  in  its  nature,  but  consists 


ABDOMINAL  SURGERY 


?7S 


coat  applied  and  tied  from  within  ; 
II.,  stitch  uniting  divided  mucous 
membrane  over  the  former,  so  as  to 
cover  it  in ;  a,  serosa ;  b,  muscu- 
laris ;  c,  mucosa. 


of  two  rows  ;  the  first  has  for  its  object  the  closure  of  the  wound  in 
the  mucous  membrane  (Fig.  441,  I.),  and  in  a  longitudinal  wound 
this  may  be  of  the  continuous  type  ;  the  second  row  consists  of  the 
ordinary  Lembert  stitches,  continued  or  interrupted  according  to 
the  requirements  of  the  case  (Fig.  441,  II.).  By  this  means  the 
knots  of  the  first  series  of  sutures 
are  covered  over  and  buried  by  the 
second  row. 

Halstead's  Mattress  Suture  (Fig. 
442)  is  a  very  valuable  one,  and 
constantly  utilized.  It  consists 
practically  of  a  double  Lembert,  a 
loop  being  thus  formed  at  one  end, 
whilst  the  knot  is  tied  at  the  other.  Fig.  443,— Wolfler's  Suture. 
It  is  introduced  with  exactly  the  l.^ stitch  through  serous  and  muscular 
same  precautions  as  the  original 
Lembert. 

Occasionally  it  happens  that 
two  segments  of  bowel  have  to  be 
stitched  together  from  inside,  since 
the  surgeon  cannot  reach  the  outer 

coats  owing  to  this  portion  being  fixed.  Thus,  in  an  exploratory 
gastrotomy  it  may  be  necessary  to  stitch  up  the  posterior  wall  of  the 
stomach  after  having  opened  it  from  the  front.  The  stitches  must 
then  be  inserted  by  what  is  known  as  Wolfler's  Method  (Fig.  443). 
They  are  first  passed  through  the  serous  and  muscular  coats  on 
either  side  (I.),  the  knots 
being  tied  on  the  inner 
aspect — i.e.,  towards  the 
lumen  of  the  open  viscus. 
The  mucous  membrane 
is  then  secured  by  a 
second  row  of  stitches 
(II.),  so  as  to  cover  over 
the  first  series  of  knots. 
In  many  forms  of  in- 
testinal anastomosis  this 
plan  has  also  to  be  em- 
ployed ;  as  soon  as  pos- 
sible,  however,  one 
changes  to  the  Czerny- 
Lembert  method. 

Gushing  s  Right- Angled  Suture  (Fig.  444)  is  a  most  useful  one  when 
surfaces  of  some  extent  have  to  be  approximated  by  a  continuous 
stitch.  The  suture  is  introduced  at  one  end  of  the  incision  and 
tied  according  to  the  usual  Lembert  method,  and  then  it  is  carried 
on  as  a  continuous  Lembert  suture,  except  that  the  needle  is  intro- 
duced parallel  to  the  margins  of  the  wound  and  at  a  distance  of  about 
^  inch    from  it,  instead  of  at  rii^ht    angles  to  it.     The   edges   are 


Fig.  444. — Cushing's  Right-angled  Suture 
FOR  Uniting  the  Sero-muscular  Coats  of 
THE  Stomach  or  Intestine. 

For  the  sake  of  clearness  the  preliminary  row  of 
stitches  through  the  mucous  membrane  is 
omitted  in  this  diagram. 


976  A  MANUAL  OF  SURGERY 

thereby  tucked  in  very  neatly.  Of  course  the  mucous  membrane 
is  first  dealt  with  separately  by  some  form  of  continuous  suture.  It 
may  be  employed  very  advantageously  in  gastro-enterostomy  or  any 
similar  procedure. 

Injuries  of  the  Abdominal  Wall. 

These  may  be  divided  into  three  main  classes — contusions,  non- 
penetrating and  penetrating  wounds ;  but,  of  course,  the  most 
important  point  about  them  is  as  to  whether  or  not  visceral  com- 
plications are  present. 

Simple  Contusions  of  the  abdominal  parietes  differ  but  little  from 
those  of  any  other  region  of  the  body.  Any  form  of  lesion,  from  a 
slight  bruise  to  an  extensive  muscular  laceration,  may  be  included  in 
this  category.  The  rectus  is  the  muscle  most  often  involved,  and  its 
laceration  may  result  not  only  from  injury,  but  also  as  a  consequence 
of  sudden  and  forcible  contractions,  e.g.,  in  tetanus.  Blood  is  extra- 
vasated  between  or  under  the  muscles,  and  a  well-marked  hsematoma 
may  follow.  In  connection  with  the  rectus  the  haemorrhage  may  be 
limited  by  the  lineas  transversae  if  it  only  involves  the  anterior  aspect, 
but  may  diffuse  itself  widely  through  the  sheath  if  the  back  of  the 
muscle  is  torn.  All  abdominal  liaematomata  are  very  liable  to 
suppurate,  the  abscess  either  pointing  locally  or  burrowing  widely 
between  the  muscular  planes,  and  coming  to  the  surface  at  some 
weak  spot,  e.g.,  Petit's  triangle  or  the  external  abdominal  ring.  The 
pus  is  usually  redolent  of  the  B.  coli,  suggesting  that  the  organism 
found  its  way  into  the  extravasated  blood  from  some  damaged  coil 
of  intestine  in  the  neighbourhood.  Occasionally  the  parietal  peri- 
toneum is  torn,  causing  shock  and  intraperitoneal  extravasation  of 
blood.  In  almost  all  cases  of  abdominal  contusion  shock  is  an  im- 
portant early  symptom,  but  in  the  absence  of  visceral  lesions  it  is 
neither  severe  nor  prolonged. 

Treatment  consists  in  keeping  the  patient  in  bed  until  the  tender- 
ness and  pain  have  disappeared.  Shock  is  dealt  with  in  the  usual 
way;  and  fomentations  or  a  firm  compress  of  dry  hot  wool  will  give 
much  comforting  support.  Rupture  of  the  rectus  muscles  necessi- 
tates the  adoption  of  the  sitting  position,  with  the  knees  flexed  over 
pillows :  at  a  later  date  support,  as  by  strapping  or  a  well-fitting 
abdominal  belt,  will  be  required. 

Non-Penetrating  Wounds  of  the  Abdominal  Wall  have  no  special 
significance,  and  if  uncomplicated  by  visceral  lesions  are  trea.ted  on 
general  principles.  If  the  epigastric  artery  is  divided,  extensive 
extravasation  is  likely  to  ensue  ;  the  v/ound  must  then  be  enlarged, 
and  the  bleeding  points  secured.  If  the  abdominal  muscles  are 
widely  divided,  steps  should  be  taken,  after  thorough  purification,  to 
draw  together  the  severed  muscular  or  aponeurotic  fibres  by  deep 
stitches,  so  as  to  diminish  the  tendency  to  a  ventral  hernia. 

Penetrating  Wounds  of  the  Abdominal  Wall  may  occur  with  or 
without  injury  or  protrusion  of  the  abdominal  viscera.  In  all  cases 
there  is  a  certain  amount  of  heemorrhage,  greater  or  less  according 


ABDOMINAL  SURGERY  977 

to  the  size  of  the  vessels  divided,  and  of  shock,  which  latter  is  very 
marked  when  the  viscera  are  injured,  whilst  mere  protrusion  without 
injury  may  cause  but  little  effect.  Thus,  cases  are  on  record  in 
which  a  patient  has  walked  to  the  surgeon  for  treatment,  supporting 
some  coils  of  intestine  in  his  hands.  The  protruded  viscera,  usually 
small  intestine  or  omentum,  are  often  large  in  amount  compared 
with  the  size  of  the  opening,  causing  them  to  be  more  or  less  con- 
gested or  even  strangled.  Necessarily,  in  all  cases  the  great  danger 
is  that  of  diffuse  septic  peritonitis,  caused  either  by  rupture  of  the 
intestine  or  by  infection  from  without. 

Treatment. — The  external  wound  is  carefully  cleansed,  whilst 
protruding  viscera  are  similarly  purified.  If  omentum  has  escaped, 
it  is  wise  to  ligature  and  remove  it,  whether  it  is  injured  or  not. 
Intestine  should  be  carefully  washed  with  warm  saline  solution  and 
replaced  ;  if  slightly  bruised,  it  may  be  returned,  but  the  external 
wound  should  not  be  entirely  closed,  and  a  drainage-tube  or  gauze  wick 
is  inserted,  so  that  if  bacillary  invasion  or  faecal  extravasation  occurs 
subsequently,  a  ready  exit  is  provided.  Small  incisions  or  punctures 
must  be  infolded  and  sutured,  but  when  small  intestine  is  seriously 
damaged,  enterectomy  should  be  undertaken  if  the  patient's  general 
condition  is  sufficiently  good;  otherwise  it  must  be  fixed  to  the  ab- 
dominal wall,  and  a  temporary  artificial  anus  provided.  With  the  large 
intestine,  this  latter  course  is  required  more  often,  and  especially  in 
cases  where  the  bowel  is  loaded  with  faeces  ;  the  gut  must  then  be 
fixed  in  the  wound  as  in  colostomy,  and  the  defect  dealt  with  at  a 
subsequent  period. 

In  cases  where  it  is  not  certain  whether  the  peritoneum  has  been 
implicated,  the  surgeon  should  always  enlarge  the  wound  so  as  to 
make  sure,  and  if  the  serous  membrane  has  been  involved,  he  should 
carry  his  investigations  still  further,  and  ascertain,  if  possible,  whether 
any  damage  has  been  done  to  the  viscera. 

The  external  wound  must  (with  the  exception  mentioned  above) 
be  carefully  closed  with  sutures,  so  as  to  minimize  the  risk  of  a 
subsequent  ventral  hernia. 

Visceral  Complications  are  likely  to  be  associated  with  any  injury  to 
the  abdominal  wall,  and  may  transform  it  into  a  lesion  of  the  gravest 
import.  The  liability  to  visceral  injury  varies  with  the  character  of 
the  violence,  and  with  the  condition  of  the  abdominal  wall  and  of  the 
subjacent  viscera.  If  the  blow  is  slight,  the  effects  are  probably 
not  serious,  and  the  patient  merely  suffers  from  a  localized  con- 
tusion with  some  amount  of  shock.  If  the  blow  is  expected,  and 
the  muscles  are  rigid,  but  little  harm  may  follow,  even  when  the 
violence  is  great ;  but  when  the  abdominal  wall  is  relaxed  and  the 
blow  unexpected,  a  slight  injury  may  do  much  mischief.  Hollow 
viscera,  such  as  the  stomach,  intestine,  or  bladder,  may  be  torn, 
and  when  distended  they  are  more  liable  to  such  an  accident. 
Solid  viscera,  such  as  the  liver,  spleen,  or  kidneys,  may  be  bruised  or 
torn,  and  grave  haemorrhage  may  result  therefrom  ;  a  soft  fatty  con- 
dition of  the  organs,  especially  of  the  liver,  may  predispose  to  such 

62 


978  A  MANUAL  OF  SURGERY 

a  lesion.  Displacement  of  organs  may  sometimes  occur,  and  it 
must  not  be  forgotten  that  any  sudden  sharp  concussion,  especially 
if  directed  to  the  epigastrium,  is  liable  to  be  followed  by  severe 
shock  from  irritation  of  the  subjacent  solar  plexus,  and  life  itself 
may  be  destroyed  in  this  way  by  syncope  without  the  appearance 
of  an  evident  lesion.  The  omenta,  mesenteries,  and  peritoneal  liga- 
ments may  also  be  torn,  and  give  rise  immediately  to  haemorrhage, 
or  subsequently  to  the  formation  of  apertures  or  bands,  which  may 
determine  obstructive  phenomena  at  a  later  date.  Thus  a  blow  in 
the  epigastrium  was  followed  by  detachment  of  the  round  ligament  of 
the  liver  from  the  falciform  ligament,  constituting  a  band  which 
compressed  the  transverse  colon. 

The  clinical  history  of  these  injuries  will  be  described  under  the 
various  organs,  and  only  a  few  general  statements  need  be  made 
here.  It  is  obvious  that  a  serious  responsibility  rests  upon  the 
medical  attendant  in  any  case  of  abdominal  injury,  and  that  the 
gravest  results  may  follow  a  mistaken  conclusion  as.  to  the  nature 
of  the  lesion,  or  a  hesitant  policy  in  undertaking  operation.  In 
a  large  proportion  of  cases  abdominal  injuries,  even  including 
rupture  of  intestine,  are  amenable  to  treatment  by  operation,  if 
only  it  is  performed  sufficiently  early ;  if,  however,  it  is  delayed 
until  the  ^gut  is  paralyzed  and  peritonitis  well  established,  death  is 
almost  certain  to  ensue  whether  the  abdomen  is  opened  or  not. 
Unfortunately,  no  absolute  rules  can  be  laid  down  as  to  when  opera- 
tion is  necessary,  but  the  surgeon  should  remember  that  exploration 
in  a  doubtful  case  will  probably  do  far  less  harm  than  by  waiting 
until  the  diagnosis  is  made  certain  by  an  outbreak  of  diffuse  in- 
flammation, providing  always  that  the  patient  is  not  so  profoundly 
collapsed  as  to  contra-indicate  all  interference. 

Cases  of  serious  abdominal  injury  group  themselves  into  three 
sets  :  (i)  Where,  in  addition  to  a  localized  lesion  of  the  parietes,  there 
is  severe  shock  due  to  contusion  of  viscera,  but  with  no  justification 
for  laparotomy;  (2)  where  there  is  serious  intraperitoneal  haemor- 
rhage, as  from  a  ruptured  liver  or  spleen,  or  a  tear  of  the  mesentery ; 
and  (3)  where  a  hollow  viscus  is  opened,  and  peritonitis  is  at  once 
lighted  up. 

Shock  is  almost  always  well  marked  in  abdominal  lesions,  but 
unless  there  is  a  serious  wound  of  some  viscus,  it  usually  passes  oft 
in  less  than  twenty-four  hours  if  the  patient  is  left  quietly  in  bed. 
Intraperitoneal  hcemorrhage  causes  various  symptoms  according  to  its 
amount  and  site  of  origin ;  in  addition  to  the  initial  shock,  the 
general  signs  characteristic  of  this  condition  show  themselves,  viz., 
pallor,  restlessness,  'air-hunger,'  and  possibly  the  large -waved 
haemorrhagic  pulse.  Dulness  may  be  noted  in  one  or  both  flanks, 
according  to  the  situation  of  the  lesion,  being  influenced  by  the 
attachment  of  the  mesentery ;  thus  blood  from  the  liver  may  gravitate 
into  and  for  a  time  be  limited  to  the  right  lumbar  region  and  iliac 
fossa  without  reaching  the  pelvic  cavity ;  blood  from  the  spleen  will 
pass  freely  down  into  the  pelvis  along  the  left  side  of  the  mesentery. 


ABDOMINAL  SURGERY 


979 


producing  dulness  in  the  left  loin  and  not  in  the  right.  It  must  be 
remembered,  however,  that  a  large  quantity  of  blood  may  escape 
into  the  peritoneal  cavity  without  the  production  of  any  recognisable 
area  of  dulness  ;  it  is  then  lodged  under  the  costal  arch,  or  amongst 
the  intestines,  or  in  the  pelvis.  When  the  bleeding  is  less  severe, 
the  patient  complains  of  a  severe  tearing  pain,  becomes  pallid  and 
ansemic,  but  may  recover,  and  the  blood  be  absorbed ;  not  unfre- 
quently  the  temperature  runs  up  after  the  initial  shock  has  passed, 
and  remains  up  for  some  days.  The  onset  of  peritonitis  is  indicated  by 
persistence  of  the  collapse,  and  vomiting  or  hiccough,  whilst  the 
abdomen  becomes  distended,  its  wall  is  held  rigidly  steady,  and  the 
breathing  becomes  thoracic ;  probably  some  fixed  spot  of  maximum 
tenderness  will  be  noted,  especially  when  the  intestine  is  injured. 

Treatment. — The  patient  having  been  put  to  bed,  and  the  initial 
shock -combated  in  the  usual  way,  a  most  careful  examination  of  the 
patient  and  his  abdomen  is  instituted.  Conditions  which  indicate 
immediate  operation  are  :  (a)  the  signs  of  intraperitoneal  haemor- 
rhage ;  ih)  blood-stained  vomiting,  indicating  a  rupture  of  the 
stomach  ;  {c)  a  fixed  and  rigid  abdominal  wall  coming  on  quickly 
after  an  injury,  with  severe  pain  and  localized  tenderness,  suggesting 
a  rupture  of  the  intestine  ;  and  {d)  the  phenomena  due  to  a  ruptured 
bladder.  Under  such  circumstances,  no  delay  is  justifiable,  and, 
even  if  severe  shock  is  present,  operation  should  be  commenced, 
unless  death  is  evidently  imminent.  A  large  intravenous  injection 
of  hot  saline  solution  will  usually  rally  the  patient  sufficiently  to 
warrant  the  surgeon  in  proceeding,  whilst  washing  out  the  peritoneal 
cavity  with  the  same  hot  solution  may  have  a  similar  effect.  If, 
however,  well-marked  shock  is  present,  with  perhaps  localized 
pain,  but  with  no  absolute  evidence  of  visceral  lesions,  expectant 
treatment  should  be  adopted.  The  patient  is  kept  warm  in  bed; 
perhaps  a  little  opium  is  administered  to  allay  pain  and  restlessness 
and  to  check  peristalsis,  but  as  little  as  possible  should  be  given, 
since  symptoms  are  so  completely  masked  thereby.  If  there  is  any 
vomiting,  rectal  alimentation  should  be  employed  after  the  lower 
bowel  has  been  washed  out.  If  the  manifestations  of  intraperitoneal 
haemorrhage  subsequently  make  themselves  evident,  or  if  at  the  end 
of  not  more  than  twenty-four  hours  the  patient  is  still,  more  or  less, 
in  a  condition  of  collapse,  and  especially  if  he  complains  of  a  fixed 
tender  spot  with  a  rigidly  contracted  abdominal  wall  over  it,  or  if 
vomiting  or  hiccough  has  supervened,  then  operation  can  still  be 
undertaken  with  some  prospect  of  success. 

There  are  but  few  other  conditions  of  the  abdominal  wall  which 
require  notice.  The  rectus  muscle  may  be  torn  as  a  result  of  injury 
or  of  tetanic  convulsions,  and  a  hernia  is  very  likely  to  follow.  One  of 
the  segments  may  become  spasmodically  contracted,  constituting 
what  is  known  as  a  'phantom  tumour,'  usually  occurring  in  hysterical 
females,  and  disappearing  under  an  anaesthetic 


98o  A    MANUAL  OF  SURGERY 

Affections  of  the  Umbilicus. 

The  various  forms  of  umbilical  hernia  are  described  elsewhere. 

Inflammation  and  Ulceration,  perhaps  running  on  to  eczema,  may 
arise  from  want  of  cleanliness  after  separation  of  the  cord.  Tetanus 
neonatorum  probably  owes  its  origin  to  this  source,  as  also  the 
erysipelas  of  infants,  both  of  which  diseases  are  exceedingly  fatal, 
whilst  the  latter  is  often  accompanied  by  sloughing  of  the  neighbour- 
ing abdominal  parietes.  The  eczematous  condition  merely  requires 
cleanliness,  and  the  application  either  of  an  antiseptic  dusting-powder 
or  of  some  simple  ointment. 

Occasionally  a  Polypoid  Excrescence  is  met  with  growing  from 
the  umbilicus,  and  is  probably  derived  from  the  remains  of  the 
umbilical  vesicle.  On  microscopic  examination,  it  is  found  to  consist 
of  a  number  of  tubular  glands  held  together  by  connective  tissue. 
All  that  is  required  is  to  ligature  the  base  and  cut  it  away. 

Warts  and  Nsevi  are  also  found  here,  but  need  no  special  notice, 
as  also  syphilitic  and  cancerous  disease.  The  latter  is  either  an 
epithelioma,  starting  in  the  skin  as  a  result  of  prolonged  irritation, 
or  a  columnar  carcinoma,  which  may  arise  primarily  in  some  foetal 
relic  or  be  secondary  to  an  intra-abdominal  focus. 

Umbilical  Fistulae  not  unfrequently  occur,  and  may  be  congenital 
or  acquired.     Three  varieties  are  described  : 

(a)  A  Fiscal  Fistula  of  congenital  origin  arises  from  non-closure  of 
the  vitello-intestinal  duct,  and  opens  into  the  intestine  either  directly, 
or  by  means  of  a  passage  of  greater  or  less  length,  which  corresponds 
to  Meckel's  diverticulum,  and  is  connected  with  the  lower  part  of  the 
ileum.  Sometimes  this  passage  is  closed  at  the  intestinal  end,  and 
then  only  discharges  mucus.  Acquired  cases  are  usually  due  to 
perforation  of  the  bowel  following  strangulation  of  an  umbilical 
hernia,  or  to  tuberculous  peritonitis. 

(b)  A  Congenital  Urinary  Fistula  is  due  to  non-closure  of  the 
urachus ;  occasionally  merely  a  sinus  persists,  leading  towards  the 
bladder,  but  not  opening  into  it.  It  may  be  dealt  with  by  excision 
of  the  mucous  membrane,  its  destruction  by  the  galvano-cautery,  or 
by  freshening  the  edges  and  subsequent  suture. 

(c)  A  Biliary  Fisttda  sometimes  forms  at  the  umbilicus,  resulting 
from  an  abscess  connected  with  the  gall-bladder. 

In  Ectopia  Vesicae  the  umbilicus  is  absent,  the  extroverted  portion 
of  the  bladder  extending  up  to  what  should  normally  be  its  situation. 

Affections  of  the  Peritoneum. 

Peritonitis  arises  from  many  different  conditions  and  presents 
many  diverse  manifestations.  It  may  be  acute  or  chronic  in  its 
course,  localized  or  diffuse  in  its  distribution,  and  protective  or 
rapidly  destructive  in  its  results. 

.Etiology. — Peritonitis  is  almost  invariably  due  to  the  action  of 
micro-organisms,  and  the  symptoms  largely  depend  on  the  toxaemia 


ABDOMINAL  SURGERY  981 

determined  thereby.  The  bacteria  Hght  up  an  inflammatory  reaction 
characterized  by  effusion  of  varying  type  ;  in  the  mildest  forms  it  is 
usually  abundant  and  localized,  in  the  severer  types  it  is  generalized, 
and  in  the  worst  cases  death  may  ensue  from  toxaemia  before  there 
has  been  time  for  the  development  of  marked  anatomical  changes. 

1.  Infection  may  start  from  any  part  of  the  intestinal  canal  or  its 
adnexa,  included  in  the  abdomen,  from  stomach  to  rectum.  It  may 
be  due  to  traumatic  or  pathological  rupture  or  perforation,  to  the 
extension  outwards  of  ulcers,  to  the  impaction  of  foreign  bodies,  or 
the  damaging  influence  of  interference  with  the  blood-supply,  as  in 
strangulation,  volvulus,  etc.  The  vermiform  appendix  is  the  com- 
monest site  of  onset  of  this  group  of  cases.  The  Streptococcus  pyogenes 
and  B.  coli  are  the  organisms  most  frequently  present,  but  some 
of  the  other  inhabitants  of  the  intestine,  especially  those  that  are 
anaerobic,  are  occasionally  causative.  On  the  whole  the  gastric 
contents  are  less  noxious  than  those  of  the  intestine,  and  the  fluid 
contents  of  the  small  gut  are  more  liable  to  be  diffused,  and  therefore 
do  more  harm  than  the  more  solid  faeces  in  the  large. 

2.  A  somewhat  similar  type  of  origin  causes  puerperal  peritonitis, 
the  organisms  (usually  streptococci,  but  of  any  pyogenic  form) 
extending  from  the  uterus  through  the  lymphatics  of  the  broad 
ligament,  etc.,  to  the  'peritoneum ;  it  is  therefore  possible  for  the 
mischief  to  limit  itself  to  the  pelvic  viscera. 

3.  Infection  may  occur  from  without,  as  in  perforating  wounds, 
operations,  etc.,  any  of  the  ordinary  pyogenic  organisms  being 
responsible,  but  especially  the  streptococcus.  The  likelihood  of  infec- 
tion depends  largely  on  the  peritoneum  remaining  unbruised ,  rough 
handling  and  prolonged  exposure  are  only  too  likely  to  destroy  the 
surface  endothelium  and  diminish  its  resisting  powers,  whilst  the 
same  conditions  check  the  power  of  absorbing  fluids,  and  hence 
permit  of  bacterial  growth. 

4.  Peritonitis  may  be  due  to  the  gonococcus,  and  then  has  usually 
spread  up  the  Fallopian  tube  (p.  990) ;  to  the  pnetmococcus,  probably 
as  a  blood  infection,  or  secondary  to  pneumonia  or  pleurisy,  the 
bacteria  travelling  through  the  lymphatics  of  the  diaphragm  (p.  989) ; 
and  possibly  to  the  organism  of  acute  rheumatism,  then,  perhaps, 
starting  in  the  appendix. 

5.  The  B.  tuberculosis  is  responsible  for  the  development  of  a  chronic 
tuberculous  peritonitis. 

6.  Simple  chronic  peritonitis  is  of  a  protective  character,  and 
arises  when  any  irritative  lesion  of  a  viscus  slowly  approaches  the 
peritoneal  surface,  which  becomes  thickened  in  consequence.  Ad- 
hesions of  various  types  may  result  from  this  reaction,  and  grave 
developments  (obstruction,  strangulation,  etc.)  may  follow  at  a  later 
date. 

7.  A  group  of  cases  occurs  in  which  the  causative  lesion  is 
mechanical  or  chemical  in  the  first  place — e.g.,  extravasation  of  bile 
from  a  ruptured  gall-bladder,  or  the  irritation  produced  by  torsion 
of  a  wandering  spleen,  of  an  ovarian  cyst,  or  even  of  the  omentum. 


982  A  MANUAL  OF  SURGERY 

Severe  reaction  follows  such  a  lesion,  but  it  is  possible  that  the  focus 
may  be  shut  off  from  the  general  cavity  by  plastic  adhesions,  and  be 
thereby  encapsuled  or  absorbed  ;  or  the  inflammation  may  extend 
to  neighbouring  coils  of  intestine,  and  when  once  these  become 
paralyzed  bacterial  invasion  is  almost  certain  to  follow,  and  septic 
peritonitis  to  ensue. 

It  is  interesting  to  note  that  a  localized  immunity  can  be  developed 
in  the  peritoneal  cavity  of  animals  by  injecting  gradually  increasing 
doses  of  toxic  material ;  it  is  probable  that  a  similar  condition  obtains 
in  man,  and  this  explains  why  the  sites  of  old  peritonitic  trouble  are 
often  favourable  for  operations,  an  attack  of  generalized  inflammation 
being  unusual. 

Varieties.^ — From  a  purely  clinical  standpoint,  peritonitis  may  be 
discussed  under  two  main  headings — the  acute  and  the  chronic.  The 
acute  is  again  divided  into  the  diffuse  and  localized,  and  the  chronic 
into  the  simple  and  the  tuberculous. 

I .  Acute  Diffuse  Peritonitis  results  from  infection  of  the  peritoneal 
cavity  with  a  large  dose  of  septic  material  (as  by  rupture  of  the 
stomach  or  intestine),  or  by  the  introduction  of  a  small  dose  of 
virulent  organisms  when  the  resisting  powers  are  low. 

Pathological  Anatomy. — The  peritoneal  surface  becomes  congested 
and  a  little  sticky,  and  its  shiny  appearance  is  lost  as  a  result  of  the 
proliferation  of  the  endothelial  cells  and  a  commencing  oedema  of  the 
subserous  connective  tissues ;  this  change  is  most  advanced  in  the 
neighbourhood  of  the  site  of  infection,  but  rapidly  spreads,  and  in 
the  gravest  forms  of  peritoneal  toxaemia,  where  death  takes  place 
under  twenty-four  hours,  there  is  but  little  other  evidence  of  the 
disease.  In  the  great  majority  of  cases,  however,  effusion  occurs ; 
sometimes  the  fibrinous  element  is  most  marked,  the  intestines  being 
matted  together,  and  the  fibrin  thickest  along  the  lines  of  contact  of 
adjacent  coils  ;  sometimes  there  is  an  abundant  serous  exudation,  but 
more  frequently  it  is  sero-purulent  or  consists  simply  of  pus,  which 
may  gravitate  to  the  loins  and  pelvis,  or  travel  upwards  under  the 
diaphragm,  or  be  shut  up  in  pockets  by  the  development  of  adhesions. 
The  effusion  is  intensely  infective,  and  the  surgeon  should  always 
protect  his  hands  by  rubber  gloves,  since  any  wounds  caused  during 
operation  or  in  the  post-mortem  examination  are  likely  to  be  followed 
by  severe  cellulitis  or  even  septicaemia.  Gas  may  be  present,  result- 
ing either  from  the  laying-open  of  an  air-containing  viscus,  or  from 
the  presence  of  a  gas-producing  organism. 

The  contents  of  the  gut  stagnate  and  undergo  decomposition.  The 
omentum  becomes  congested  and  infiltrated  with  effusion,  or  even 
pusj  it  may  occasionally,  however,  form  a  barrier  across  the 
abdomen,  shutting  off  the  lower  from  the  upper  part,  and  thus  limit- 
ing the  mischief  to  one  or  other  section. 

The  toxins  developed  in  the  exudate  are  absorbed  by  the  peritoneum, 
and  whilst  causing  a  generahzed  toxaemia  of  varying  severity,  they 
may  also  determine  a  well-marked  subperitoneal  cedema.  The 
rapidity  of  absorption  is  very  considerable,  especially  from  the  under 


ABDOMINAL  SURGERY  -  983 

surface  of  the  diaphragm,  where  the  lymphatics  are  practically  con- 
tinuous with  the  peritoneal  cavity,  and  quickly  carry  toxins  and 
bacteria  to  the  mediastinal  glands.  The  upper  half  of  the  abdomen 
is  therefore  a  less  favourable  site  for  peritonitic  trouble  than  the 
lower,  and  all  available  means,  such  as  position,  drainage,  etc.,  must 
be  employed  to  limit  or  prevent  the  extension  of  the  trouble  in  this 
direction. 

Symptoms. — The  onset  varies  somewhat  with  the  cause  of  the 
affection ;  but  when  due  to  traumatic  infection  from  without,  the 
symptoms  usually  commence  with  abdominal  pain  and  distension, 
together  with  flatulence  and  vomiting.  The  pain  may  be  localized 
at  first  to  some  particular  region,  or  is  referred  to  the  umbilicus ; 
soon,  however,  it  becomes  diffuse,  and  is  associated  with  exquisite 
tenderness  and  great  distension.  In  a  typical  case  the  phenomena 
are  very  characteristic.  The  patient  lies  on  his  back  with  the  knees 
drawn  up,  partly  to  relax  the  abdominal  muscles,  partly  to  prevent 
the  bedclothes  touching  the  body.  The  abdomen  is  distended,  hard, 
and  extremely  tender  ;  it  is  at  first  generally  tympanitic,  but  later  on, 
if  effusion  should  become  marked,  dulness  may  be  noted  in  the 
flanks,  although  this  is  not  a  common  feature.  The  pulse  is  quick, 
hard,  and  wiry  in  the  early  stages,  though  later  it  becomes  weak, 
rapid,  and  compressible.  The  respirations  are  quick,  shallow,  and 
thoracic  in  character.  The  temperature,  perhaps  raised  at  first  as 
a  result  of  the  causative  lesion,  sometimes  becomes  subnormal  from 
toxaemia  before  the  end  is  reached.  Vomiting  is  usually  a  prominent 
symptom,  associated  perhaps  with  hiccough ;  to  commence  with,  the 
contents  of  the  stomach  alone  are  expelled,  but  later  on  they  may  be 
mixed  with  bile,  or  with  the  decomposing  contents  of  the  upper  coils 
of  intestine.  Though  very  constant  and  troublesome,  it  is  much  less 
distressing  than  that  which  arises  from  intestinal  obstruction,  and, 
owing  to  the  pain  induced  by  any  sudden  contraction  of  the  abdominal 
muscles,  the  patient  ejects  the  vomit  with  but  little  force.  Constipa- 
tion and  the  absolute  arrest  of  flatus  are  almost  always  present  in 
peritonitis,  owing  to  the  cessation  of  peristalsis  induced  by  the  in- 
flammation, and  hence  meteorism  is  a  marked  symptom.  As  the 
case  progresses,  the  patient's  strength  rapidly  diminishes,  his  face 
becomes  pinched  and  drawn  (fades  Hippocratica),  the  extremities  are 
cold,  the  temperature  is  usually  subnormal,  and  death  results  from 
collapse  and  toxaemia. 

When  due  to  sudden  perforation  of  the  bowel,  the  onset  of  the 
symptoms  is  associated  with  profound  shock,  and  the  course  is  very 
rapid  if  the  opening  is  large,  and  the  intestinal  contents  early  extra- 
vasated.  Vomiting,  too,  is  usually  more  marked  than  when  due  to 
other  causes.  If,  however,  the  perforation  is  small,  the  immediate 
shock  is  less,  and  the  symptoms  progress  more  gradually. 

As  already  mentioned,  there  are  certain  grave  cases  in  which  the 
general  toxaemia  is  the  most  marked  phenomenon,  and  these  may 
succumb  from  exhaustion  in  from  twelve  to  twenty-four  hours.  The 
majority  of  cases,  however,  last  for  three  or  four  days.     Recovery 


9^4  A  MANUAL  OF  SURGERV 

is  heralded  in  by  a  diminution  or  cessation  of  the  vomiting  and  the 
passage  of  flatus,  whilst  the  pulse-rate  falls,  and  the  local  symptoms 
gradually  clear  up. 

Treatment. — In  the  early  stages,  whilst  the  diagnosis  is  still  in 
doubt,  the  patient  is  kept  quietly  in  bed,  and  preferably  in  what  is 
known  as  Prowler's  position— i.e.,  with  the  head  and  trunk  raised  from 
the  horizontal  plane  about  30°  or  40°,  so  as  to  determine  the  flow  of 
fluid  exudate  down  towards  the  pelvis  rather  than  backwards  into 
the  kidney  pouches,  whence  it  may  spread  up  to  the  dangerous  sub- 
diaphragmatic area.  No  food  is  administered  by  the  mouth,  and  no 
purgative  given  ;  the  lower  bowel  may  be  emptied  by  enema,  and 
subsequently  saline  injections  administered  to  relieve  thirst.  Mor- 
phia and  opium  are  prohibited  as  long  as  the  diagnosis  is  uncertain, 
for  fear  of  masking  symptoms.  By  determining  a  cessation  of  vomit- 
ing and  a  false  sense  of  comfort,  false  hopes  may  be  encouraged,  and 
delay  in  operation  result.  As  soon  as  a  definite  opinion  as  to  the 
necessity  for  this  procedure  is  reached,  the  objection  to  a  moderate 
dose  of  morphia  ceases  ;  and  whilst  the  patient  is  being  prepared  for 
operation  and  the  necessary  arrangements  are  being  made,  it  may 
save  him  much  suffering  and  help  to  conserve  his  powers. 

The  actual  scope  and  particular  features  of  the  operation  vary 
naturally  with  the  many  causes  that  may  have  been  operative  in 
determining  the  outbreak  of  the  condition,  and  these  will  be  suitably 
referred  to  afterwards.  It  is  only  possible  here  to  deal  with  the 
general  features.  The  incision  is  made  in  the  linea  alba,  unless  the 
causative  lesion  is  obviously  on  one  side,  as  in  the  case  of  a 
perforated  appendix  ;  and  the  lower  half  of  the  abdomen  is  opened 
rather  than  the  upper,  unless  the  latter  is  distinctly  indicated.  The 
objects  of  the  operation  are  threefold :  (i)  To  find  and  deal  with  the 
cause  of  the  affection,  such  as  a  perforation  which  needs  to  be 
closed,  or  a  perforated  or  gangrenous  appendix  which  must  be 
removed.  (2)  To  cleanse  the  peritoneum  and  remove  the  effusion. 
Some  surgeons  rely  on  mopping  up  the  exudate  with  dry  sterile 
swabs,  and  if  it  is  localized,  and  not  diffuse,  this  may  act  excellently. 
When,  however,  there  is  a  considerable  sero-purulent  effusion, 
occupying  the  pelvis,  and  perhaps  spreading  up  through  the  kidney 
pouches  to  the  under  surface  of  the  diaphragm,  irrigation  of  the 
cavity  is  probably  desirable.  Sterile  salt  solution  at  a  temperature 
of  about  107°  is  used,  and  the  whole  proceeding  should  be  effected 
without  the  escape  of  much  of  the  intestine.  Counter-openings  in 
the  loins  or  above  the  pubes  may  be  required  to  give  exit  to  the 
fluid,  and  then  the  end  of  a  sterilized  rubber  tube  coming  from  the 
irrigator  is  carried  here  and  there  through  the  abdomen  by  the  hand, 
and  the  exudate  effectively  washed  out  through  glass  tubes  placed 
in  the  various  incisions.  It  is  most  undesirable  to  allow  the  escape 
of  many  coils  of  intestine,  and  general  evisceration  with  the  object 
of  cleansing  the  intestines  adds  seriously  to  the  shock,  and  will  do 
more  harm  than  good.  '  Quickly  in  and  more  quickly  out,'  is  an 
ideal  that  ought  to  be  striven  after.     (3)  Drainage  is  necessary  in 


ABDOMINAL  SURGERY  985 

almost  all  cases,  and  may  be  effected  by  the  use  of  glass  or  rubber 
tubes  with  or  without  gauze  wicks.  Strips  of  gauze  may  also  be 
carried  here  and  amongst  the  intestines.  When  employing  a  Keith's 
tube,  the  enclosed  gauze  wick  is  removed  twice  a  day,  and  any 
effusion  lying  at  the  bottom  sucked  up  through  a  sterile  rubber 
catheter  attached  to  the  nozzle  of  a  glass  syringe.  It  is  probably 
wise  to  omit  the  glass  tube  at  the  end  of  forty-eight  hours,  and  replace 
it  by  a  smaller  and  shorter  rubber  tube,  which  in  turn  is  replaced  by 
a  gauze  drain  as  soon  as  the  discharge  diminishes  sufficiently. 
The  abdominal  wall  is,  of  course,  only  partially  closed  after  these 
proceedings. 

The  importance  of  overcoming  intestinal  paralysis  is  so  great  that 
it  has  been  suggested  by  McCosh  that  several  ounces  of  a  saturated 
solution  of  Epsom  salts  should  be  injected  into  the  upper  part  of  the 
jejunum  before  closing  the  abdomen.  The  advice  is  sound  and  may 
be  wisely  followed.  With  the  same  end  in  view  regular  hypodermic 
administration  of  strychnine  may  be  commenced  after  the  operation 
with  the  idea  of  stimulating  the  unstriped  muscle  fibres  of  the 
intestinal  wall. 

As  soon  as  the  patient  has  recovered  from  the  anaesthetic,  he 
should  be  raised  from  the  recumbent  to  the  sitting  posture  (^Fowler's 
position),  with  a  view  to  permitting  the  fluid  effusion  to  gravitate 
into  the  pelvis.  Continuous  infusion  of  salt  solution  into  the  rectum 
(proctoclysis)  or  subcutaneous  tissues  should  also  be  employed  in 
order  to  dilute  the  toxins  and  facilitate  their  elimination.  A  reservoir 
slightly  raised  above  the  patient's  pelvis  is  placed  at  the  side  of  the 
bed,  and  salt  solution  kept  in  it  at  a  temperature  of  110°  F.  A  long 
rectal  tube  is  passed  as  high  as  possible,  and  connected  with  the 
reservoir  by  a  tube  of  such  calibre  as  shall  permit  the  solution  to 
trickle  gently  into  the  rectum — about  one  pint  an  hour  suffices. 
Four  or  five  pints  can  be  introduced  in  this  way  without  discomfort, 
and  subsequently  repeated. 

For  infusion  into  the  subcutaneous  tissues  the  outer  side  of  the 
thighs  will  be  convenient.  Two  needles  are  introduced,  only  one  of 
which  is  used  at  a  time.  Four  or  five  ounces  are  injected  on  one 
side,  and  then  the  other  limb  is  employed  ;  the  needles  are  kept  in 
place  whilst  the  fluid  is  being  absorbed. 

Im_provement  in  the  condition  of  the  patient  shows  itself  almost 
at  once  by  a  fall  of  temperature  and  of  pulse  ;  the  vomiting  ceases 
or  becomes  less  urgent,  pain  and  tenderness  decrease,  and  the 
patient  looks  and  feels  better.  On  the  second  day  the  bowels  are 
likely  to  become  distended  with  flatus,  and  it  is  necessary  to  obtain 
relief ;  this  is  best  effected  by  a  turpentine  enema  in  the  first  place, 
followed  by  a  dose  of  castor  oil,  or  of  sulphate  of  soda,  or  repeated 
small  doses  of  calomel.  As  soon  as  the  bowels  have  acted  well,  the 
urgency  of  the  symptoms  diminishes,  and  it  is  probable  that  the 
patient  will  recover. 

The  wound  requires  constant  dressing  for  some  time,  as  there 
will  be  a  good  deal  of  offensive  discharge,  and  in  all  probability 


g86  A  MANUAL  OF  SURGERY 

the  fatty  and  fascial  margins  of  the  wound  will  slough.  The 
tubes  are  gradually  dispensed  with  as  the  discharge  diminishes, 
and  replaced  by  gauze  drains  ;  and  when  the  deeper  tracks  have  filled 
with  granulations,  the  superficial  wounds  may  be  drawn  together 
with  strapping,  and  thus  the  strength  of  the  abdominal  wall  may  be 
maintained.  It  will  be  wise  to  order  an  efficient  belt  or  support 
after  operations  of  this  type. 

If  the  patient  has  unfortunately  been  left  long  without  operation, 
so  that  he  is  suffering  from  severe  toxaemia,  with  the  intestines 
distended  and  paralyzed,  and  faecal  vomiting  present,  it  is  quite  a 
question  whether  operation  is  desirable,  and  whether  the  necessarily 
fatal  issue  will  not  be  hastened  rather  than  hindered.  In  such  cases, 
if  operation  be  undertaken  at  all,  it  should  be  limited  to  a  small 
incision  under  cocaine  anaesthesia  in  the  middle  line  below  the 
umbilicus,  and  the  introduction  of  a  glass  or  rubber  drainage-tube, 
in  order  to  remove  the  fluid  exudate.  A  larger  opening  will  involve 
the  escape  of  distended  and  paralyzed  intestines,  and  to  return  these, 
even  after  puncture  and  removal  of  the  contained  gas  is  often  a 
matter  of  serious  difficulty.  It  is  just  possible  that  benefit  may  be 
derived  by  opening  and  draining  one  of  these  distended  coils  (enter- 
ostomy) by  tying  in  a  Paul's  tube  ;  but  in  all  probability  the 
intestinal  paralysis  is  so  great  that  a  very  limited  relief  to  the 
distension  follows. 

2.  Acute  Localized  Peritonitis  usually  arises  in  connection  with 
some  limited  lesion  of  the  abdominal  contents,  which  is  of  such  a 
nature  as  to  permit  of  the  general  peritoneal  cavity  being  shut  off 
by  adhesions,  the  process  being  thereby  localized.  It  is  frequently 
followed  by  suppuration,  the  abscess  being  thus  intraperitoneal, 
although  not  involving  the  general  peritoneal  cavity.  The  abscesses 
arising  in  connection  with  appendicitis  or  pelvic  peritonitis  are  not 
uncommonly  of  this  nature.  They  may  burst  through  the  barrier  of 
adhesions,  and  thus  light  up  a  diffuse  inflammation  of  the  peritoneal 
sac,  or  they  may  burrow  to  the  surface  and  point  externally,  or  open 
into  one  of  the  hollow  viscera. 

The  Symptoms  complained  of  are  deep  pain  and  tenderness,  more 
or  less  localized  to  the  afl"ected  area,  together  with  fever,  vomiting, 
and  constipation.  At  first  no  swelling  or  tumour  is  to  be  made  out, 
but  a  feeling  of  resistance  may  be  noticed  in  the  abdominal  wall, 
which  is  held  tense  and  rigid,  as  if  guarding  some  focal  point  of 
mischief.  As  the  eff"usion  increases  in  amount,  a  tumour  dull  or 
tympanitic  on  percussion  may  become  evident ;  it  is  mainly  due  to  a 
matting  together  of  the  intestines  and  omentum,  but  is  often  associated 
with  a  variable  amount  of  effusion ;  if,  however,  it  is  placed  deeply, 
the  dulness  may  be  absent  owing  to  the  fixation  of  one  or  more  coils 
of  intestine  in  front  of  the  inflammatory  focus.  If  an  abscess  forms 
and  travels  towards  the  surface,  the  abdominal  wall  becomes  infil- 
trated, red,  and  oedematous,  the  component  tissues  being  bra-v\my  to 
the  touch,  and  cutting  like  bacon.  Finally,  a  fluctuating  area 
presents  itself  in  the  midst  of  this  indurated  mass,  and  the  abscess 


ABDOMINAL  SURGERY  987 

either  discharges  itself  or  is  opened.  The  pus  contained  therein  is 
often  offensive,  owing  to  the  presence  of  the  B.  coli.  Of  course  this 
process  is  attended  with  considerable  increase  in  the  pain  and  con- 
stitutional disturbance.  If  the  cavity  is  opened  aseptically  and 
drained,  it  rapidly  contracts  and  a  cure  is  accomplished,  although 
intraperitoneal  adhesions  may  persist  and  lead  to  subsequent  trouble 
from  hampering  the  intestinal  movements.  If  a  communication  is 
established  with  the  intestine,  a  faecal  fistula  is  apt  to  follow  ;  whilst 
if  the  cavity  becomes  septic,  chronic  suppuration  may  result,  and 
thereby  the  patient's  health  and  strength  are  undermined.  The 
determination  as  to  the  existence  or  not  of  suppuration  is  by  no 
means  easy,  and  a  blood  count,  perhaps  repeated  more  than  once,  is 
often  of  the  greatest  value  (see  p.  53). 

Treatment. — In  these  cases  resolution  can  sometimes  be  obtained 
by  keeping  the  patient  absolutely  quiet  and  on  a  low  diet,  with 
perhaps  a  little  morphia,  and  by  applying  fomentations  locally,  whilst 
the  lower  bowel  is  emptied  by  an  enema.  Such  a  course  must,  how- 
ever, not  be  persisted  in  for  too  long  when  suppuration  is  likely  to 
have  occurred,  for  fear  of  the  inflammation  spreading  to  the  general 
peritoneal  cavity,  or  of  the  abscess  bursting  into  it.  An  early  explora- 
tory laparotomy  is  advisable  under  such  circumstances.  The  line  of 
treatment  marked  out  for  appendicitis  (p.  1055)  is  that  which  should 
always  be  followed. 

3.  Simple  Chronic  Peritonitis  in  itself  rarely  requires  surgical 
attention,  since  it  is  to  be  looked  on  rather  as  a  protective  than  as  a 
destructive  process.  It  is  characterized  by  infiltration  and  thickening 
of  the  peritoneum,  whereby  the  intestinal  wall  is  strengthened  and 
bacterial  invasion  hindered.  It  is  localized  or  diffuse  in  character, 
and  arises  as  the  result  of  some  pre-existing  inflammation.  In  tlfe 
more  diffuse  forms  the  intestines  may  be  hopelessly  matted  together, 
or  the  omentum  rolled  up  and  contracted  into  a  rounded  cord- like 
mass,  lying  transversely  across  the  upper  part  of  the  abdomen ; 
chronic  obstruction  is  almost  certain  to  arise  sooner  or  later  from 
this  condition. 

More  frequently  it  is  the  consequence  of  some  localized  injury 
or  inflammation.  In  the  former  plastic  lymph  is  deposited  over 
any  breach  of  continuity  of  the  serous  membrane,  and  to  this  the 
omentum  or  intestine  becomes  adherent ;  the  under  surface  of  a 
laparotomy  wound  is  not  unfrequently  affected  in  this  way.  Localized 
areas  of  inflammation  are  similarly  liable  to  originate  adhesions, 
which  are  thus  found  in  connection  with  gastric  ulcers,  an  inflamed 
vermiform  appendix,  enlarged  mesenteric  glands,  or  a  pyosalpinx. 
Under  favouring  circumstances  many  such  adhesions  are  absorbed 
in  the  early  stages ;  but  if  they  persist,  they  are  modified  by  the 
intestinal  movements,  and  are  likely  to  become  lengthened  and 
rounded,  thus  originating  the  bands  and  cord-like  structures  so  often 
the  causes  of  acute  obstruction.  The  anatomical  arrangements  of 
the  omentum  explain  why  this  structure  is  so  frequently  involved  in 
this  process,  and  thereby  it  constitutes  one  of  the  most  important 


98S  A  MANUAL  OF  SURGERY 

agents  for  checking  the  spread  of  inflammatory  affections.  Intestinal 
adhesions  often  give  rise  to  no  symptoms  ;  but  sometimes  they  deter- 
mine attacks  of  cohc  and  of  irregular  peristalsis,  and  occasionally  an 
adhesion  to  the  abdominal  wall — e.g.,  one  springing  from  the  stomach 
— causes  a  locaHzed  constant  pain  which  justifies  exploration. 

4.  Tuberculous  Peritonitis.  —  This  disease  is  almost  limited  to 
young  people,  and  is  usually  secondary  to  some  other  focus  of  tuber- 
culosis— e.g.,  in  the  intestine,  mesenteric  glands.  Fallopian  tube,  testis, 
etc.  It  is  sometimes  limited  in  its  development  to  a  portion  of  the 
peritoneal  cavity,  especially  when  originating  from  the  pelvis  or 
vermiform  appendix,  but  is  more  frequently  diffuse.  It  manifests 
itself  in  several  different  ways,  which  may  be  associated  with  or  follow 
one  another  :  (i)  In  the  ascitic  variety  the  peritoneum  becomes  thick 
and  hyperaemic,  and  is  studded  over  with  tubercles,  some  of  them 
small,  gray  and  translucent,  others  larger  and  undergoing  caseation. 
The  effusion  is  generally  abundant,  and  consists  of  straw-coloured  or 
opalescent  serum,  perhaps  blood-stained  in  the  more  active  cases. 
Flakes  of  fibrin  may  be  found  covering  the  membrane  here  and  there, 
but  there  is  no  extensive  matting  of  the  intestines.  Occasionally  the 
effusion  becomes  encapsuled,  giving  rise  to  cystic  swellings  shut  in 
between  the  coils  of  intestine.  (2)  In  the  fibrous  variety |^  the  intes- 
tines are  matted  together  by  extensive  adhesions,  and  between  them 
foci  of  tubercle  are  found.  The  mesentery  may  become  infiltrated 
and  shrink,  fixing  the  intestines  back  en  bloc  to  the  posterior  abdominal 
wall.  The  omentum  is  often  invaded,  and  contracts  upwards  to  form 
a  sausage-like  tumour  lying  transversely  above  the  umbilicus.  There 
is  but  little  effusion,  and  that  is  usually  encapsuled.  It  is  obvious 
that  such  a  condition  is  very  likely  to  lead  to  obstructive  phenomena, 
due  to  kinking  of  the  intestine.  (3)  The  ulcerous  variety  is  charac- 
terized by  an  exaggeration  of  the  above  phenomena.  Tuberculous 
foci  of  some  size  are  found  between  the  coils  of  intestine  ;  caseation 
and  suppuration  follow,  and  the  abscesses  are  likely  either  to  open 
into  the  intestine,  possibly  into  two  coils,  causing  thereby  a  fistulous 
communication  {fistula  bimucosa),  or  perhaps  to  travel  to  the  surface 
and  open  externally,  and  then  most  frequently  at  the  umbilicus, 
possibly  giving  rise  to  a  faecal  fistula. 

In  each  of  these  varieties  acute  manifestations  may  develop  at 
any  time  as  a  result  of  infection  from  the  bowel  with  the  B.  coli,  and 
then  the  symptoms  of  acute  diffuse  peritonitis  may  supervene. 

^  The  Symptoms  are  extremely  variable,  and  the  early  stages  of  the 
disease  are  sometimes  not  easy  to  recognise. 

A  few  cases  have  an  acute  onset  with  abdominal  pain  and  disten- 
sion, and  continued  pyrexia  which  may  suggest  the  existence  of 
enteric  fever.  The  abdominal  wall,  however,  is  not  rigid  ;  the  tender- 
ness is  not  great ;  there  is  well-marked  evidence  of  free  fluid,  and 
though  vomiting  and  constipation  may  be  present,  they  are  not 
marked  features.  Naturally  the  patient  in  such  a  condition  wastes 
quickly. 

In  the  more  chronic  forms  the  earliest  symptoms  are  weakness  with 


ABDOMINAL  SURGERY  989 

some  slight  abdominal  discomfort,  and  not  uncommonly  diarrhoea, 
alternating,  perhaps,  with  constipation.  The  temperature  becomes 
of  a  hectic  type,  and  periods  of  improvement  may  alternate  with 
attacks  of  increasing  pain  and  weakness.  On  the  whole,  the  patient 
gradually  gets  worse,  his  wasted  frame  comparing  markedly  with  the 
protuberant  and  enlarged  belly.  The  phenomena  discoverable  on 
abdominal  palpation  vary  considerably  with  the  conditions  present 
within. 

Treatment  in  the  early  stages,  and  especially  in  the  acute  variety, 
is  often  successfully  undertaken  by  the  physician.  Hygienic 
measures  are  adopted,  the  patient  living  in  the  fresh  air,  and,  of 
course,  being  always  in  the  recumbent  position.  Plenty  of  good 
digestible  food  is  given,  as  also  cod-liver  oil  and  perhaps  intestinal 
antiseptics,  such  as  salol,  creasote,  etc.  The  external  application  t(3 
the  abdomen  of  iodine,  either  as  a  paint  or  an  ointment,  is  much  com- 
mended by  some  physicians,  whilst  Scott's  dressing  is  relied  on  by 
others.  Tuberculin  injections  may  also  be  of  value.  Should  the 
condition  undergo  no  improvement,  it  may  be  justifiable  to  operate. 
When  chronic  ascitic  accumulation  is  present,  all  that  is  needed  is  to 
remove  the  fluid  by  tapping  or  laparotomy  ;  in  the  latter  case  irrigation 
is  not  required,  and  the  wound  should  be  closed  completely  ;  in  nearly 
75  per  cent,  of  the  cases  a  cure  may  be  anticipated.  Possibly  it  may 
be  well  to  ascertain  first  the  condition  of  the  opsonic  index,  and,  if 
need  be,  to  raise  it  by  injections  of  tuberculin.  In  the  acute  forms 
tuberculous  infection  of  the  wound  usually  follows  the  escape  of 
the  highly  infective  fluid  from  the  peritoneal  cavity,  and  healing  may 
be  thereby  delayed  ;  hence  it  is  undesirable  to  operate  in  such  cases. 
Where  diffuse  or  localized  suppuration  is  present,  adhesions  which 
can  be  reached  may  be  gently  broken  down,  and  exit  given  to  the 
pus ;  but  no  prolonged  search  after  suppurating  foci  should  be 
made,  or  the  intestine  may  be  torn.  The  results  of  treatment  in  this 
variety  are  not  nearly  as  satisfactory  as  in  the  former,  at  least  40  per 
cent,  of  the  cases  dying.  As  to  the  way  in  which  cure  is  established, 
two  factors  probably  co-operate  :  (i)  the  removal  of  the  exudation  and 
its  contained  toxins  ;  and  (2)  a  flushing  of  the  intra-abdominal  tissues 
with  blood  plasma  (a  well-ascertained  fact  after  laparotomy)  and 
the  effect  of  the  antibodies  contained  therein,  the  tubercles  thereby 
having  their  vitality  destroyed.  In  this  connection  one  may  note 
the  statement  that  too  early  a  laparotomy  does  but  little  good,  an 
insufficient  amount  of  antibody  having  presumably  developed  in  the 
system. 

Pneumococcal  Peritonitis  is  in  the  majority  of  cases  secondary  to  a  similar 
infection  of  the  lungs  or  pleura,  the  organisms  being  transmitted  by  the  blood  or 
through  the  lymphatics  of  the  diaphragm  ;  less  frequently  the  primary  focus  is  in 
the  pharynx  or  middle  ear.  Occasionally  the  trouble  is  apparently  primary,  the 
pneumococci  finding  their  way  through  a  healthy  mucous  membrane,  as  from  the 
bowel  or  appendix,  or  more  directly  by  the  Fallopian  tube.  The  disease  is 
specially  common  in  female  children,  and  usually  sets  in  acutely.  In  some  cases 
the  trouble  quickly  becomes  circumscribed,  and  a  chronic  encapsuled  abscess 
results  ;  in  other  cases  the  course  is  acute,  and  the  symptoms  are  persistent  and 
more  violent.    In  the  former,  pain  and  vomiting  are  moderately  severe  in  the  early 


990  A  MANUAL  OF  SURGERY 

stages,  but  diarrhoea  is  often  present,  and  pyrexia  is  moderate.  Pus  is  likely  to 
accumulate  slowly,  and  without  marked  pain  and  discomfort ;  at  first  it  occupies 
the  lower  part  of  the  abdomen,  but  gradually  encroaches  on  the  whole  cavity, 
and  typical  dulness  may  be  noted,  whilst  the  patient  wastes  rapidly.  In  some 
cases  the  pus  has  pointed  at  the  umbilicus,  and  a  spontaneous  cure  has  followed 
its  discharge.  In  the  more  acute  cases  the  course  is  very  similar  to  the  diffuse 
pyococcal  type  described  above ;  prostration  is  generally  rapid,  and  death  early ; 
the  only  distinguishing  feature  is  the  existence  of  diarrhoea  in  some  cases.  The 
pus  is  usually  like  that  in  a  pneumococcal  empyema  (p.  935),  with  abundance  of 
false  membrane,  but  in  other  cases  it  is  of  the  ordinary  type  ;  pneumococci  can 
easily  be  found  in  it.  A  blood  count  will  show  a  well-marked  leucocytosis, 
which  is  usually  absent  in  the  worst  forms  of  pyococcal  peritonitis.  Treatment 
consists  in  laparotomy  and  drainage  in  the  more  acute  varieties,  but  in  the 
milder  the  patient  must  be  carefully  watched  for  localizing  phenomena. 

Gonorrhoeal  Peritonitis  almost  always  occurs  in  women  as  a  direct  extension  of 
a  gonococcal  inflammation  upwards  from  the  uterus,  being  preceded  or  accom- 
panied by  the  phenomena  of  salpingitis  or  ovaritis  ;  it  has,  however,  been 
known  to  develop  in  men.  There  is  usually  a  definite  history  of  gonorrhoea  with 
a  more  or  less  abundant  discharge,  but  the  attack  generally  follows  a  menstrual 
period,  or  the  manipulation  of  the  tubes  and  ovaries.  The  onset  is  sudden  and 
acute,  the  patient  complaining  of  severe  pelvic  pain,  which  is  accompanied  by 
vomiting,  abdominal  distension,  and  fever.  A  swelling  may  be  felt  above  the 
brim  of  the  pelvis.  Under  suitable  treatment  the  trouble  often  abates  rapidly, 
and  the  patient  recovers ;  but  adhesions  are  likely  to  be  left,  determining 
sterility,  or  the  tubes  may  remain  full  of  pus  (pyosalpinx).  In  other  cases 
exudation  is  abundant,  though  there  is  a  tendency  to  limitation  of  the  trouble, 
and  the  prognosis  is  generally  favourable.  Treatment  consists  in  absolute  rest, 
fomentations  to  the  abdomen,  hot  vaginal  douches,  and  suitable  limitation  of 
diet.  If  rapid  improvement  does  not  follow,  a  median  laparotomy  should  be 
undertaken  in  order  to  let  out  the  pus  and  permit  of  suitable  drainage.  The 
tubes  and  ovaries  should  always  be  explored  in  such  cases,  and  may  perhaps  need 
to  be  removed. 

Subphrenic  Abscess  is  the  term  applied  to  a  suppurating  focus  which 
is  in  more  or  less  intimate  relation  with  the  under  surface  of  the  dia- 
phragm. Two  main  varieties  are  described,  viz.,  the  intraperitoneal, 
which  is  much  the  more  common,  and  the  retro-  or  extra-peritoneal. 
The  former  are  not  unfrequently  subhepatic  as  well  as  subdiaphragmatic. 

The  causes  are  very  diverse,  and  the  manifestations  vary  some- 
what with  the  causative  lesion,  i.  The  stomach  is  the  most  frequent 
source  of  the  trouble,  the  infection  being  due  to  the  extension  of 
a  chronic  ulcer.  If  the  anterior  wall  is  involved,  the  pus  will 
be  limited  by  the  lesser  omentum  and  stomach  behind,  by  the 
diaphragm  and  left  lobe  of  the  liver  above,  by  the  falciform  ligament 
on  the  right,  and  by  adhesions  between  the  stomach  or  omentum  and 
anterior  abdominal  wall  below  (Fig.  445).  This  type  of  abscess 
usually  points  to  the  left  of  the  ensiform  appendix.  Should  the  ulcer 
be  situated  on  the  anterior  wall  near  to  the  fundus,  the  abscess  may 
get  into  close  relationship  with  the  spleen,  and  point  beneath  the  left 
costal  margin.  When  the  abscess  arises  in  relation  with  the  posterioy 
wall,  the  lesser  sac  of  the  peritoneum  may  be  filled  with  pus,  which 
is  prevented  from  escaping  from  the  foramen  of  Winslow  by 
adhesions,  whilst  the  stomach  itself  is  pushed  forwards,  and  the  pus 
travels  up  and  presents  above  it  to  the  left  of  the  middle  line.  More 
often  the  lesser  sac  has  been  previously  obliterated,  and  the  abscess 
develops  in  the  retroperitoneal   tissues.     2.  Ulcer  of  the  duodenum 


ABDOMINAL  SURGERY 


991 


may  give  rise  to  very  similar  conditions.  If  the  ulcer  is  in  the  first 
or  second  part,  an  intraperitoneal  abscess  is  likely  Lo  form,  bounded 
by  the  liver,  colon,  omentum,  and  anterior  abdominal  wall ;  occa- 
sionally the  pus  also  tracks  up  behind  the  liver.  When  retroperi- 
toneal suppuration  occurs  in  connection  with  the  duodenum,  the 
pus  travels  up  between  the  liver  and  diaphragm,  or  downwards 
towards  the  loin.  3.  The  appendix  vevmifovmis  is  also  a  cause  of 
subphrenic  abscess,  the  pus  burrowing  behind  the  peritoneum, 
or  finding  its  way  along  the  inner  or  outer  walls  of  the  ascend- 
ing colon.  4.  It  may  be  caused  by  extension  of  suppuration  from 
the  liver,  colon,  intestine,  or  from  retroperitoneal  structures,  such 
as  the  kidney,  ribs,  or  vertebrae.  According  to  Fenwick,  however, 
80  per  cent,  of  all  cases  of  subphrenic  abscess  are  due  to  ulceration 
of  the  stomach  or  duodenum. 


Fig.   445. — Diagram  of  Subphrenic  and  Subhepatic  Abscess,  due  to  Exten- 
sion FROM  AN  Ulcer  of  the  Anterior  Wall  of  the  Stomach. 

S,  Stomach  ;  C,  colon  ;  I,  small  intestine  ;  L,  liver ;  GO,  great  omentum ; 
SO,  small  omentum;  LPS,  lesser  peritoneal  sac;  P,  pancreas;  D,  duo- 
denum. 

The  abscess  thus  induced  may  contain  pus  alone  or,  in  addition, 
gas,  which  is  derived  either  from  a  direct  communication  with  the 
bowel,  or  from  the  activity  of  the  B.  coli  without  any  definite  opening 
being  present.  It  was  to  this  condition  that  Leyden  originally  gave 
the  name  of  siihphrenic  pyo-pneumothorax .  The  extension  of  the  abscess 
along  the  under  surface  of  the  diaphragm  often  leads  to  that  structure 
being  displaced  considerably  upwards,  and  to  a  secondary  infection  of 
the  pleura,  either  by  lymphatic  absorption  and  extension,  or  by  an 
actual  solution  of  continuity.     The  effect  is  an  effusion  of  serum  or 


992  A  MANUAL  OF  SURGERY 

pus  into  the  base  of  the  pleural  cavity,  the  latter  constituting  a  basal 
empyema.* 

The  Symptoms  vary  considerably.  They  may  be  preceded  by  those 
referable  to  the  causative  lesion,  and  their  onset  may  be  sudden  ,or 
gradual.  Ordinary  febrile  phenomena,  and  perhaps  one  or  more 
rigors,  may  occur,  whilst  the  patient  complains  of  pain  in  the  upper 
part  of  the  abdomen,  together  with  vomiting  and  constipation.  The 
pain  is  often  increased  on  respiratory  movements,  and  may  extend 
upwards  to  the  shoulder.  On  palpation,  the  abdominal  muscles  on 
one  or  other  side  are  held  rigidly  contracted,  but  possibly  a  swelling, 
either  dull  or  tympanitic  according  to  its  contents,  may  be  noted. 
There  may  be  some  bulging  of  the  intercostal  spaces.  On  the  right 
side  the  diaphragm  may  be  pushed  up,  and  the  liver  dowmwards ;  and 
if  the  abscess  contains  gas,  an  area  of  tj^mpanitic  resonance  may  be 
noted  between  the  dulness  of  the  liver  and  the  resonance  of  the 
lung.  On  the  left  side  the  heart  may  be  pushed  upwards  together 
with  the  diaphragm,  and  the  absence  of  lateral  displacement  of  the 
heart  is  an  important  diagnostic  feature  from  a  pure  empyema  or 
pneumothorax.  The  X  rays  will  sometimes  be  useful  in  recognising 
displacement  upwards  of  the  diaphragm,  and  immobility  of  the 
affected  half.  A  blood  count  is  important  in  indicating  the  existence 
of  suppuration. 

The  Treatment  consists  in  opening  and  draining  the  abscess 
whereA'er  it  is  most  accessible.  In  many  cases  this  can  be  effected 
through  the  anterior  abdominal  wall  along  the  lower  margin  of 
the  ribs,  but  even  then  a  counter-opening  is  often  needed.  When 
the  abscess  does  not  project  anteriorly,  the  best  situation  for  an 
opening  is  through  the  pleural  cavit}^  as  for  some  abscesses  of  the 
liver.  The  incision  lies  behind  the  mid-axillary  line,  a  portion  of  the 
eighth  or  ninth  rib  being  excised.  If,  as  often  happens,  there  is  also 
an  empyema,  this  is  drained,  and  then  an  additional  opening  can 
be  made  through  the  diaphragm  if  one  does  not  already  exist ;  if, 
however,  the  pleural  cavity  is  not  affected,  the  serous  membrane 
covering  the  upper  surface  of  the  diaphragm  must  be  stitched  to  the 
parietal  pleura  before  the  diaphragm  is  incised. 

Ascites. — By  this  term  is  meant  an  accumulation  of  fluid,  and  that 
usually  of  a  serous  type,  w-ithin  the  peritoneal  cavity.  It  results 
chiefly  from  lesions  which  fall  to  the  care  of  the  physician — viz., 
cirrhosis  of  the  liver,  chronic  Bright's  disease,  and  various  cardiac 
affections.  It  is  also  a  consequence  of  any  obstructive  pressure  oa 
the  portal  vein,  as  by  malignant  glands  in  the  portal  fissure  secondary 
to  carcinoma  of  the  stomach  or  of  the  intestine,  or  by  fibrous 
adhesions,  the  consequence  of  duodenal  ulceration  or  stones  in  the 
gall-bladder.  Fluid  also  collects  in  the  abdomen  as  the  result  of 
diffuse  malignant  deposits  scattered  over  the  peritoneum,  or  from 
the  presence  of   mildly  irritative  foci,  such  as  hydatid  cysts,   etc. 

*  For  a  complete  and  masterly  study  of  subphrenic  abscess,  by  the  late 
Mr.  Harold  L.  Barnard,  see  British  Medical  Journal,  February  15  and  22,  1908. 


ABDOMINAL  SURGERY  593 

Chylous  ascites  is  a  condition  in  which  the  fluid  is  milky  from  an 
admixture  of  chyle,  and  usually  results  from  rupture  of  the  recepta- 
culum  chyli  in  consequence  of  the  pressure  on  the  thoracic  duct 
above  it  of  malignant  glands  secondary  to  cancer  of  the  stomach. 
Encysted  ascites  results  from  the  distension  of  a  portion  of  the  cavity 
which  has  been  shut  off  by  inflammatory  adhesions. 

The  Physical  Conditions  resulting  from  ascites  are  easy  of  recog- 
nition. The  abdomen  is  distended,  like  a  barrel,  but  with  bulging 
flanks.  Dulness  is  present  in  the  loins  when  the  patient  is  recumbent, 
and  extends  forwards  to  about  the  same  level  all  round,  the  only 
resonant  area  being  about  the  umbilicus;  this  is  due  to  the  floating 
forward  of  the  intestines.  On  rolling  the  patient  over  to  one  side, 
the  dull  and  resonant  areas  shift,  the  part  that  is  highest  becoming 
resonant.  This  sign  is  occasionally  absent  if  the  mesentery  is  short 
or  if  the  intestines  are  tied  down  posteriorly.  On  tapping  the  abdomen, 
a  well-marked  thrill  is  usually  transmitted  from  one  side  to  the  other. 
Necessarily,  the  fluid  also  finds  its  way  into  any  diverticula  of  the 
peritoneum,  such  as  an  unclosed  funicular  process  or  a  hernial  sac. 
The  diagnosis  of  ascites  should  not  be  difficult,  but  the  practitioner 
must  not  be  satisfied  until  he  has  discovered  the  cause,  and  this 
may  not  be  easy  even  when  the  fluid  has  been  removed,  so  that 
the  abdominal  viscera  become  palpable. 

Treatment  necessarily  varies  with  the  cause  of  the  accumulation. 
Should  it  persist,  and  the  patient's  breathing  be  hampered  by  the 
abdominal  distension,  removal  by  paracentesis  is  essential.  The  usual 
plan  adopted  is  to  seat  the  patient  on  a  chair  and  to  encircle  the 
abdomen  with  a  flannel  binder,  the  ends  of  which  are  split  to  within 
6  inches  of  the  middle  line.  The  unslit  portion  is  placed  over  the 
abdominal  wall  in  front,  whilst  the  divided  portions  cross  behind,  and 
are  held  by  assistants,  so  as  to  make  continuous  pressure  upon  the 
abdominal  contents.  The  bladder  is  completely  emptied,  and  then 
the  abdomen  is  carefully  percussed,  and  a  spot  of  absolute  dulness 
selected ;  here  a  small  incision  is  made  with  a  scalpel  after  careful 
purification  of  the  skin,  and  a  suitable  trocar  and  cannula  inserted. 
The  median  line  below  the  umbilicus  is  the  place  usually  chosen  for 
the  puncture,  but  there  is  no  objection  to  inserting  the  trocar  through 
the  flanks.  Some  surgeons  prefer  to  withdraw  the  fluid  more  slowly, 
so  as  to  prevent  the  shock  often  experienced  from  its  rapid  removal. 
Two  or  three  Southey's  trocars  and  cannulse  may  then  be  inserted. 

Not  unfrequently  the  fluid  re-accumulates,  and  the  process  has  to 
be  repeated  after  a  time.  When  the  cause  of  the  collection  is 
doubtful,  the  practitioner  will  take  the  opportunity  offered  by  the  lax 
abdominal  wall  to  palpate  the  viscera  ;  light  may  also  be  thrown  on 
an  obscure  case  by  a  cytological  examination  of  the  fluid.  In  malig- 
nant disease,  cancer  cells  and  blood  may  often  be  found.  If  the 
cause  is  still  uncertain,  an  exploratory  laparotomy  may  be  advisable. 

In  cases  due  to  hepatic  cirrhosis.  Talma's  operation  of  Epiplopexy 
may  possibly  be  of  some  use.  The  object  is  to  relieve  the  obstruction 
to  the  portal  system  by  opening  up  fresh  communications  between  it 

63 


994  A  MANUAL  OF  SURGERY 

and  the  systemic  veins.  The  method  consists  in  fixing  the  great 
omentum  to  the  abdominal  wall  and  determining  the  formation  of 
adhesions  ;  necessarily  the  peritoneum  has  to  be  drained  and  kept 
dry  during  this  procedure,  and  the  question  arises  as  to  whether  this 
drainage  is  not  the  cause  of  the  improvement.  The  mortality  is  not 
inconsiderable,  especially  when  the  liver  is  small ;  the  best  results 
have  been  gained  with  hypertrophic  cirrhosis.  The  method  is  still 
on  its  trial,  but  appears  to  be  justifiable  in  suitable  cases. 

Affections  of  the  Great  Omentum. 

The  omentum  is  of  great  surgical  importance  in  the  abdomen,  in 
that  it  covers  in  and  protects  the  viscera,  and  by  its  mobility  is  able 
to  apply  itself  to  many  a  weak  spot  where  perforation  or  infection 
might  occur,  and  thereby  guard  the  patient  from  serious  inflam- 
matory mischief.  The  result  of  this  process  is,  hoAvever,  the 
formation  of  adhesions  which  by  the  irritation  of  constant  movement 
may  stretch  and  become  rounded  and  cord-like,  and  various  forms  of 
intestinal  obstruction  (by  strangulation,  kinking,  etc.)  may  result  there- 
from. The  value  of  this  protective  power  of  the  omentum  is  recognised 
by  surgeons  in  the  employment  of  omental  grafts  to  add  security  to 
a  line  of  junction  in  the  intestinal  wall  with  which  they  are  not  quite 
satisfied.  It  is  only  occasionally  that  such  a  provision  is  required. 
The  best  method  to  adopt  is  to  detach  the  graft  entirely  from  its 
former  connections,  wrap  it  round  the  gut,  and  stitch  it  in  place. 

The  omentum  may  be  torn,  and  holes  may  be  formed  in  it  as  a 
result  of  injury.  The  immediate  symptoms  would  be  pain,  shock,  and 
the  phenomena  of  intraperitoneal  haemorrhage  ;  but  it  is  likely  that 
other  injuries  co-exist.  At  a  later  date  the  hole  might  be  the  site  of 
an  attack  of  internal  strangulation. 

Acute  Inflammation  (epiploitis)  has  been  lighted  up  as  a  result  of 
the  application  to  the  omentum  in  a  hernia  operation  of  a  septic  liga- 
ture. The  phenomena  vary  with  the  virulence  of  the  organisms,  an 
acute  diffuse  peritonitis  perhaps  resulting.  In  the  milder  forms  a 
localized  inflammatory  disturbance  follows,  with  all  the  phenomena 
of  a  limited  peritonitis  ;  suppuration  may  ensue,  and  a  large  intra- 
peritoneal collection  of  pus  may  result. 

Torsion  of  the  omentum  is  an  occasional  complication  of  an  irre- 
ducible hernia,  and  that  usually  on  the  right  side.  The  lesion  generally 
follows  some  heavy  strain,  and  results  in  venous  stasis,  effusion  of  a 
blood-stained  fluid,  the  formation  of  extensive  adhesions,  and  possibly 
gangrene  and  general  peritonitis,  if  left  long  enough.  The  symptoms 
often  start  abruptly  with  colicky  pain  in  the  right  iliac  fossa  and 
scrotum,  together  with  constipation  and  sickness  ;  the  hernial  swelling 
becomes  enlarged,  and  extending  upwards  from  the  iliac  region  a 
sensitive  mass  may  be  detected  on  palpation,  which  is  dull  on  per- 
cussion, and  sometimes  reaches  to  the  epigastrium.  The  tempera- 
ture is  normal,  though  the  pulse-rate  is  accelerated.  Treatment  is 
obviously  operative,  and  consists  in  removal  of  the  omentum. 

Chronic  peritonitis,  whether  simple  or  tuberculous,  may  cause  the 


ABDOMINAL  SURGERY-  995 

omentum  to  be  rolled  up  into  a  more  or  less  solid  mass,  which  lies 
transversely  across  the  abdomen  a  little  above  the  umbilicus.  There 
is  usually  a  band  of  clear  resonance  between  it  and  the  hepatic 
dulness,  which  is  of  great  diagnostic  importance. 

The  omentum  also  becomes  infiltrated  with  secondary  cancerous 
nodules,  which  can  sometimes  be  palpated,  and  their  presence 
gives  important  indications  as  to  the  desirability  or  not  of  operative 
treatment.  Colloid  degeneration  is  not  uncommon  in  omental  cancers, 
and  huge  masses  of  this  growth  have  been  sometimes  discovered  in 
the  dead-house.  Omental  carcinoma  usually  leads  to  a  considerable 
effusion  of  fluid  into  the  peritoneal  sac. 

Affections  of  tlie  Mesentery. 

Wounds  result  from  penetrating  or  non-penetrating  injuries.  They 
are  usually  associated  with  laceration  of  the  intestine,  and  the  result- 
ing phenomena  will  be  those  of  haemorrhage,  followed  by  general 
peritonitis  from  the  intestinal  lesion.  Pure  mesenteric  wounds  not 
involving  the  bowel  are  generally  due  to  penetrating  or  gunshot 
injuries.  Haemorrhage  to  a  varying  degree  may  result,  and  if  the 
patient  lives,  the  nutrition  of  the  intestine  may  be  seriously  endangered. 
If  such  a  lesion  is  found  on  exploration,  bleeding  points  must  be 
secured  and  the  opening  in  the  mesentery  closed ;  before  this  is 
accomplished,  however,  careful  consideration  must  be  given  to  the 
vascular  supply  of  the  intestine,  as  the  ligature  of  a  main  branch  of  a 
mesenteric  artery  may  determine  gangrene,  and  necessitate  resection 
of  a  portion  of  the  bowel. 

Thrombosis  of  the  Mesenteric  Vessels,  apart  from  strangulation  or 
volvulus,  is  usually  the  result  of  embolic  obstruction  of  the  artery,  but 
may  sometimes  commence  in  the  veins,  spreading  down  from  the 
liver,  or  originating  in  some  intestinal  ulcer.  The  process  is  associ- 
ated with  acute  pain,  and  is  followed  by  the  symptoms  of  acute 
obstruction.  The  bowel  becomes  engorged  with  venous  blood,  and 
dies  ;  it  is  often  occupied  by  a  blood-stained  effusion,  and  the  passage 
of  dark  tarry  stools  may  be  noted.  The  peritoneal  cavity  contains 
a  quantity  of  blood-stained  serum,  which  after  a  time  becomes  offen- 
sive. A  diagnosis  is  rarely  reached  apart  from  operation  for  the  ob- 
structive phenomena,  and  the  only  hope  for  the  patient  is  removal  of  the 
gangrenous  bowel  (if  that  be  possible),  and  a  temporary  enterostomy. 
Should  the  patient  live,  a  very  doubtful  contingency,  the  continuity 
of  the  gut  may  be  subsequently  restored. 

The  Mesenteric  Glands  frequently  become  inflamed  in  consequence 
of  some  intestinal  lesion — e.g.,  typhoid  ulceration.  No  special  notice  is 
taken  of  this  occurrence,  unless  suppuration  ensues,  when  the  abscess 
must  be  opened.  In  less  severe  cases,  however,  it  is  often  asso- 
ciated with  a  patch  of  localized  peritonitis,  resulting  in  the  deposit  of 
plastic  lymph  ;  to  this  some  other  viscus — e.g.,  the  free  end  of  the 
omentum,  the  fimbriated  extremity  of  the  Fallopian  tube,  the  vermi- 
form appendix,  one  of  the  appendices  epiploic^,  etc. — may  become 
adherent,  and  an  adhesion  may  develop  which  subsequently  leads  to 


996  A  MANUAL  OF  SURGERY 

intestinal  obstruction.  As  a  matter  of  fact,  the  great  majority  of 
intra-abdominal  bands  are  connected  at  one  end  with  the  mesentery. 

Tuberculous  Disease  of  the  mesenteric  glands  is  a  common  afi^ction 
in  children,  constituting  a  condition  known  as  tabes  mesenferica.  It  is 
probably  secondary  to  intestinal  lesions,  and  when  widely  diffused 
through  the  mesentery  is,  of  course,  to  be  dealt  with  only  by  hygienic 
and  medical  measures.  The  results  of  such  treatment  are  frequently 
very  satisfactory,  but  after-effects  may  be  left.  Sometimes  the  glands 
undergo  calcification,  and  these  may  lead  to  a  mistaken  diagnosis  if 
a  patient  is  examined  radiographically  for  supposed  ureteral  calculus. 
At  other  times  the  caseated  glands  may  Hquefy  and  give  rise  to  an 
inflammatory  attack  that  may  be  mistaken  for  appendicitis,  if  the 
mesentery  of  the  lower  end  of  the  ileum  is  involved.  Limited  masses 
in  the  iliac  fossa  may  sometimes  be  amenable  to  surgical  measures, 
and  be  removed ;  whilst  occasionally  the  surgeon  has  to  deal  with  a 
gland  which  has  suppurated,  and  requires  to  be  opened  with  the 
same  precautions  as  one  would  take  in  dealing  with  an  appendix 
abscess.  Finally,  tuberculous  peritonitis  may  originate  in  this 
condition. 

Cysts  of  the  mesentery  are  not  common,  and,  as  might  be  expected, 
they  are  usually  of  lymphatic  origin  ;  they  may  be  single,  containing 
either  lymph  or  chyle,  or  multiple,  then  constituting  a  cavernous 
lymphangioma.  Blood  cysts  have  also  been  known,  and  also  der- 
moids, which  are  usually  located  in  the  mesentery  of  the  ileum.  A 
rounded,  tense  intra-abdominal  swelHng  gradually  develops  behind  or 
below  the  umbilicus  ;  it  is  freely  moveable  from  side  to  side,  and  is 
usually  accompanied  by  some  derangement  of  intestinal  movement 
or  function.  When  of  large  size,  the  swelling  is  dull,  but  is  often 
crossed  by  the  affected  loop  of  bowel ;  it  may  possibly  be  mistaken 
either  for  an  ovarian  or  a  pancreatic  cyst.  The  diagnosis  is  usually 
made  on  the  operating -table,  and  the  treatment  consists  in  enu- 
cleation or  drainage,  with  or  without  removal  of  the  affected  coil 
of  intestine. 

Tumours  form  occasionally  in  the  root  of  the  mesentery  and  behind 
it,  constituting  the  retroperitoneal  lipoma  or  sarcoma.  The  former 
may  grow  to  a  large  size,  and  destroy  life  by  its  pressure  phenomena  ; 
the  latter,  though  sometimes  resembling  the  former  in  structure, 
invades  surrounding  tissues  earlier.  The  diagnosis  is  uncertain  until 
the  abdomen  is  opened,  and  the  question  of  removal  is  dependent  on 
the  relation  of  the  growth  to  the  mesenteric  vessels,  which  must  not  be 
injured.    It  is  seldom  that  a  retroperitoneal  sarcoma  can  be  enucleated. 

Affections  of  the  Stomacli. 

The  cardiac  orifice  lies  about  4  inches  behind  the  junction  of  the  seventh 
costal  cartilage  with  the  sternum ;  the  highest  part  of  the  fundus  reaches  the 
fifth  left  rib  in  the  mammary  line  ;  the  pylorus  when  the  stomach  is  empty  is  in 
the  middle  line  midway  between  the  suprasternal  notch  and  the  symphysis  pubis 
(Addison's  transpyloric  plane).  When  the  stomach  is  full,  the  pylorus  passes 
more  or  less  to  the  right  of  the  middle  line  and  descends  slightly.  The  lower 
border  can  usually  be  defined  with  tolerable  accuracy  by  auscultatory  percussion ; 


ABDOMINAL  SURGERY  997 

this  is  performed  by  applying  a  stethoscope  over  the  centre  of  the  stomach  area 
and  percussing  outwards  over  the  margin  ;  a  change  in  note  is  readily  recognised 
on  reaching  the  border  of  the  stomach. 

When  pathologically  dilated,  the  stomach  becomes  enlarged  downwards,  the 
pylorus  and  lesser  curvature  being  retained  more  or  less  in  position  by  the 
gastro-hepatic  omentum,  so  that  the  organ  pouches  down  towards  the  pelvis  and 
becomes  an  elongated  sac  in  which  fluids  accumulate  and  decompose  and  gas 
collects.  Peristaltic  waves  can  often  be  seen  crossing  the  viscus,  and  on  succus- 
sion  or  tapping  the  organ  with  the  finger-tips,  gurgling  and  splashing  sounds  are 
heard.  The  stomach  can  be  inflated  and  its  exact  size  and  shape  thereby  deter- 
mined more  accurately  either  by  passing  an  oesophageal  tube  and  injecting  air 
with  a  bicycle  pump,  or  by  the  administration  of  effervescent  solutions,  such  as 
tartaric  acid  and  bicarbonate  of  soda  (10  to  20  grs.  of  each),  or  of  the  component 
parts  of  a  Seidlitz-powder  separately  dissolved  in  water. 

Radiography  has  also  proved  of  service  in  demonstrating  the  activity  and 
shape  of  the  stomach  after  the  administration  of  a  bismuth  meal,  which  consists 
of  a  mixture  of  i  or  2  ounces  of  bismuth  subnitrate  in  gruel  or  bread  and 
milk.  X-ray  photographs  or  screen  examinations  are  then  made  at  intervals  so 
that  the  changes  in  shape  of  the  stomach  as  indicated  by  the  shadow  cast  by  the 
bismuth  can  be  ascertained.  Similarly  a  flexible  bougie  filled  with  bismuth  sub- 
nitrate  may  be  introduced  into  the  stomach,  and  the  position  and  shape  of  the 
greater  curvature  be  demonstrated  by  the  radiographic  screen.  Direct  visual 
examination  of  the  gastric  cavity  is  also  possible  (gastroscopy). 

Much  may  be  learnt  of  the  functions  of  the  stomach  by  a  careful  examination 
of  its  contents  and  secretions.  This  is  best  accomplished  by  administering  a  test 
meal  consisting  of  a  piece  of  toast,  or  a  rusk  and  a  cup  of  tea  without  milk,  on  a 
fasting  stomach.  This  is  withdrawn  in  one  or  one  and  a  half  hours  by  a  stomach 
pump  or  oesophageal  tube,  and  the  fluid  thus  obtained  is  examined  as  follows  : 

(a)  Chemically — to  ascertain  the  amount  of  total  acidity,  the  amount  of  free 
hydrochloric  acid,  and  the  presence  or  not  of  lactic  acid. 

(b)  Microscopically — for  the  presence  of  yeasts,  sarcinas,  or  bacteria,  especially 
the  long  non-motile  Oppler-Boas  bacilli ;  shreds  of  tumour,  pus  cells,  or  blood, 
may  also  be  found.  The  healthy  stomach  is  practically  free  from  organisms,  as 
those  swallowed  with  the  food  soon  disappear.  Not  unfrequently,  however,  they 
are  found  in  the  empty  stomach  of  those  suffering  from  pyorrhoea  alveolaris,  and 
are  then  likely  to  be  of  the  same  character  as  those  around  the  teeth. 

The  following  are  suggestive  samples  of  the  results  obtained  by  test  meals  : 

1.  In  the  normal  stomach  the  amount  of  fluid  withdrawn  is  about  2  to  4  ounces. 
It  contains  no  undigested  food.  Free  hydrochloric  acid  is  about  15  to  2'o  per 
cent.     No  lactic  acid  or  organisms  are  found. 

2.  In  gastric  ulcer  the  amount  withdrawn  is  normal  in  quantity  or  decreased. 
Digestion  is  complete.  Free  hydrochloric  acid  is  increased  (hyperchlorhydria) — 
2-5  to  3-0  per  cent.  No  lactic  acid,  organisms,  or  growth  found.  Blood  may  be 
present. 

3.  In  atony  of  the  stomach  the  amount  withdrawn  is  increased  (6  to  8  ounces) 
and  digestion  is  imperfect.  Free  hydrochloric  acid  is  decreased  or  absent 
(hypochlorhydria) — o'5,  i 'o,  or  o"o  per  cent.  Traces  of  lactic  or  butyric  acid 
present.     Yeasts  and  sarcinse  present. 

4.  In  carcinoma  of  the  fundus  the  amount  withdrawn  is  normal  or  increased 
3  to  5  ounces.  Hydrochloric  acid  is  absent,  but  lactic  acid  exists  (o'2  to 
o'5  per  cent.).  Oppler-Boas  bacilli  may  be  present,  and  fragments  of  growth  or 
blood  may  be  found. 

Rupture  of  the  Stomach  results  from  blows  or  falls  upon  the  epi- 
gastrium, especially  after  a  heavy  meal,  and  then  usually  involves 
the  pyloric  end  or  the  greater  curvature  near  the  cardiac  orifice.  It 
may  also  follow  a  penetrating  injury,  such  as  a  stab  or  a  fall  upon  a 
spike  or  railings.  Neighbouring  viscera  are  not  unfrequently  in- 
volved in  the  lesion,  especially  the  liver  or  spleen. 

The  Symptoms  are  those  of  severe  and  prolonged  shock,  with  epi- 


998  A  MANUAL  OF  SURGERY 

gastric  pain  and  vomiting,  the  ejected  material  sometimes  containing 
blood  ;  acute  septic  peritonitis  usually  ensues  in  a  very  short  time, 
causing  rapid  collapse  and  death.  Occasionally,  when  the  wound  is 
small,  or  the  organ  empty  at  the  time  of  the  accident,  there  is 
little  or  no  extravasation,  and  then  a  localized  intraperitoneal  abscess 
may  form,  shut  off  from  the  general  peritoneal  cavity  by  adhesions, 
and  sooner  or  later  bursting  and  discharging  into  the  stomach,  colon, 
or  one  of  the  hollow  viscera,  or  else  coming  to  the  surface  and  burst- 
ing externally  ;  sometimes  the  barrier  of  adhesions  gives  way,  and 
a  late  general  peritonitis  results.  If  the  posterior  wall  of  the  stomach 
is  alone  injured,  the  resulting  phenomena  are  very  similar  to  those 
due  to  the  perforation  of  an  ulcer  in  this  region  (g.v.). 

Treatment. — No  time  must  be  lost  in  undertaking  a  laparo- 
tomy when  the  diagnosis  is  tolerably  certain,  since  the  only  hope 
of  saving  the  patient's  life  lies  in  early  interference.  A  median 
incision  is  made  above  the  umbilicus,  the  situation  of  the  injury  in 
the  stomach  ascertained,  and  the  aperture  closed  by  a  double  row  of 
sutures  (Czerny-Lembert),  which  infold  the  margins,  and  extend  a 
little  beyond  the  lesion  at  either  end  (Figs.  439  and  441).  All  extra- 
vasated  material  should  be  carefully  sponged  or  swabbed  away,  and 
if  the  general  cavity  has  not  yet  become  inflamed,  irrigation  should 
be  avoided  for  fear  of  carrying  infective  material  to  other  regions.  If 
the  posterior  wall  is  also  injured,  as  by  a  bullet  wound,  an  opening 
should  be  made  through  the  omentum  so  as  to  explore  and  cleanse 
the  lesser  sac  of  the  peritoneum.  If  the  case  has  been  operated  on 
early  and  there  is  bat  little  peritoneal  inflammation,  it  may  be 
possible  to  close  the  parietal  wound  entirely  ;  but,  as  a  rule,  it  is 
necessary  to  insert  a  gauze  drain  in  the  upper  part  of  the  serous 
cavity.  If  the  general  cavity  is  inflamed,  the  treatment  suitable  to 
acute  peritonitis  must  be  instituted  (p.  984). 

Foreign  Bodies  in  the  stomach  consist  either  of  those  which  have 
been  swallowed  accidentally  or  intentionally,  or  of  concretions,  e.g., 
hairs,  wool,  etc.,  due  to  the  constant  ingestion  of  small  portions,  v./hich 
remain  in  the  viscus  and  may  after  a  time  form  large  masses.  The 
presence  of  the  former  is  known  from  the  history,  whilst  the  latter 
may  give  rise  to  symptoms  of  gastric  irritation,  the  cause  of  which  is 
inexplicable  until  the  mass  has  attained  such  a  size  as  to  suggest  the 
presence  of  a  tumour.  The  only  treatment  possible  for  a  foreign 
body  of  any  size  is  to  open  the  organ  and  remove  it  (gastrotomy) ; 
where,  however,  it  is  of  small  dimensions,  e.g.,  a  coin,  it  may  be 
allowed  to  pass  onwards. 

Acute  Phlegmonous  G-astritis  is  an  affection  due  to  bacterial  in- 
vasion of  the  submucous  coat  of  the  stomach,  which  is  infiltrated 
with  leucocytes  and  fibrinous  exudation,  together  with  many 
organisms,  especially  streptococci.  This  process  usually  ends  in 
suppuration,  which  may  manifest  itself  as  a  diffuse  purulent  infiltra- 
tion, or  as  a  more  or  less  localized  abscess  ;  or  the  whole  mucous 
lining  of  the  stomach  may  be  cast  off  as  a  slough  and  vomited.  Such 
a  condition,  if  not  fatal  from  exhaustion,  toxaemia,  or  general  peritonitis, 


ABDOMINAL  SURGERY  999 

will  be  followed  by  extensive  stenosis,  which  may  demand  operative 
treatment.  The  disease  usually  occurs  in  men  who  suffer  from 
chronic  dyspepsia,  and  is  lighted  up  by  injudicious  dietary,  excess 
of  alcohol,  or  possibly  the  taking  of  corrosive  poisons.  It  may 
develop  as  a  secondary  result  of  ulceration  or  of  operation.  The 
symptoms  consist  of  epigastric  pain,  persistent  vomiting,  and  marked 
restlessness,  going  on  to  delirium  or  collapse  ;  the  pulse  is  quickened, 
and  there  is  moderate  fever.  The  diagnosis  is  usually  uncertain,  and 
treatment  is  consequently  merely  symptomatic.  Lavage  of  the 
viscus  will  be  of  some  use. 

Ulcer  of  the  Stomach,  is  an  exceedingly  common  ailment,  the  conse- 
quences of  which  are  often  very  serious,  a  considerable  mortality 
being  associated  with  it,  its  complications,  or  its  sequelae.  Two  chief 
types  may  be  mentioned  here,  although  others  are  not  unknown. 

(a)  The  acute  ulcer  is  rarely  larger  than  a  sixpenny-piece,  and 
'  develops  with  almost  equal  frequency  at  any  spot  between  the 
cardia  and  the  pylorus  along  the  upper  margin  of  the  stomach,  and 
more  frequently  on  the  posterior  than  on  the  anterior  surface '  (Fen- 
wick).  It  is  not  unusually  multiple,  two  ulcers  being  often  found 
exactly  opposite  one  another,  suggesting  an  infective  origin  of  the 
trouble.  They  are  circular  in  shape,  and  with  the  edges  sharply 
defined  and  clearly  cut ;  each  successive  coat  is  destroyed  to  a  lesser 
degree  than  the  one  internal  to  it,  so  that  the  sore  is  truncated  or 
funnel-shaped.  Should  perforation  occur,  the  opening  is  not  central, 
but  slightly  to  one  side.  These  acute  ulcers  heal  without  much  diffi- 
culty, as  is  evident  from  the  number  of  radiating  cicatrices  seen  on 
the  post-mortem  table.  They  give  rise  to  no  stenosis,  except  perhaps 
when  they  are  actually  situated  within  the  pyloric  orifice.  Haemor- 
rhage from  this  variety  is  not  uncommon,  but  rarely  fatal.* 

(b)  The  chronic  ulcer  may  attain  considerable  dimensions,  perhaps 
many  square  inches  of  each  surface  being  involved.  It  is  usually 
single,  and  situated  on  the  posterior  wall  near  the  pyloric  orifice, 
which  may  be  involved  in  the  trouble  by  extension.  Its  shape  is 
very  variable,  though  in  the  earlier  stages  it  is  rounded ;  one  impor- 
tant type  is. the  horseshoe  ulcer,  which  spreads  down  along  either 
surface  from  the  lesser  curvature,  and  may  subsequently  cause  an 
hour-glass  contraction  of  the  organ.  The  edges  are  often  raised, 
hard,  and  infiltrated,  whilst  the  gastric  wall  is  generally  thick  and 
sclerosed.  In  old-standing  cases  there  may  be  considerable  destruc- 
tion of  tissue,  surrounding  viscera,  such  as  the  pancreas,  being  some- 
times exposed  thereby.  Haemorrhage  is  not  uncommon,  and 
may  prove  fatal ;  one  of  the  larger  branches  of  the  coronary  artery, 
or  perhaps  the  splenic,  is  then  involved,  or  the  bleeding  may  arise 
from  one  of  the  enlarged  varicose  gastric  veins  which  are  often  found 
in  the  neighbourhood  of  an  old  ulcer.  Perigastric  inflammation  of 
an  adhesive  or  suppurative  type  is  almost  certain  to  occur,  and 
cicatricial  contraction  of  various  forms  is  likely  to  follow. 

*  See  Fenwick,  'Ulcer  of  the  Stomach  and  Duodenum,'  J.  and  A.  Churchill, 
T900 ;  and  Mayo  Robson  and  Moynihan,  '  Diseases  of  the  Stomach  and  their 
Surgical  Treatment,'  Bailliere,  Tindall  and  Cox. 


looo  A  MANUAL  OF  SURGERY 

Women  are  much  more  liable  to  gastric  ulcer  than  men,  in  the  pro- 
portion of  three  to  one  ;  but  it  is  the  acute  variety  to  which  they  are 
most  prone,  and  from  which,  apart  from  perforation,  they  seldom  die. 
The  usual  age  of  such  patients  is  from  fifteen  to  thirty  years.  Men, 
on  the  other  hand,  are  more  liable  to  chronic  ulcers,  and  though  acute 
perforation  is  less  common,  they  are  subject  to  a  number  of  serious 
complications  which  may  prove  fatal.  Their  average  age  when 
attacked  is  from  thirty  to  fifty  years. 

Into  the  aetiology,  general  symptoms,  and  routine  treatment  of  gastric 
ulcers  it  is  unnecessary  to  enter ;  they  are  sufficiently  described  in 
medical  text-books.  A  number  of  complications,  however,  arise 
which  may  require  surgical  assistance,  whilst  it  must  be  remembered 
that  the  mere  persistence  of  symptoms  may  justify  operative 
measures,  especially  since  the  observation  has  been  made  and  con- 
firmed that  malignant  disease  may  commence  on  the  site  of  an  old- 
standing  ulcer. 

1.  Excessive  and  Persistent  Hsemorrhage  is  responsible  for  a  con- 
siderable proportion  of  the  deaths  from  gastric  ulcer.  It  may  arise 
from  arteries,  veins,  or  capillaries,  and  at  first  it  is  difficult  to 
say  from  what  source  it  is  derived.  Inasmuch,  hoAvever,  as  in  over 
90  per  cent,  of  the  cases  it  can  be  stopped  by  medical  means,  it  is 
obvious  that  the  capillary  origin  is  most  common.  It  is  uncommon 
for  the  patient  to  succumb  to  the  first  attack  of  bleeding,  and  hence 
the  rule  of  practice  which  is  usually  adopted,  viz.,  to  treat  the  first 
acute  haemorrhage  by  medical  means ;  but  should  it  recur  or  persist 
unduly,  surgical  assistance  may  be  required. 

If  the  bleeding  is  small  in  amount,  but  recurs  constantly,  gastro- 
enterostomy should  be  undertaken,  in  order  to  put  the  organ  at  rest 
and  allow  the  ulcer  to  heal.  When,  however,  the  haemorrhage  is 
more  severe  a  determined  attempt  must  be  made  to  find  the  bleeding 
spot  and  deal  with  it.  The  abdomen  is  opened  and  the  stomach  care- 
fully explored.  Some  puckering  or  thickening  of  the  coats  may 
indicate  the  situation  of  the  ulcer ;  failing  this,  a  free  opening  in  the 
longitudinal  axis  is  made  through  the  anterior  wall,  and  the  interior 
of  the  viscus  methodically  examined.  When  the  bleeding  point  has 
been  found,  it  may  be  possible  to  pick  it  up  and  tie  it ;  or  the  whole 
ulcer  may  be  picked  up  and  ligatured  en  masse ;  or  the  base  of  the 
ulcer  may  be  cauterized ;  or  excision  of  the  ulcer  may  be  practicable. 
Failing  these  measures,  gastro-enterostomy  will  be  indicated,  and  the 
result  is  usually  satisfactory. 

2.  Perforation  is  by  no  means  an  uncommon  occurrence  in  con- 
nection with  the  acute  type  of  ulcer,  and  is  therefore  seen  most 
frequently  in  young  women;  it  is  alway  fraught  with  the  greatest 
danger.  The  anterior  wall  is  more  frequently  involved  than  the 
posterior  (7  to  i),  owing  to  its  greater  mobility,  which  prevents  the 
formation  of  protective  adhesions.  The  cardiac  end  is  more  often 
affected  than  the  pyloric  (5  to  3),  whilst  the  opening  is  usually  nearer 
the  lesser  rather  than  the  greater  curvature.  In  20  per  cent,  of  the 
cases  two  perforations  are  present  (Moynihan).    The  character  of  the 


ABDOMINAL  SURGERY  looi 

symptoms  varies  with  the  size  of  the  perforation,  and  with  the  dis- 
tension or  not  of  the  viscus.  If  a  large  opening  is  produced  in  the 
anterior  wall,  so  that  the  gastric  contents  are  allowed  a  free  entrance 
into  the  peritoneal  cavity,  the  patient  is  seized  with  severe  epigastric 
pain  and  profound  shock,  and  this  is  followed  by  acute  septic  peri- 
tonitis, which  rapidly  proves  fatal  if  surgical  interference  is  not  at 
hand.  When  the  perforation  is  small,  and  only  a  gradual  leakage 
occurs,  the  onset  is  subacute  ;  the  primary  shock  is  then  inconsider- 
able, but  epigastric  pain  and  tenderness  are  present,  together  with 
marked  rigidity  of  the  abdominal  wall ;  a  short  period  of  improvement 
follows  the  primary  shock,  and  then  the  symptoms  steadily  increase 
until  the  characteristic  features  of  general  peritonitis  supervene. 

The  Prognosis  of  gastric  perforation  is  exceedingly  grave,  since, 
unless  active  surgical  interference  is  obtainable  within  a  compara- 
tively short  time,  hopeless  peritonitis  ensues.  Statistics  indicate  that 
95  per  cent,  of  untreated  patients  die,  whilst  the  later  the  operation, 
the  worse  the  results.  If  operation  is  undertaken  within  six  hours, 
recovery  is  usual ;  if  within  twelve  hours,  it  is  not  unusual ;  but  later 
than  that  it  is  most  uncertain. 

Treatment. — Should  it  be  decided  for  any  particular  reason  not  to 
operate  in  a  given  case,  the  horizontal  position,  rectal  feeding,  and 
the  use  of  morphia  to  check  peristalsis,  are  the  only  means  which 
hold  out  any  prospect  of  benefit.  Operation,  as  already  indicated, 
must  be  undertaken  at  as  early  a  period  as  possible,  although  it  is 
often  wise  to  delay  for  an  hour  or  two  to  allow  the  patient  to  recover 
in  measure  from  the  initial  shock.  The  median  incision  is  the  best 
to  employ,  since  it  is  not  possible  to  be  certain  as  to  the  situation  of 
the  lesion.  The  rules  given  above  as  to  the  treatment  of  a  pene- 
trating injury  hold  good  in  connection  with  this  subject,  especially  as 
to  the  use  of  swabs  for  the  removal  of  any  extravasated  gastric  con- 
tents, and  as  to  the  value  of  peritoneal  irrigation.  There  is  no  need 
to  excise  the  ulcer  when  found ;  all  that  is  required  is  to  close  the 
aperture  by  means  of  Lembert's  sutures,  which  infold  and  bury  the 
perforation;  this  is  sometimes  a  matter  of  some  difficulty  when  the 
margins  are  thick  and  sclerosed.  In  a  few  cases  it  may  seem 
unwise  to  attempt  closure  of  the  lesion,  whilst  in  others  it  may  be  so 
situated  as  to  render  such  closure  impossible ;  a  drainage-tube,  free 
from  lateral  openings,  is  then  introduced  into  the  stomach,  and  gauze 
packed  around  it  so  as  to  lessen  the  risk  of  intraperitoneal  leakage. 
The  patient  is  fed  by  the  rectum  for  some  time,  and  the  fistula 
usually  closes  without  much  difficulty  at  a  subsequent  date. 

The  operation  should  always  include  an  examination  of  the  lesser 
sac,  which  may  have  been  infected  through  the  foramen  of  Winslow 
or  by  a  second  perforation.  This  is  the  more  necessary  when  the 
clinical  symptoms  point  to  a  serious  lesion,  and  nothing  is  found  in 
the  main  peritoneal  cavity  to  explain  them ;  under  such  circum- 
stances, if  the  lesser  sac  is  also  free  from  inflammation,  the  vermi- 
form appendix  should  be  examined,  as  it  is  often  responsible  for 
many  atypical  conditions.  Another  point  may  also  require  con- 
sideration before  closing  the  abdominal  wound,  viz.,  whether  or  not 


I002  A  MANUAL  OF  SURGERY 

it  may  be  desirable  to  undertake  a  gastro-enterostomy  at  once.  The 
situation  and  character  of  the  ulcer,  and  the  condition  of  the  patient 
must  determine  this. 

After-treatment  is  as  for  all  cases  of  diffuse  septic  peritonitis  (p.  98^). 
The  patient  is  placed  as  soon  as  possible  in  the  sitting  position. 
Mouth-feeding  is  of  course  forbidden  for  two  or  three  days,  and 
rectal  alimentation  relied  on.  Turpentine  enemata  are  employed  to 
relieve  distension  and  empty  the  bowel. 

3-  Perigastric  Inflammation  is  a  common  result  of  ulceration;  it 
may  be  either  adhesive  or  suppurative  in  character. 

Adhesive  Perigastritis  is  in  the  first  place  protective  in  nature,  con- 
sisting of  a  localized  thickening  of  the  serous  wall.  It  is  more 
marked  in  connection  with  chronic  than  with  acute  ulcers.  The 
posterior  gastric  wall  is  often  adherent  across  the  lesser  sac  of  the 
peritoneum  to  the  serous  membrane  lying  in  front  of  the  pancreas, 
and  this  fixity  may  be  one  of  the  factors  which  prevent  the  ulcer 
from  healing,  even  as  fixation  to  the  periosteum  over  the  tibia  delays 
healing  in  an  ulcer  of  the  leg. 

In  a  few  cases  adhesions  form  between  the  anterior  wall  of  the 
stomach  and  the  parietal  peritoneum,  and  these  may  give  rise  to  a 
localized  fixed  epigastric  pain,  usually  increased  considerably  by 
distension  of  the  organ.  It  can  sometimes  be  treated  by  abdominal 
section,  and  division  of  the  adhesion  between  ligatures.  If  left  alone, 
not  only  may  it  cause  inconvenience  by  the  pain  induced,  but  it 
may  also  determine  internal  strangulation  or  obstruction. 

Suppurative  Perigastritis  may  follow  a  small  perforation  with  limited 
leakage,  but  is  more  usually  due  to  an  extension  of  the  ulcer  and  an 
invasion  of  the  perigastric  tissues  by  organisms  which  escape  from 
the  stomach.  The  result  of  this  is  the  formation  of  what  has  been 
already  described  as  a  subphrenic  abscess  (p.  990),  which  may  or 
may  not  contain  gas.  It  may  burst  anteriorly  through  the  abdo- 
minal wall,  or  may  perforate  the  diaphragm,  giving  rise  to  a  basal 
empyema ;  and  this  in  turn  may  burst  into  the  lung  or  through  the 
chest  wall,  so  that  fistulas  may  appear  in  various  places,  through 
which  the  contents  of  the  stomach  may  be  discharged. 

The  abscess  should  be  opened  and  drained  in  the  way  already 
indicated,  but  should  a  fistula  form,  it  is  almost  hopeless  to  attempt 
to  deal  with  it  locally,  and  a  gastro-enterostomy  may  then  be 
required. 

4.  Stenosis  is  always  liable  to  follow  the  cicatrization  of  ulcers  of 
the  stomach.  In  the  small  acute  ulcer  the  contraction  rarely  leads 
to  more  than  a  puckering  of  the  organ  ;  but  in  the  chronic  ulcers  of 
large  size  the  organ  may  be  much  altered  in  shape,  and  definite 
stenosis  may  arise.  If  the  contraction  is  in  or  near  the  cardiac 
orifice,  symptoms  akin  to  oesophageal  stenosis  may  be  produced,  the 
patient  returning  his  food  shortly  after  swallowing  it.  If  the  pylorus 
is  affected,  the  stomach  is  often  much  dilated,  and  vomiting  of  a 
special  type  ensues  (see  Simple  Stenosis  of  the  Pylorus,  p.  1008).  It 
is  important  to  note  that  muscular  spasm  plays  a  considerable  part 


ABDOMINAL  SURGERY 


1003 


in  the  production  of  these  symptoms  when  due  to  ulcer  ;  the  spasm 
is  probably  induced  by  the  hyper-acidity  of  the  gastric  juice  (hyper- 
chlorhydria)  which  is  often  present. 

The  most  exaggerated  forms  of  gastric  stenosis  follow  the  cicatriza- 
tion of  a  horse-shoe  ulcer,  and  this  constitutes  the  most  common 
cause  of  an  hour-glass  stomach  ;  adhesive  perigastritis  and  cancer  are 
occasional  causes.  The  constriction  is  usually  situated  about 
4  inches  from  the  pylorus,  and  may  be  so  narrow  as  almost  to 
divide  the  organ  into  two  halves.  Generally  the  great  convexity  is 
drawn  up  towards  the  lesser,  and  thereby  two  pouches  are  formed 
which  sag  downwards ;  in  them  food  collects  and  undergoes  decom- 
position. Vomiting  more  or  less  of  a  pyloric  type  ensues  from  the 
distension  of  the  cardiac  pouch,  which  is  usually  much  the  larger. 
On  washing  out  the  organ  with  a  measured  quantity  of  water,  a 
smaller  quantity  often  returns,  some  being  retained  in  the  lesser  sac. 


Fig.  446. — Hour-glass  Stomacpi, 
indicating  the  method  of 
Treatment  by  Anastomosis 
OF  THE  Two  Pouches. 


Fig.  447.  —Treatment  of  Hour- 
glass Stomach  by  Double 
Gastro-enterostomy. 


On  palpation  this  latter  may  occasion  a  succussion  splash,  even  when 
the  organ  is  apparently  empty.  On  again  passing  the  tube  after  a 
short  interval,  offensive  fluid  may  return,  especially  if  the  pyloric 
pouch  has  been  palpated.  Distension  of  the  viscus  causes  a  definite 
bulging  on  the  left  side  of  the  epigastrium  in  the  first  place ;  subse- 
quently this  may  diminish,  and  the  pyloric  pouch  become  evident  on 
the  right  side.  Sometimes  both  pouches  can  be  distinctly  felt,  or  even 
seen,  as  well  as  the  sulcus  between  them.  No  treatment  is  of  any 
avail  which  does  not  provide  for  the  drainage  of  both  pouches  and 
the  efficient  emptying  of  the  whole  organ.  A  few  cases  may  be 
treated  by  excision  of  the  stricture,  or  by  its  longitudinal  division  and 
suture  transversely  by  a  method  similar  to  that  employed  for  the 
pylorus  (see  Pyloroplasty,  p.  1014).  In  some  cases  the  two  pouches 
may  be  united  below  the  stricture  (Fig.  446),  but  there  can  be 
no    question    that   the    great    majority    are   best   dealt   with   by   a 


I004  A  MANUAL  OF  SURGERY 

double  gastro-enterostomy  (Fig.  447),  which  gives  a  direct  com- 
munication between  each  segment  and  the  jejunum. 

5.  Finally,  cases  are  met  with  in  which  the  symptoms  of  gastric 
ulcer  persist  or  recur  in  spite  of  the  most  careful  dieting  and  treat- 
ment, and  it  is  now  considered  quite  justifiable  to  submit  such  cases 
to  operation.  Two  lines  of  treatment  are  possible,  {a)  The  ulcer 
may  be  excised,  if  it  be  in  a  convenient  position  for  such  a  proce- 
dure, and  if  the  infiltration  around  it  is  not  too  extensive.  This  is 
the  more  desirable,  since  many  cases  apparently  benign  are  really 
malignant,  and  the  cicatrices  of  such  conditions,  even  if  benign,  are 
likely  to  become  malignant.  This  practice  is,  however,  seldom 
possible,  (h)  In  most  cases  gastro-enterostomy  (p.  1015)  should  be 
undertaken  in  order  to  relieve  symptoms  by  enabling  the  viscus  more 
rapidly  to  empty  itself  after  the  ingestion  of  food,  so  that  the  ulcer 
may  be  given  a  better  opportunity  of  healing.  In  some  cases 
excellent  results  follow  such  a  measure,  but  not  in  all. 

It  must  be  remembered  that  gastro-enterostomy  is  not  a  magic 
charm  which  at  once  and  for  ever  cures  all  the  troubles  arising 
from  gastric  ulceration.  The  ulcer  is  still  present  when  the  opera- 
tion is  completed,  and  if  chronic  may  take  a  long  time  to  heal,  and 
require  a  continuance  of  the  dietetic  and  medical  treatment  that 
preceded  the  operation,  such  as  the  limitation  of  the  dietary  to  soft 
articles,  and  only  a  very  gradual  increase  in  the  list  of  things  per- 
mitted ;  and  the  use  of  drugs,  such  as  an  alkaline  bismuth  mixture 
to  neutralize  the  hyperchlorhydria  usually  present.  The  teeth  must 
also  be  carefully  attended  to.  Sometimes  the  symptoms  result  from 
an  atonic  gastritis  with  absence  of  HCl,  and  then  operation  will  do 
no  good.  In  fact,  it  is  probable  that  unless  some  degree  of  obstruction 
is  present  to  the  onward  passage  of  food  through  the  pylorus  and 
duodenum,  gastro-enterostomy  does  but  little  good.  It  is  quite 
clear  that,  unless  the  practitioner  selects  his  cases  for  operation  with 
great  care,  he  will  often  be  disappointed  with  the  results,  which 
do  not  by  any  means  always  conform  to  the  coiikiir-de-rose  picture  of 
some  writers. 

Recurrence  of  symptoms  after  gastro-enterostomy  may  be  due  to  many 
causes  :  (i.)  The  ulcer  may  have  broken  down  again,  as  a  result 
of  careless  or  unsuitable  diet,  or  of  a  general  loss  of  health  and 
tone.  A  servant  girl  going  back  to  her  old  work  and  habits  is 
very  liable  to  this,  (ii.)  Adhesions  between  the  ulcerated  stomach 
and  surrounding  parts  may  have  been  stretched  as  the  result  of 
some  traumatic  influence,  (iii.)  Adhesions  due  to  the  operation 
itself  may  be  present  and  give  rise  to  trouble,  (iv.)  The  opening 
into  the  jejunum  may  have  contracted,  and  difficulty  in  the  onward 
passage  of  the  food  may  again  be  present,  (v.)  A  peptic  ulcer  may 
have  developed  in  the  efferent  loop  of  the  jejunum.  The  history 
and  character  of  the  symptoms  should  suffice  to  guide  the  practitioner 
to  a  correct  diagnosis. 

Treatment. — The  patient  should  be  put  to  bed  and  treated  on 
medical  lines  for  a  while  ;  this  will  suffice  in  most  instances  to  give 


ABDOMINAL  SURGERY 


1005 


relief.  Should  it  fail  and  symptoms  persist,  it  may  be  necessary  to 
open  the  abdomen  again  and  explore  the  parts  involved.  Adhesions 
may  be  divided,  and  if  it  seems  likely  that  the  opening  has 
contracted,  it  may  be  enlarged,  or  a  fresh  anastomosis  may  be 
performed. 

Cancer  of  the  Stomach. — The  stomach  is  more  frequently  invaded 
by  cancer  than  any  other  organ  in  the  body  in  the  male  sex,  whilst 
in  females  it  comes  next  to  the  breast  and  uterus  in  order  of  fre- 
quency. Any  and  every  part  of  the  viscus  may  be  affected,  but  in 
60  per  cent,  of  the  cases  the  tumour  starts  in  or  about  the  pylorus. 
It  may  be  of  a  spheroidal-  or  columnar-celled  type,  but  is  often 
sufficiently  hard  to  warrant  the  use  of  the  term  '  scirrhous  '  which  is 
usually  applied  to  it.     When  the  cardiac  end  is  attacked,  the  disease 


<^^- 


Fig. 


-Cancer   of  Pyloric  End  of  Stomach.     (King's  College 
Hospital  Museum.) 


The  abrupt  limitation  of  the  growth  at  the  commencement  of  the  duodenum 

is  well  seen. 


may  spread  from  the  oesophagus  and  is  a  squamous  epithelioma ;  but 
when  the  body  of  the  organ  is  invaded,  the  condition  is  generally 
a  columnar  carcinoma. 

Cancer  frequently  starts  at  the  site  of  an  old  ulcer,  but  often 
there  is  no  assignable  cause  for  its  onset,  except  an  indefinite 
history  of  injury.  It  may  occur  as  a  nodular  outgrowth,  perhaps 
covered  with  papillomatous  projections  and  early  undergoing  ulcera- 
tion ;  if  it  is  of  a  hard  type,  the  ulcerated  surface  has  a  characteristic 
everted  margin.  Sometimes  the  whole  organ  becomes  infiltrated  by 
a  diffuse  carcinomatous  growth,  constituting  a  firm  mass  incapable 
of  dilatation  or  much  contraction,  which  has  been  aptly  termed  the 
'leather-bottle  stomach.'  At  the  pyloric  end  (Fig.  448 j  the  growth 
is  always  of  a  hard  nature,  and  forms  an  annular  constriction, 
through  which  it  may  be  difficult  to  pass  even  a  small  catheter ;  it 


ioo6  A   MANUAL  OF  SURGERY 

is  sharply  limited  on  its  duodenal  aspect,  but  spreads  into  the  body 
of  the  organ,  and  especially  towards  the  lesser  curvature,  following 
the  main  line  of  the  lymphatic  stream.  The  lymphatic  glands  lying 
along  the  lesser  curvature  are  involved,  usually  extending  as  far  as 
the  point  where  the  coronary  artery  reaches  the  stomach,  whilst  those 
along  the  pyloric  end  of  the  great  curvature  are  implicated  to  a  less 
degree  (Fig.  452).  Thence  the  affection  spreads  to  the  liver  and  to 
the  cceliac  glands,  and  rnay  there  compress  the  inferior  vena  cava 
and  thoracic  duct.  Adhesions  form  around  the  growth,  but  are 
relatively  later  in  appearance  than  in  a  simple  ulcer ;  they  may  fix 
the  tumour  to  the  under  surface  of  the  liver,  to  the  head  of  the 
pancreas,  the  colon,  and  even  when  of  large  size  to  the  anterior 
abdominal  wall.  These  adhesions  often  prepare  the  way  for  an- 
extension  of  the  disease  to  the  peritoneum,  over  which  disseminated 
nodules  of  cancer  may  be  scattered,  giving  rise  to  a  considerable 
effusion  of  serous  fluid.  The  omentum  also  becomes  infiltrated,  and 
colloid  degeneration  is  not  unusual  in  this  region,  the  omentum 
being  converted  into  a  solid  translucent  mass,  looking  sometimes 
like  firm  sago  pudding. 

Speaking  generally,  the  malignancy  of  gastric  carcinoma  is 
decidedly  less  than  that  of  such  organs  as  the  breast  or  uterus,  in 
that  secondary  glandular  affections  are  later  in  developing,  and  even 
when  the  nearest  group  is  involved  it  may  be  some  time  before  the 
affection  spreads  to  distant  parts. 

Clinical  Phenomena. — Gastric  cancer  begins  with  certain  inde- 
finite symptoms,  the  significance  of  which  is  easily  overlooked  in 
the  early  stages,  so  that  a  thorough  and  exhaustive  examination  is 
not  made,  and  the  time  for  radical  interference  passes  without  the 
disease  being  recognised.  Pain  is  generally  the  first  symptom,  slight 
at  first,  but  gradually  increasing,  and  referred  to  the  epigastrium  or 
back.  Food  may  increase  or  relieve  it,  but  as  time  progresses  the 
pain  comes  on  independently  of  meals.  Acid  eructations  and  a  sense 
of  epigastric  oppression  soon  follow,  and  these  in  time  give  place  to 
actual  attacks  of  vomiting,  the  ejecta  perhaps  containing  blood,  but 
usually  not  till  late  in  the  case,  and  as  a  rule  not  in  great  quantity. 
Loss  of  appetite  and  steady  wasting  are  also  marked  features  in  the 
early  stages,  but  the  patient  usually  has  a  clean  tongue.  The  per- 
sistence of  such  a  group  of  symptoms  should  always  determine 
a  complete  investigation  of  the  stomach  and  its  functions,  (i.)  The 
epigastric  region  is  carefully  palpated,  and  the  nature  and  position  of 
any  unusual  swelling  noted.  It  may  be  desirable  to  inflate  the  organ 
with  air  or  gas  and  ascertain  its  exact  size ;  by  this  means  it  is 
sometimes  possible  to  detect  a  tumour  which  would  otherwise  escape 
notice,  (ii.)  The  composition  of  the  gastric  juice  is  investigated  by 
the  use  of  a  test  meal  (p.  997).  In  cancer  the  amount  of  HCl  is 
usually  diminished,  whilst  that  of  lactic  acid  is  increased ;  the  latter 
is  probably  a  fermentation  product.  This  test  must  be  looked  on  as 
a  valuable,  but  not  as  a  constant,  indication  of  the  presence  of  cancer. 
HCl  is  generally  increased,  and  not  diminished,  in  the  cancer  that 


ABDOMINAL  SURGERY  1007 

supervenes  on  a  chronic  ulcer.  Moreover,  HCl  is  absent  in  many 
gastric  lesions  other  than  cancer,  and  hence  the  results  of  this  inves- 
tigation must  always  be  considered  in  conjunction  with  the  clinical 
symptoms,  (iii.)  The  motor  power  of  the  viscus  is  very  considerably 
lessened,  so  that  the  passage  of  its  contents  into  the  duodenum  is 
delayed ;  this  is  due  to  a  chronic  interstitial  gastritis,  (iv.)  A  blood 
count  in  carcinoma  usually  reveals  a  well-marked  secondary  anaemia, 
together  with  a  moderate  leucocytosis  (p.  58).  (v.)  Microscopic 
examination  of  the  vomit  may  also  throw  light  on  the  case  by  the 
discovery  of  fragments  of  the  growth. 

To  these  general  signs  certain  special  ones  may  be  added,  varying 
with  the  location  of  the  growth,  i.  If  the  cardiac  end  is  involved,  a 
tumour  can  rarely  be  detected,  the  stomach  being  small  and  con- 
tracted. The  patient  complains  chiefly  of  pain  on  swallowing,  and 
the  vomiting  occurs  immediately  after  each  meal.  The  symptoms  are 
practically  those  of  oesophageal  cancer. 

2.  When  the  pylorus  is  affected,  a  tumour  can  often  be  felt  a  little 
above  and  to  the  right  of  the  umbilicus,  which  is  at  first  rounded 
and  nodular ;  it  is  moveable  in  the  early  stages,  but  later  on  becomes 
fixed  by  adhesions  ;  it  is  firm  in  consistence,  and  somewhat  tender  on 
manipulation  and  pressure,  and  may  receive  pulsation  from  the 
underlying  aorta.  Owing  to  the  stenosis  of  the  pylorus,  which 
almost  invariably  accompanies  this  condition,  the  stomach  becomes 
dilated,  and  its  great  curvature  displaced  do"\\Tiwards,  perhaps  almost 
into  the  pelvis.  In  this  a  large  accumulation  of  fluid  takes  place, 
which  can  be  heard  splashing  about  when  the  patient  is  moved  ; 
every  day  or  two  he  brings  up  a  large  quantity  of  fluid  and 
decomposing  food,  covered  with  a  yeast-like  scum,  and  sometimes 
containing  sarcinae  in  abundance.     Haematemesis  is  not  uncommon. 

3.  When  the  body  of  the  organ  is  involved,  a  tumour  may  or  may  not 
be  felt,  according  to  its  situation.  In  these  cases  the  amount  of  pain 
and  vomiting  depends  on  the  degree  of  ulceration  of  the  growth,  and 
is  sometimes  comparatively  slight,  especially  if  the  exit  to  the  organ 
through  the  pylorus  is  not  obstructed.  It  is  quite  possible  that  the 
tumour  may  have  attained  considerable  proportions  before  it  is  dis- 
covered. The  '  leather-bottle  '  stomach  can  be  sometimes  detected  as 
a  solid  mass  emerging  from  under  the  left  costal  margin.  The  organ 
is  not  dilated,  and  the  vomiting  has  no  special  characters ;  haemate- 
mesis is  usually  absent,  but  the  dyspeptic  phenomena  are  pronounced. 

In  the  later  stages  pressure  phenomena  manifest  themselves. 
Ascites  may  result  from  compression  of  the  portal  vein ;  jaundice, 
from  implication  of  the  common  bile-duct ;  oedema  of  the  legs  and 
varix  of  the  superficial  abdominal  veins  may  arise  from  pressure 
upon  the  inferior  vena  cava,  whilst  the  peritoneal  cavity  may  be 
distended  with  chyle  owing  to  the  pressure  of  lymphatic  glands  on 
the  receptaculum  chyli  or  thoracic  duct.  All  these  later  signs  are 
indications  that  the  time  has  passed  when  radical  treatment  is 
possible.  A  similar  indication  is  given  by  enlargement  of  a  gland  in 
the  left  supraclavicular  fossa,  which  sometimes  occurs  ;  this  results 
from  dissemination  of  cancer  cells  up  the  thoracic  duct. 


ioo8  A  MANUAL  OF  SURGERY 

Treatment. — When  the  symptoms  of  chronic  gastritis  persist  in  spite 
of  careful  dieting  and  treatment,  and  the  patient  is  losing  flesh,  one 
should  always  look  on  the  case  with  suspicion.  Granted  that  the 
examination  of  the  gastric  juice  reveals  the  characteristic  changes 
referred  to  above,  and  still  more  when  a  blood  count  indicates 
leucocytosis  and  a  diminishing  quantity  of  haemoglobin,  then  an  ex- 
ploratory operation  is  quite  justifiable  whether  a  tumour  is  to  be  felt 
or  not.  On  the  other  hand,  the  discovery  of  a  tumour  in  the 
epigastrium  does  not  warrant  an  operation.  It  is  quite  possible  that 
under  such  circumstances  the  disease  has  extended  beyond  the  reach 
of  surgery,  and  therefore,  unless  there  are  distinct  indications  for 
palliative  treatment — e.g.,  the  signs  of  pyloric  stenosis — the  patient  is 
often  better  left  to  the  care  of  the  physician.  Of  course,  in  many 
cases  an  operation  is  undertaken  in  the  almost  vain  hope  of  being 
able  to  do  something  to  prevent  the  patient  being  condemned  to 
certain  death  ;  but  when  ascites,  jaundice,  or  definite  evidences  of  dis- 
semination are  present,  the  surgeon  should  be  very  chary  of  interfering. 

For  cancer  of  the  cardiac  orifice,  gastrostomy  (p.  loii)  may  possibly 
be  desirable,  the  artificial  stoma  being  placed  nearer  to  the  pylorus 
than  usual. 

For  cancer  of  the  body  of  the  stomach,  a  partial  or  total  gastrec- 
tomy (p.  1014)  may  be  feasible  in  the  absence  of  massive  adhesions ; 
but  the  conditions  which  permit  of  such  procedures  are  unusual.  If 
there  is  any  evidence  of  obstruction  to  the  passage  of  food,  a  gastro- 
enterostomy (p.  1015)  is  undertaken  ;  owing  to  the  usual  location  of 
the  carcinoma  on  the  posterior  wall,  the  surgeon  may  be  driven, 
to  utilize  the  anterior  operation.  Sometimes  the  disease  is  so 
extensive  that  even  this  procedure  is  impracticable ;  the  patient's 
nutrition  is  then  likely  to  fail  rapidly,  but  possibly  life  may  be 
prolonged  (if  such  be  desirable)  by  the  formation  of  an  artificial 
opening  into  the  jejenum  (jejunostomy),  through  which  he  may  be 
fed  without  using  the  stomach. 

For  cancer  of  the  pylorus,  operation  is  more  frequently  possible. 
If  the  mass  is  comparatively  moveable,  and  there  are  but  few 
adhesions,  pylorectomy  (p.  1014)  or  removal  of  the  diseased  portion 
of  the  organ  may  be  undertaken,  and  even  should  secondary  deposits 
be  present  in  the  liver,  the  patient  is  probably  better  off  after  such  a 
procedure  than  if  left  alone.  When  the  growth  is  firmly  adherent  to 
adjacent  viscera,  gastro-enterostomy  is  alone  practicable,  and  will  be 
most  beneficial. 

Failing  all  operative  measures,  the  patient's  nutrition  must  be 
maintained  by  such  food  as  causes  him  the  least  discomfort,  and 
considerable  relief  will  be  experienced  from  regular  and  systematic 
lavage  of  the  organ.     Opium  will  be  needed  for  pain. 

Simple  Stenosis  of  the  Pylorus  results  from  a  number  of  different 
conditions.  It  gives  rise  to  hypertrophy  and  dilatation  of  the 
stomach,  which  becomes  enlarged  downwards,  and  forms  a  sac,  in 
which  food  collects  perhaps  for  days,  and,  undergoing  fermentative 
changes,   is  finally  ejected  in  large   quantities,  mixed  with  frothy 


ABDOMINAL  SURGERY  1009 

mucus  and  a  yeast-like  scum  containing  an  abundance  of  sarcinae. 
The  stomach  may  in  time  almost  reach  the  pelvis,  the  pylorus  being 
dragged  down  with  it. 

The  causes  of  this  condition  are  as  follows  :  (i)  Most  frequently 
it  is  due  to  the  healing  of  a  gastric  ulcer,  situated  within  or  close 
to  the  pyloric  orifice ;  in  the  acute  form,  where  the  ulcers  are 
small,  spasm  as  a  result  of  the  associated  hyperchlorhydria  is 
an  important  element  in  aggravating  the  symptoms  caused  by  a 
slight  contraction.  The  treatment  ii  these  cases  is  at  first  medical, 
and  includes  daily  washing  out  of  the  organ.  Should  it  fail  to  give 
relief,  operation  is  required,  and  consists  in  excision  of  the  pylorus 
or  in  gastro-enterostomy.  (2)  It  may  result  from  the  contraction 
of  extrinsic  adhesions.  These  may  be  massive  or  band-like  ;  in  the 
former  case  the  pylorus  is  imbedded  in  the  newly-formed  fibrous 
tissue  ;  in  the  latter  it  is  kinked,  and  subsequently  contracted. 
Such  adhesions  may  be  secondary  to  gastric  ulcer,  or  may  arise 
from  an  inflamed  gall-bladder  (peri-cholecystitis).  Operative  treat- 
ment is  usually  necessary  in  order  to  divide  the  adhesions,  or  to 
remedy  the  dilatation  by  gastro-enterostomy.  (3)  It  is  occasionally 
met  with  as  a  congenital  hypertrophy  of  the  pylorus,  in  which  the  over- 
growth chiefly  involves  the  muscular  fibres.  It  usually  occurs  in 
male  children,  and  the  pylorus  is  transformed  into  a  solid  cylindrical 
mass,  about  an  inch  in  length,  pale  in  colour,  and  as  hard  as  cartilage. 
Symptoms  commence  within  two  or  three  weeks  of  birth  ;  after  taking 
food  there  is  not  much  evidence  of  pain,  although  the  child  may 
appear  to  be  uncomfortable,  and  relief  is  obtained  by  vomiting.  But 
little  food  appears  to  pass  into  the  intestine,  so  that  constipation  is 
marked  and  the  child  soon  wastes.  The  stomach  becomes  enlarged 
after  a  time,  as  in  the  other  varieties,  and  the  pylorus  can  sometimes 
be  palpated  as  a  moveable  tumour.  There  has  been  a  good  deal  of 
discussion  as  to  the  treatment  of  these  cases,  but  practically  it 
is  limited  to  two  procedures  :  (a)  The  pylorus  is  dilated  by  a 
modification  of  Loreta's  method,  metal  dilators  of  the  Hegar  type 
being  employed  (Burghard)  ;  or  {b)  pyloroplasty  is  relied  on  by 
others.  Gastro-enterostomy  is,  of  course,  desirable,  but  the  mortality 
is  high,  the  children  not  having  sufficient  vitality  to  stand  such 
a  serious  operation. 

Gastroptosis  is  a  condition  met  with  not  very  unfrequently,  in 
which  the  stomach  is  displaced  downwards  and  dilated,  usually  as  a 
complication  of  a  generalized  enteroptosis  (Glenard's  disease,  q-v.), 
and  hence  is  likely  to  be  associated  with  dropping  of  the  liver  and 
mobility  of  the  right  kidney.  The  symptoms  produced  are  those  of  a 
chronic  atonic  gastritis  with  a  dilated  stomach  ;  vomiting  is  not  a 
marked  sign,  but  acid  eructations,  gastric  discomfort,  and  constipa 
tion  are  very  troublesome,  and  the  patient  steadily  loses  weight  ; 
neurasthenic  manifestations  are  prominent.  The  downward  dis- 
placement of  the  stomach  may  be  such  as  to  permit  the  pancreas  to 
be  felt  above  the  lesser  curvature.  Haematemesis  is  sometimes 
present,  but  the  acidity  is  normal  or  diminished,  and  the  diagnosis 

64 


iblo  A  MANUAL  OF  SURGERY 

from  gastric  ulcer  is  thereby  determined.  Treatment  consists  in 
lavage  and  electricity  to  the  organ  in  the  first  place  with  careful 
dieting,  and  external  support  by  a  suitable  belt  is  of  some  value.  In 
more  advanced  cases,  operative  treatment  is  necessary,  and  many 
diflferent  methods  have  been  suggested.  Theoretically,  it  is  desirable 
to  lift  the  stomach  by  folding  up  and  shortening  the  lesser  omentum, 
as^  suggested  by  Beyea ;  but  unfortunately  this  structure  is  often  so 
thin  and  attenuated  as  to  render  this  procedure  impossible.  Eve* 
points  out  that  it  is  essential  in  many  cases  to  deal  with  the  liver 
first,  fixing  it  up  to  the  anterior  abdominal  wall  by  suitable  sutures, 
and  then  the  lesser  curvature  of  the  stomach  may  be  raised  by  pass- 
ing sutures  through  it  and  through  the  liver  itself  along  the  attach- 
ment of  the  lesser  omentum.  Four  or  five  sutures  of  this  type  will 
fix  the  stomach  satisfactorily.  It  may  be  needful  in  a  few  cases  to 
diminish  the  size  of  the  cavity  by  the  formation  of  a  series  of  tucks 
or  folds  in  the  anterior  wall  by  sutures  passing  from  above  down- 
wards {gastfo plication)  ;  wherever  obstruction  is  present,  gastro- 
enterostomy will  also  be  required. 

Acute  Dilatation  of  the  Stomachf  is  a  curious  condition  occasion- 
ally met  with  in  surgical  practice,  as  an  unexpected  and  unwelcome 
sequela  of  injury  or  operation,  and  that  by  no  means  necessarily 
limited  to  the  abdomen.  It  is  rather  more  common  in  medical  work, 
arising  either  without  apparent  cause,  or  in  the  course  of  debilitating 
illnesses.  It  is  characterized  by  a  sudden  onset,  the  vomiting  of  enor- 
mous quantities  of  fluid,  and  severe  general  symptoms,  which  usually 
terminate  fatally  in  a  few  days.  The  stomach  becomes  enormously 
dilated,  even  sagging  down  into  the  pelvis,  and  the  walls  are  more  or 
less  paralyzed,  as  peristalsis  is  rarely  evident.  The  pathology  of  this 
condition  is  uncertain,  but  it  is  possibly  due  to  constriction  of  the 
third  piece  of  the  duodenum  by  the  root  of  the  mesentery  through  a 
downward  drag  of  the  intestines.  Treatment  consists  in  regular  lavage, 
and  in  some  cases  the  abdominal  decubitus  has  given  relief ;  rectal 
alimentation  is  required.  Surgical  treatment  is  very  unlikely  to  do 
good,  unless  there  is  some  associated  obstruction  near  the  pylorus. 

Operations  upon  the  Stomach. 

1.  Washing  out  the  Stomach  is  needed  in  cases  of  poisoning,  in 
chronic  catarrh,  in  dilatation  of  the  organ,  and  as  a  preliminary  to 
some  operations  in  which  its  cavity  is  to  be  laid  open.  It  may  be 
accomplished  by  the  ordinary  stomach-pump,  or  by  the  simpler 
method  of  passing  a  long  tube  of  good-sized  calibre,  to  the  upper  end 
of  which  is  attached  a  funnel.  Fluid  is  introduced  through  the 
funnel,  and  syphoned  out  by  lowering  it  below  the  level  of  the 
stomach. 

2.  Gastrotomy,  or  opening  the  stomach,  is  required  for  the  removal 

*  Sir  F.  S.  Eve,  Transactions  of  Medical  Society,  vol.  xxxiii.,  p.  252. 
t  For  further  details,  see  '  Acute  Dilatation  of  the  Stomach,'  by  H.  Campbell 
Thomson,  M.D.     Bailliere,  Tindall  and  Cox,  1902. 


ABDOMINAL  SURGERY 


of  foreign  bodies  from  it  or  from  the  lower  end  of  the  oesophagus, 
for  exploratory  purposes,  and  as  a  means  of  dilating  simple  strictures 
of  either  the  pyloric  or  cardiac  orifices  (Loreta's  operation). 

Operation. — An  incision  is  made  in  the  middle  line  above  the 
umbilicus  unless  there  is  some  special  indication  to  the  contrary. 
The  peritoneum  is  opened,  and  the  stomach  recognised  by  its  posi- 
tion immediately  under  the  liver,  and  by  the  thickness,  pink  colour, 
and  opacity  of  its  walls.  If  the  omentum  or  transverse  colon  presents 
in   the   wound,   it  must  be  pushed  -     , 

down,  and  the  stomach  looked  for 
above.  The  spot  where  the  stomach 
is  to  be  opened  is  now  selected,  and 
the  part  drawn  out  and  carefully 
packed  around  with  sterilized  gauze 
so  as  to  prevent  contamination  of 
the  general  peritoneal  cavity.  The 
incision  is  made  in  the  long  axis  of 
the  stomach,  and  the  finger  inserted. 
The  removal  of  a  foreign  body 
must  be  undertaken  with  great  care, 
so  as  not  to  inflict  injury  on  the 
organ,  the  wound  being  enlarged,  if 
necessary.  The  stomach  is  subse- 
quently closed  by  Czerny-Lembert 
sutures,  and  replaced  ;  all  traces  of 
blood,  etc.,  are  removed,  and  the 
external  wound  is  closed  in  the  usual 
way. 

The  cardiac  orifice  is  not  easily 
reached,  as  it  lies  deeply  just  in  front 
of  the  aortic  opening  in  the  dia- 
phragm. It  can  be  dilated  by  the 
fingers  or  by  suitable  dilators,  and 
a  foreign  body  by  this  means  re- 
moved from  the  lower  end  of  the 
oesophagus.  The  utmost  gentleness 
must  be  observed  in  this  proceeding, 
as  serious  symptoms  may  be  caused 
by  irritation  or  injury  of  the  pneumo- 

gastric  nerves,  the  terminations  of  which  pass  through  this  opening 
in  the  diaphragm. 

The  operations  on  the  pyloric  orifice  are  dealt  with  below. 

3.  Gastrostomy  consists  in  the  formation  of  a  permanent  artificial 
opening  into  the  stomach,  through  which  the  patient  can  be  fed.  It 
is  needed  in  cases  of  malignant  disease  or  intractable  stenosis  of  the 
oesophagus,  w^here  the  patient  is  exposed  to  the  risk  of  starvation, 
owing  to  his  inabiUty  to  take  nourishment.  It  is  most  important 
that  the  opening  should  be  of  a  valvular  type  so  that  there  shall  be 
no  escape  of  gastric  juice,  followed  by  irritation  and  digestion  of  the 


Fig.    449. — Incisions    utilized   in 
Various  Abdominal  Operations. 

A,  Fenger's  incision  for  exposing  the 
stomach;  A^,  additional  incision  in 
Frank's  gastrostomy  ;  B,  incision 
for  exposing  the  gall-bladder ; 
C,  incision  for  operations  on 
appendix  ;  D,  left  iliac  colostomy  ; 
E,  median  incision  for  ovariotomy 
or  suprapubic  cystotomy ;  F,  for 
radical  cure  of  inguinal  hernia  or 
varicocele ;   G,  for  femoral  hernia  ; 

1,  anterior   superior   iliac    spine; 

2,  pubic  spine. 


A  MANUAL  OF  SURGERY 


surrounding  skin,  which  were  so  constantly  seen  in  the  old  days. 
The  chief  methods  of  operation  are  those  known  as  Frank's,  Witzel's, 
and  the  Kader-Senn  procedure. 

Frank's  Operation. — Fenger's  obhque  incision  (Fig.  449,  A)  for 
exposure  of  the  stomach  is  first  made,  the  viscus  withdrawn  and 
examined,  and  a  silk  sling  passed  through  the  serous  and  muscular 
coats  at  the  site  selected  for  the  artificial  opening,  so  that  a  cone- 
shaped  portion  of  the  wall  can  be  drawn  up  into  the  wound.  The 
parietal  peritoneum  is  then  sutured  all  round  to  the  base  of  the  cone, 
so  as  to  shut  it   off  from  the  general  serous  cavity.     A  second  in- 


^-  ^\V 


I 

/J 


i/" 


Fig.  450.  Fig.  451. 

Gastrostomy  (Frank's  Modified  Operation). 

In  Fig  450  the  base  of  the  cone  is  seen  sutured  to  the  peritoneum  and  sheath  of 
the  rectus ;  in  Fig.  451  the  stomach  has  been  opened,  a  tube  stitched  in,  and 
the  sutures  passed  through  the  rectus  are  in  place. 

cisioa  (A^),  about  i  inch  in  length,  is  now  made  on  the  outer  side  of 
the  first  wound,  parallel  to  it,  and  about  li  inches  from  it.  The 
bridge  of  skin  and  subcutaneous  tissue  between  the  two  is  separated 
from  the  subjacent  structures,  and  the  apex  of  the  cone  of  gastric 
wall  drawn  under  the  bridge  into  the  second  wound.  A  small  opening 
is  then  made  into  the  viscus  through  the  apex,  and  the  mucous 
membrane  stitched  accurately  to  the  skin.  The  remainder  of  this 
incision  is  then  closed  in  the  ordinary  way,  as  also  the  first.  Heal- 
ing readily  occurs,  and  a  valvular  opening  is  established,  through 
which  the  patient  may  be  fed  at  once. 

As  a  modification  of  this  procedure,  a  vertical  incision  (as  suggested 


ABDOMINAL  SLRGERY  loij 

by  Kocher)  is  employed  instead  of  the  oblique,  extending  for  3  or 
4  inches  downwards  from  the  eighth  costal  cartilage  and  passing 
through  the  substance  of  the  rectus  muscle  (Fig.  450),  which  is  split 
by  the  fingers  or  handle  of  the  knife  into  two  portions.  A  cone- 
shaped  portion  of  the  stomach  wall  is  withdrawn,  and  its  base  stitched 
to  the  parietal  peritoneum  and  posterior  layer  of  the  sheath  of 
the  rectus.  A  small  hole  is  made  in  the  apex  of  the  cone,  and  into 
this  a  piece  of  rubber  drainage-tube,  free  from  lateral  openings,  and 
not  larger  than  a  No.  10  catheter,  is  stitched,  so  that  about  i^  inches 
project  inside  the  cavity  (Fig.  451).  The  halves  of  the  rectus 
muscle  are  freed  from  the  posterior  layer  of  the  sheath  and  drawn 
together  by  sutures,  so  as  to  cover  in  all  the  exposed  gastric  wall 
except  the  apex  of  the  cone,  which  with  the  tube  is  drawn  to  the 
upper  end  of  the  wound,  and  projects  from  it.  The  incision  in  the 
skin  is  then  closed,  and  finally  the  serous  and  muscular  coats  of  the 
projecting  portion  are  carefully  stitched  to  the  skin.  The  results  of 
this  procedure  have  been  most  satisfactory,  many  cases  having  run 
their  course  without  a  drop  of  gastric  juice  escaping.  The  amount 
of  food  at  first  administered  is  small,  and  rectal  feeding  may  be 
required  in  addition ;  but  it  is  gradually  increased  until  perhaps 
17  ounces  can  be  retained  four  times  a  day.  The  patient  should  be 
kept  in  the  recumbent  posture  for  three  weeks.* 

Witzel's  Operation  consists  in  making  a  valvular  opening  into  the 
stomach  by  introducing  and  stitching  a  tube  into  it  as  in  the  last 
proceeding,  and  then  burying  the  projecting  portion  as  far  as  possible 
by  suturing  the  serous  and  muscular  coats  together  over  it.  The 
stomach  is  then  fixed  to  the  abdominal  parietes  and  the  skin  closed. 
The  result  of  this  operation  is  very  good,  but  the  fixation  to  the 
abdominal  wall  is  not  so  secure  as  in  the  former  plans,  and  inasmuch 
as  the  newly-formed  passage  is  lined  with  serous  membrane  con- 
traction is  liable  to  occur.  It  may  be  employed  advisably  when  the 
stomach  is  small,  and  it  is  difficult  to  find  enough  tissue  for  the  per- 
formance of  Frank's  operation. 

In  the  Kader-Senn  Operation  a  tube  is  stitched  into  the  stomach  and 
buried  in  the  stomach  wall  by  a  series  of  purse-string  sutures  intro- 
duced at  intervals  of  about  f  inch.  The  stomach  itself  is  then 
secured  to  the  margins  of  the  abdominal  incision. 

4.  G-astrectomy. — A  good  many  cases  have  now  been  reported  in 
which  a  limited  portion  of  the  gastric  wall  has  been  removed  success- 
fully, either  for  simple  or  malignant  ulcers  or  growths.  Incisions  are 
made  so  as  to  include  the  mass,  and  the  wound  is  subsequently 
closed  by  Czerny-Lembert  sutures. 

Total  excision  of  the  stomach  has  been  undertaken  for  extensive 
malignant  disease,  which,  however,  has  left  enough  of  the  oesophageal 
end  free  to  allow  of  its  apposition  and  fixation  either  to  the  upper  end 
of  the  duodenum,  or,  if  that  cannot  be  brought  across  to  it,  to  a 
suitable  coil  of  the  jejunum. 

*  For  further  details,  see  Carless,  '  On  Gastrostomy,'  King's  College  Hospital 
Reports,  vol.  v.,  1897-1898,  and  in  Edinburgh  Medical  Journal,  July,  1902. 


IOI4 


A  MANUAL  OF  SURGEBY 


5.  Pylorectomy,  or  paitial  gastrectomy,  for  malignant  disease  of 

the  pyloric  end  of  the  stomach  is  now  frequently  undertaken  and 
with   excellent    results,  if  the  patient  is  not  too  debilitated  and  if 
too  many  adhesions  are  not  present. 

Operation. — The  abdomen  is  opened  by  a  median  incision,  through 
which  the  diseased  area  is  explored,  and  a  final  decision  made  as  to 
the  practicability  or  not  of  removing  it.    If  an  operation  is  determined 
on,  the  growth  is  carefully  isolated  from  surrounding  parts  by  divid- 
ing the  attachments  of  the  great  and  lesser  omenta,  any  enlarged 
glands  being  also  included  in  the  scope  of  the  operation.     Clamps 
are  then  applied  to  the  stomach  and  duodenum,  and  the  surrounding 
part  of  the  abdomen  carefully  protected  with  sterilized  gauze.     The 

mass  is  now  removed  (Fig.  452), 
the  incisions  being  so  placed  as 
to    extend   beyond    the   pylorus 
about  f  inch  into  the  duodenum 
on  the  one  side,  and  on  the  other 
/^\  ^^%  y\  \    ^°    ^^    t°    include    the    greater 

/     >Ast.?;- '''!^>N.«L^-^  /  /    portion  of  the  lesser  curvature, 

thereby  removing  the  lymphatic 
glands.     Bleeding-points  are  se- 
cured,   and    the    two    incisions 
completely    closed,   no    attempt 
being  made  to  appose  or  unite 
them.      The    first    part    of    the 
Fig.    452.  — Cancer   of    Pylorus,    in-  jejenum  is  then  drawn  up,  and 
DicATiNG    THE    SITUATION    OF    THE  au     Ordinary    posterior    gastro- 
Lymphatic  Glands  along  the  Two  enterostomy  performed  ;  this  is 
r^.........    ^^^  OF   THE   Incisions  g^^etimes  undertaken  as  a  pre- 

liminary  operation. 

The  chief  danger  of  the  opera- 
tion is  shock,  but  if  this  can  be  avoided  by  careful  protection  of 
the  viscera,  by  the  prevention  of  haemorrhage,  and  by  rapidity  of 
execution  a  good  result  may  be  expected.  The  patient  is  fed  pev 
rectum  for  the  first  forty-eight  hours,  if  possible,  but  after  that  interval 
small  quantities  of  fluid  may  be  allowed,  and  the  dietary  gradually 
increased. 

Pylorectomy  for  simple,  stenosis  is  quite  a  different  matter  ;  the 
pylorus  alone  needs  to  be  removed,  and  there  should  be  no  difficulty 
in  performing  an  end-to-end  anastomosis  similar  to  that  recommended 
for  intestinal  lesions  {q.v.). 

6.  Pyloroplasty  consists  in  incising  the  pylorus  and  reclosing  the 
incision  in  such  a  way  as  to  increase  the  calibre  of  the  tube.  It  has 
been  performed  for  various  types  of  stricture,  but  is  now  rarely 
employed  (except  for  congenital  stenosis),  having  been  replaced  by 
gastro- enterostomy.  The  operation  commences  by  clearing  the 
pylorus  from  adhesions.  A  longitudinal  incision  is  then  made 
through  the  stricture,  and  by  a  little  careful  manipulation  this 
wound   can   be  opened   out  and  brought  together  in  a  transverse 


Curvatures 

needed  to  include  them 


ABDOMINAL  SURGERY  1015 

manner  so  as  greatly  to  increase  the  lumen  of  the  orifice  (Fig.  453). 
Two  rows  of  stitches  are  inserted,  one  through  the  mucous  membrane, 
and  the  other  through  the  muscular  and  serous  coats. 

7.  Gastro-enterostomy,  or,  more  correctly,  gastro-jejunostomy,  is 
constantly  resorted  to  in  the  treatment  of  gastric,  pyloric,  or  duodenal 
lesions,  and  in  careful  and  skilful  hands  the  death-rate  is  now  small 
(well  under  10  per  cent.).  Indications. — i.  For  obstruction  to  the 
onward  course  of  the  food,  whether  in  the  stomach,  pylorus,  or 
duodenum,  and  w^hether  simple  or  malignant  in  origin.  2.  For  per- 
sistent phenomena  of  ulceration,  either  of  stomach  or  duodenum,  in 
spite  of  suitable  treatment,  but  it  is  doubtful  whether  it  is  of  much 
value  apart  from  a  lesion  which  obstructs  more  or  less  the  passage  of 
food.  3.  For  recurrent  haemorrhage  under  similar  conditions,  in 
order  to  put  the  parts  at  rest  by  rapidly  emptying  the  stomach,  or  by 
diverting  the  food  from  the  duodenum.  4.  i\s  a  part  of  the  modern 
operation  of  pylorectomy  or  gastrectomy. 

The  operation  consists  in  the  formation  of  an  artificial  communica- 
tion between  the  stomach  and  intestine.     It  is  important  that  the 


t 
""^ustjenuiimniiii 


Fig.  433 . — Pyloroplasty. 

The  contracted  bowel  is  divided  longitudinally,  and  the  aperture  thus  made 
opened  out,  so  that  it  can  be  brought  together  transversely. 

selected  portion  of  bowel  should  be  the  upper  part  of  the  jejunum, 
since,  if  the  communication  is  established  too  low,  a  much  greater 
absorbing  surface  is  isolated,  with  the  result  that,  even  if  the  operation 
is  immediately  successful,  the  patient  gradually  loses  ground  owing 
to  lack  of  nutriment ;  and  the  rapidity  of  the  emaciation  will  increase 
as  the  communication  is  placed  farther  from  the  duodenum. 

Operation. — The  abdomen  is  opened  in  the  middle  line  and  the 
stomach  is  readily  found  ;  a  careful  examination  of  the  parts  is  made 
to  confirm  the  necessity  for  the  anastomosis  and  to  select  the  most 
favourable  site.  This  should  be  placed  on  the  posterior  wall  of  the 
stomach,  if  possible,  close  to  the  greater  curvature,  but  well  away 
from  the  growth  or  ulcer,  and  yet  as  near  to  the  pylorus  as  is  prac- 
ticable. The  selected  spot  in  the  jejunum  must  be  as  near  to  its 
origin  as  is  convenient,  so  as  to  leave  as  short  a  loop  as  possible 
betw^een  its  origin  and  the  anastomosis.  The  anti-mesenteric  border 
is  utilized,  and  the  jejunum  must  be  so  placed  that  the  peristaltic 
wave  passing  from  stomach  to  jejunum  shall  be  continuous — i.e.,  shall 
travel  from  left  to  right.  To  find  the  upper  end  of  the  jejunum,  the 
transverse  colon  is  withdrawn  from  the  wound,  together  with  part  of 
the  omentum.     By  tracing  down  the  transverse  meso-colon  to  its 


ioi6 


A  MANUAL  OF  SURGERY 


attachment  the  termination  of  the  duodenum  is  reached  as  it  crosses 
the  middle  Hne  at  the  lower  border  of  the  pancreas,  and  the  coil  of 
bowel  which  emerges  on  the  left  side  is  necessarily  the  commence- . 
ment  of  the  jejunum.  It  is  now  possible  to  decide  finally  whether 
the  anastomosis  is  to  be  effected  to  the  anterior  or  posterior  wall  of 
the  stomach. 

I.  The  anterior  operation  (Fig.  454)  has  fallen  into  disrepute  of 
recent  years,  but  with  care  excellent  results  can  be  obtained  when 
the  condition  of  affairs  prevents  the  posterior  wall  from  being 
employed.  The  objections  to  it  are  twofold  :  (a)  The  jejunum  is 
drawn  up  over  the  transverse  colon,  and  may  possibly  constrict  it  and 
lead  to  obstruction  ;  this  is  the  more  likely  to  occur  when  the  opening 
in  the  jejunum  is  as  near  as  possible  to  the  duodenum,  a  desirable 

arrangement  from  many  other 
points  of  view  ;  and  (h)  the 
necessary  drag  of  the  gut  is  apt 
to  bring  the  two  ends  parallel 
to  each  other,  and  thus  produce 
a  spur,  or  kink,  by  means  of 
which  the  bile  is  directed  into 
the  stomach  instead  of  into  the 
efferent  limb,  thus  establishing 
a  vicious  circle.  Severe  bilious 
vomiting  results,  which  may 
prove  fatal.  The  actual  method 
of  anastomosis  is  similar  to 
that  for  the  posterior  operation. 
2.  In  the  posterior  operation 
^  ,  .  .  ,  ,    of  Von  Hacker  the  jejunum  is 

A.  Transverse  colon  ;  B  jejunum  dragged         •  ^         ^     posterior  wall  of 
up  over  the  colon  and  omentum  (pur-  i      i  1 

posely  omitted)  to  be  brought  into  the  stomach  through  an  open- 
apposition  with  the  stomach.  ing  in  the  transverse  meso- 
colon, the  lesser  sac  of  the  peri- 
toneum being  thereby  traversed.  Long  metallic  clamps,  with  smooth 
blades  guarded  by  rubber  tubing,  are  then  applied  to  the  stomach 
and  intestine  in  such  a  way  that  they  can  be  brought  easily  into 
apposition  one  with  the  other  (Fig.  455),  and  with  sufficient  force 
to  prevent  extravasation  of  the  contents,  and  to  control  haemorrhage. 
A  suitable  packing  of  strips  and  abdominal  cloths  is  then  made,  and 
all  other  viscera  are  replaced.  The  clamps  are  held  together  by 
gripping  the  rubber  tubing  at  each  end  with  Spencer  Wells  forceps. 
Incisions,  2  inches  in  length,  are  made  into  stomach  and  intestine  so 
as  to  correspond  exactly,  and  any  fluid  which  escapes  is  received  on 
swabs  or  gauze  strips. 

The  actual  anastomosis  is  effected  by  simple  suturing  without  the 
aid  of  any  other  mechanical  contrivance;  either  sterilized  silk  or 
iodized  catgut  may  be  employed  for  the  purpose.  The  suturing  is 
undertaken  in  four  stages.  Firstly,  a  sero-muscular  suture  secures 
the  posterior  aspects  of  the  viscera  in  apposition,  the  stitches  extend- 


FiG.  454. — Anterior  Gastro-enteros- 

TOMY, 


ABDOMINAL  SURGERY 


IOT7 


ing  beyond  each  end  of  the  incision.  Then  the  mucous  membrane 
of  stomach  and  jejunum  are  united  by  a  continuous  suture.  This 
may  be  performed  in  two  sections,  back  and  front,  or  one  stitch  may 
suffice  for  the  whole  anastomosis.  Finally,  the  anterior  sero-muscular 
suture  completes  the  junction.  Occasionally  a  few  extra  supporting 
stitches  are  required  in  addition  to  the  two  rows,  and  it  is  well  to 
secure  any  large  vessel  going  to  the  site  of  anastomosis  by  passing 
a  suture  under  and  tying  it.  The  suturing  must  be  accurate  and 
close,  as  one  depends  on  it  to  prevent  bleeding  from  the  divided 
visceral  walls. 

The  usual  peritoneal  toilette  follows :  clamps  are  removed,  blood 
is  sponged  away,  swabs  and  strips  of  gauze  are  removed  and  counted, 
the  viscera  replaced,  and  the  abdominal  incision  closed. 

The  after-treatment  consists  in  the  adoption  of  the  sitting  posture,  and 


Fig.  455. — Posterior  Gastro-enterostomy. 

Clamps  guarded  by  rubber  tubing  have  been  applied  to  the  stomach  and  jejunum, 
and  their  apposition  is  maintained  by  clipping  the  rubber  tubing  with 
Spencer  Wells  forceps  at  each  end.  The  incisions  have  been  made,  and  the 
posterior  walls  have  been  sutured  together. 

in  abstaining  from  stomach-feeding  for  twenty-four  to  forty-eiglit 
hours,  if  practicable,  rectal  alimentation  being  resorted  to  in  the 
interval.  Haemorrhage  from  the  divided  visceral  walls  is  sometimes 
troublesome,  the  patient  vomiting  blood-stained  fluid.  Ice  is  then 
applied  to  the  epigastrium,  and  a  full  dose  of  ergotin  administered 
hypodermically,  or  20  grains  of  lactate  of  calcium  by  rectum. 
Not  unfrequently  there  will  be  some  regurgitation  of  bile  into  the 
stomach,  and  this  may  lead  to  troublesome  vomiting  for  a  few  days ; 
but  if  the  junction  is  satisfactory,  it  soon  passes  off,  especially  when 
food  is  administered  by  the  mouth,  as  may  usually  be  undertaken  on 
the  third  day,  or  earlier,  if  necessary.  At  first  only  fluid  nourishment 
should  be  permitted,  but  in  a  week's  time  soft  solids  may  be  given, 


I0i8  A  MANUAL  OF  SURGERY 

and  gradually  a  more  liberal  diet  is  ordered.  The  effect  of  the  opera- 
tion is  necessarily  only  palliative  when  cancer  is  present,  but  the 
general  condition  often  improves  considerably  for  a  time,  and  the  final 
exitus  lethalis  is  associated  with  less  suffering. 

Should  serious  biliary  vomiting  occur,  the  patient  must  sit  up  and 
the  stomach  be  washed  out.  Failing  that,  it  may  be  necessary  to 
open  the  abdomen,  and  establish  a  fresh  opening  between  the  afferent 
and  efferent  coils.  To  prevent  the  possibility  of  such  an  occurrence, 
Roux  has  suggested  making  a  Y-anastomosis.  The  jejunum  is  cut 
across,  the  lower  segment  being  implanted  at  right  angles  into  the 
stomach  wall,  and  the  upper  or  duodenal  end  into  a  second  opening 
in  the  gut  lower  down.  Excellent  results  have  followed  this  pro- 
cedure. 

Peptic  Ulceration  may  occur  at  the  site  of  anastomosis  or  a  little 
below  it,  but  is  uncommon,  except  after  the  anterior  operation,  and 
even  then  only  occurs  in  2  per  cent,  of  the  cases.  It  may  determine 
pain  and  vomiting  after  food,  accompanied  perhaps  by  haemor- 
rhage or  perforation.  Treatment  is  as  for  ordinary  ulcer  of  the 
stomach. 

Ulcers  of  the  Duodenum  are  very  similar  in  nature  and  origin  to 
those  of  the  stomach,  to  which  indeed  they  may  be  secondary.  They 
occur  most  frequently  in  men  thirty  to  forty  years  of  age,  and  often 
without  any  obvious  cause.  Oral  sepsis  is  not  uncommonly  present, 
as  also  hyperchlorhydria  ;  in  some  cases  chronic  nephritis  or  arterio- 
sclerosis has  existed,  and  in  others  the  lesion  follows  some  operation. 
The  ulceration  which  forms  a  very  occasional  sequela  of  burns  has 
been  already  alluded  to  (p.  118).  The  first  part  of  the  duodenum  is 
that  usually  affected,  and  the  anterior  rather  than  the  posterior  wall ; 
the  character  of  the  ulcer  is  similar  to  that  seen  in  the  stomach. 

The  Symptoms  are  tolerably  characteristic,  even  apart  from  the 
dangerous  complications,  haemorrhage,  perforation,  and  stenosis.  The 
patient,  who  may  appear  to  be  fairly  well  nourished,  complains  ol 
pain  coming  on  after  meals,  not  immediately,  but  after  an  interval  of 
two  or  three  hours,  and  often  relieved  by  taking  more  food.  Begin- 
ning with  a  sense  of  fulness  and  heat  in  the  epigastrium,  it  develops 
into  acute  pain  located  in  the.  right  hypochondrium  and  shooting 
through  to  the  back.  On  examination  of  the  abdomen  a  tender  spot 
is  usually  to  be  detected  a  little  above  and  to  the  right  of  the  umbilicus 
(Fig.  456,  D).  The  patient  complains  much  of  acid  eructations,  but 
vomiting  is  not  a  very  frequent  symptom  ;  when  present,  it  may 
relieve  the  pain.  The  ejecta  may  contain  a  certain  proportion  of  bile. 
The  patient  is  constipated  and  loses  weight  during  an  attack.  Fre- 
quently he  has  intervals  of  complete  freedom  from  pain,  in  which  he 
can  digest  anything  and  enjoy  life.  In  a  considerable  percentage  of 
cases,  moreover,  the  condition  is  absolutely  latent  and  free  from 
symptoms  until  acute  manifestations  of  perforation  or  haemorrhage 
super\^ene. 

Perforation  usually  involves  the  first  part  of  the  duodenum,  and 


ABDOMINAL  SURGERY 


1019 


may  be  intra-  or  retro-peritoneal.  The  conditions  produced  are 
practically  identical  with  those  following  a  perforated  gastric  ulcer, 
but  with  slight  differences  due  to  the  change  of  situation.  Thus, 
with  the  usual  acute  intraperitoneal  perforation  the  fluid  on  escaping 
from  the  duodenum  is  guided  downwards  by  the  ascending  meso-colon 
to  the  right  iliac  fossa,  and  hence  the  symptoms  of  acute  appendicitis 
are  somewhat  simulated  ;  but  it  may  be  possible  to  locate  the  primary 
pain  to  the  hypochondrium.  The  mischief  soon  spreads,  however,  to 
the  general  cavity,  and  the  localizing  symptoms  disappear.  The 
effusion  includes  the  fluid  duodenal  contents,  often  very  abundant 
and  perhaps  bile-stained,  and  usually  free  gas.  If  the  opening  in  the 
duodenum  is  small  and  the  contents  escape  slowly,  a  subphrenic  or 


Fig.  456. — Tender  Spots  in  Abdominal  Lesions. 
C,  In  ulcer  of  stomach  near  the  cardiac  orifice  ;  G,  in  the  ordinary  type  of 
gastric  ulcer;  D,  in  duodenal  ulcer;  GB,  in  affections  of  the  gall  bladder- 
A,  in  appendicitis  (McBurney's  spot).  ' 

subhepatic  abscess  may  form,  but  the  adhesions  are  not  very  firm, 
and  it  may  burst  secondarily  into  the  general  serous  cavity.  A  retro- 
peritoneal perforation  of  the  duodenum  is  the  origin  of  a  subacute 
subphrenic  abscess,  which  is  placed  behind  the  peritoneal  cavity,  but 
always  to  the  right  side  of  the  falciform  ligament. 

Hcsmorrhage  is  evident  in  most  cases  in  the  form  either  of  hsma- 
temesis  or  metena.  The  history  generally  given  is  that  during  a 
dyspeptic  attack  a  sensation  of  faintness  occurs  followed  by  ansmia. 
Part  of  the  blood  lost  may  be  vomited,  but  the  greater  portion  passes 
down  the  intestine,  giving  rise  to  melsna.  The  patient  may  die  from 
loss  of  blood,  and  then  usually  some  large  branch  of  the  pancreatico- 
duodenal vessels  has  been  laid  open  ;  more  frequently  it  ceases  after 
a  time,  but  may  be  repeated  again  and  again. 


to20  A  MANUAL  OF  SURGERY 

Steatosis  of  the  duodenum  results  from  the  cicatrization  of  ulcers, 
and  may  lead  to  frequently  repeated  vomiting,  dyspepsia  of  an 
intractable  type,  a  greatly  distended  stomach,  and  emaciation  to  an 
alarming  degree. 

Treatment. — If  a  diagnosis  can  be  made  and  no  complications  are 
present,  the  same  treatment  is  instituted  as  for  gastric  ulcer — viz.,  rest 
in  bed  and  rectal  alimentation.  Persistence  of  symptoms — e.g.,  vomit- 
ing, haemorrhage,  etc. — is  treated  by  gastro-jejunostomy,  and  the  restdts 
are  most  satisfactory.  Perforation,  of  course,  needs  immediate  opera- 
tion, as  described  for  the  stomach  (p.  ggi).  In  the  earlier  stages  of  a 
duodenal  perforation,  the  incision  will  probably  be  located  along  the 
right  semilunar  line  for  4  or  6  inches.  The  opening,  when  found, 
should  be  stitched  up  in  the  transverse  axis  of  the  bowel,  so  as  not  to 
diminish  its  calibre.  Stenosis  of  the  duodenum  is  treated  most 
successfully  by  gastro-enterostomy,  and  there  are  few  operations  in 
surgery  which  give  more  gratifying  results. 

Affections  of  the  Intestine. 

Congenital  Conditions  are  occasionally  met  with  affecting  the  intes- 
tine, and  perhaps  giving  rise  to  serious  complications,  {a)  The  most 
common  of  these  consists  in  what  is  known  as  Meckel's  divevticuliiw , 
which  occurs  as  an  outgrowth  from  the  lower  end  of  the  ileum.  It 
may  be  patent  for  i  or  2  inches,  terminating  possibly  in  a  fibrous 
cord,  which  floats  free  among  the  intestines,  or  may  contract  ad- 
hesions, and  thus  determine  an  internal  strangulation;  sometimes  it 
persists  as  an  open  tube  as  far  as  the  umbilicus,  giving  rise  to  a  con- 
genital faecal  fistula.  It  is  due  to  non-obliteration  of  the  omphalo- 
mesenteric duct.  Many  forms  of  acute  abdominal  trouble  have  been 
caused  by  this  structure,  and  even  inflammatory  attacks  similar  to 
acute  appendicitis  ;  gallstones  or  enteroliths  have  lodged  within  it 
and  caused  perforative  peritonitis,  (h)  Congenital  stenosis  of  the  duo- 
denum occurs  opposite  the  entrance  to  the  common  bile-duct,  and  a 
similar  condition  may  arise  in  the  lower  part  of  the  ileum  at  a  spot 
corresponding  to  the  site  of  Meckel's  diverticulum. 

Contusion  of  the  Intestine  may  result  from  any  serious  blow  on  the 
abdomen, .and  necessarily  varies  in  its  effects  with  the  nature  and 
force  of  the  injury,  the  amount  of  distension  of  the  gut,  and  the 
strength  and  power  of  resistance  of  the  parietes.  In  its  simplest  form, 
it  merely  produces  a  little  bruising  of  the  intestinal  wall,  followed  by 
a  subacute  or  chronic  enteritis,  from  which  with  care  the  patient 
quickly  recovers.  In  the  more  severe  cases,  an  acute  enteritis  ensues, 
due  to  bacillary  invasion,  which  may  even  run  on  to  ulceration  or 
sloughing  of  the  coats  of  the  bowel.  The  latter  result  is  more  likely 
to  follow  if  the  mesentery  has  also  been  involved  in  the  injury  so  as 
to  produce  thrombosis  of  the  mesenteric  vessels.  Under  these  circum- 
stances, the  final  issue  depends  largely  upon  the  rapidity  of  the  inflam- 
matory process.     If  adhesions  have  had  time  to  form  between  the 


ABDOMINAL  SURGERY  io2l 

parietes  and  the  injured  gut,  the  mischief  is  limited,  and  the  patient 
may  recover  with  a  faecal  fistula,  the  formation  of  which  has  been 
preceded  by  a  localized  intraperitoneal  abscess,  containing  extremely 
offensive  pus,  owing  to  the  presence  of  the  B.  coli,  which  has  migrated 
through  the  intestinal  wall.  If,  however,  the  inflammatory  affection 
is  rapid  in  its  onset,  and  adhesions  have  not  had  time  to  develop, 
acute  diffuse  peritonitis  is  almost  certain  to  follow.  When  the 
injured  portion  of  the  bowel  is  retro-peritoneal,  as  in  the  duodenum 
or  colon,  a  retro-peritoneal  abscess  may  form. 

The  Symptoms  of  intestinal  contusion  consist  primarily  of  shock 
and  pain.  The  amount  of  shock  varies  necessarily  with  the  severity 
of  the  injury  and  the  nervous  susceptibility  of  the  patient.  The  pain 
may  not  be  severe  at  first,  but  is  always  very  marked  subsequently, 
and  increased  by  examination,  movement,  or  during  violent  respira- 
tory efforts.  To  limit  such  movement,  the  abdominal  parietes  are 
maintained  in  a  state  of  firm  contraction,  and  can  be  felt  hard  and 
resistant.  Vomiting  may  be  present,  but  is  not  a  marked  feature. 
The  later  symptoms  necessarily  vary  with  the  course  taken  by  the 
case,  and  need  not  be  described  in  further  detail. 

Treatment  is  conducted  along  the  same  lines  as  that  of  contusions  of 
the  abdominal  wall  (p.  977) ;  viz.,  where  there  is  no  absolute  evidence 
of  rupture,  an  expectant  attitude  must  be  adopted,  but  the  surgeon 
must  be  ready  to  interfere  should  any  grave  or  suspicious  symptoms 
arise.  Acute  enteritis  induces  diarrhoea  and  the  passage  of  blood- 
stained mucus,  and  such  symptoms  will  indicate  the  use  of  bismuth, 
and  perhaps  a  little  morphia,  whilst  a  fluid  diet  or  rectal  feeding  is 
alone  permissible. 

Rupture  of  the  Intestine  follows  abdominal  injuries  of  a  more  severe 
character,  such  as  when  a  cart  or  cab  has  traversed  the  abdomen,  or 
when  the  patient  has  been  tightly  squeezed  or  kicked.  The  bowel 
does  not  always  give  way  at  the  point  of  impact,  but  occasionally  at 
a  distance  from  it ;  under  these  circumstances  the  tear  is  more  likely 
to  be  ragged  and  irregular,  whilst  if  it  yields  at  the  point  struck,  the 
gut  may  be  cleanly  torn  across.  The  parts  most  frequently  affected 
by  this  form  of  injury  are  the  junction  of  the  moveable  jejunum  with 
the  fixed  duodenum,  and  the  lower  3  feet  of  the  ileum.  The  fluidity 
of  the  contents  of  the  small  intestine  has  a  grave  prognostic  signifi- 
cance, since  they  are  readily  diffused. 

The  early  Symptoms  consist  of  severe  and  usually  lasting  shock, 
accompanied  by  intense  abdominal  pain,  which  may  at  first  be 
localized.  If  there  is  an  abundant  escape  of  the  intestinal  contents, 
a  virulent  form  of  acute  peritonitis  follows  immediately,  from  which 
the  patient  rapidly  succumbs.  If,  however,  the  gut  was  empty  at  the 
time  of  the  accident,  the  symptoms  are  less  severe  ;  acute  peritonitis 
ensues,  but  it  is  slower  in  onset,  and  some  attempt  to  limit  it  is 
observed.  An  important  diagnostic  point  is  that  the  maximum  ten- 
derness is  always  fixed  to  a  localized  area.  Free  gas  is  sometimes, 
but  not  frequently,  present  in  the  peritoneal  cavity,  as  in  rupture  of 
the  stomach.     In  a  few  cases  emphysema  of  the  abdominal  walls 


1022  A  MANUAL  OF  SURGERY 

has  been  noted,  and  in  the  absence  of  thoracic  injuries  or  of  diffuse 
celluhtis  is  an  absolutely  certain  sign  of  rupture  of  the  intestinal 
tube.  Vomiting  occurs,-  but  not  to  an  excessive  degree  ;  if  blood  is 
found  in  the  vomit,  it  suggests  that  either  the  stomach  or  upper  part 
of  the  intestinal  canal  has  been  injured.  Occasionall}^  a  blood- 
stained motion  is  passed,  but  only  late  in  the  case. 

The  Diagnosis  of  a  ruptured  intestine  is  always  a  matter  of  uncer- 
tainty in  the  absence  of  emphysema  of  the  abdominal  walls,  which  is 
very  uncommon.  Formerly  it  was  supposed  that  free  air  or  gas  in 
the  peritoneal  cavity  would  be  certain  to  find  its  way  up  between  the 
liver  and  the  abdominal  wall ;  hence  loss  of  the  liver  dulness  was  con- 
sidered an  important  sign.  It  is  by  no  means  certain,  however,  that 
the  gas  does  travel  in  this  direction,  and  a  resonant  note  over  the  liver 
is  a  common  result  of  distension  of  the  colon.  If,  however,  the 
abdominal  wall  is  retracted  and  not  distended,  the  existence  of  this 
sign  is  suggestive.  The  amount  of  shock  is  also  an  uncertain  guide, 
as  it  varies  both  in  degree  and  duration.  The  temperature  does  not 
help  much,  although  a  secondary  fall  below  normal  after  reaction, 
especially  if  associated  with  increasing  rapidity  of  pulse  and  respira- 
tion, is  very  suggestive  of  grave  mischief.  The  presence  of  an  area 
of  deep  fixed  tenderness  and  pain  w^ith,  perhaps,  a  rigid  abdominal 
wall  over  it,  and  the  incidence  of  early  acute  peritonitis,  are  probably 
the  only  signs  that  we  can  depend  upon  with  any  certainty.  The 
history  and  nature  of  the  accident  are  important,  and  should  be  care- 
fully investigated. 

In  the  non-existence  of  any  distinct  signs  of  rupture,  Treatment  in 
the  early  stages  can  only  be  expectant,  and  directed  towards  com- 
bating the  shock  and  relieving  the  pain.  A  small  dose  of  opium 
should  be  administered  with  this  object,  and  also  to  check  peristalsis 
and  hinder  further  extravasation  of  the  intestinal  contents ;  but  as 
little  as  possible  should  be  given,  since  it  tends  to  mask  symptoms. 
If  the  surgeon  has  good  grounds  for  suspecting  that  the  intestine  is 
torn,  he  ought  at  once  to  undertake  an  exploratory  laparotomy,  and 
deal  with  the  condition  found. 

Punctures  or  Stabs  involving  the  intestine  lead  to  a  similar  series  of 
phenomena  ;  but  the  diagnosis  may  be  easier,  as  gas  or  faecal  material 
may  escape  through  the  external  wound.  The  direction  of  the  in- 
cision in  the  gut  is  of  importance,  since  a  longitudinal  cut  (running 
parallel  to  the  axis  of  the  bowel)  is  more  likely  to  gape  than  a  trans- 
verse one,  owing  to  the  greater  power  of  the  circular  muscle  fibres  ; 
a  small  puncture  may  be  almost  closed  by  a  protrusion  of  mucous 
membrane.  Shock  is  not  necessarily  so  severe  as  when  the  intestine 
is  ruptured  by  violence  without  penetration  ;  abdominal  pain  is 
always  present,  and  the  phenomena  of  acute  peritonitis  may  quickly 
follow. 

Treatment. — Every  case  of  suspected  penetration  should  be  care- 
fully explored.  The  skin  and  superficial  parts  of  the  wound  are  first 
thoroughly  purified,  and  then  the  wound  is  enlarged  and  the  deeper 
parts  are  examined.     If  the  peritoneum  is  not  opened,  the  different 


ABDOMINAL  SURGERY  1023 

layers  of  the  abdominal  wall  are  sutured  together.  If  the  peritoneum 
has  been  involved,  the  opening  in  it  should  be  enlarged,  so  as  to 
explore  the  viscera  and  determine  with  certainty  whether  or  not  the 
gut  has  been  wounded.  If  a  small  punctured  or  incised  wound  of 
the  intestine  is  present,  it  is  invaginated  and  closed  by  a  purse-string 
stitch  or  by  a  row  of  Czerny-Lembert  sutures.  If  a  more  extensive 
lesion  exists,  excision  of  the  damaged  portion  may  be  necessary  ;  but 
if  the  patient  is  deeply  collapsed  from  the  supervention  of  peritonitis, 
it  may  be  wiser  to  bring  the  divided  ends  to  the  abdominal  wall,  and 
form  a  temporary  artificial  anus,  which  is  subsequently  dealt  with 
when  the  patient's  general  condition  has  improved.  As  to  the  treat- 
ment of  the  resulting  peritonitis,  we  must  refer  to  what  has  been 
written  concerning  rupture  of  the  stomach  (p.  998). 

For  Grunshot  Wounds  and  their  treatment,  see  pp.  243  and  245. 

Perforation  of  the  Intestine  arises  from  many  different  causes,  such 
as  the  impaction  of  a  foreign  body,  or  the  yielding  of  an  intestinal 
ulcer,  as  occurs  in  tuberculous  disease  or  typhoid  fever,  or  from  that 
form  of  enteritis  which  follows  strangulated  hernia.  The  phenomena 
resulting  from  the  perforation  of  an  ulcer  of  the  stomach  or  duodenum 
have  been  already  discussed  (pp.  1000  and  1018),  and  another  variety 
caused  by  perforation  of  the  appendix  will  be  alluded  to  subsequently 
(p.  1048). 

When  the  jejunum  or  upper  portion  of  the  ileum  is  involved,  per- 
foration is  usually  due  to  the  impaction  of  a  foreign  body,  such  as  a 
fish-bone,  or  to  yielding  of  a  tuberculous  ulcer.  In  the  former  case, 
general  peritonitis  is  almost  certain  to  follow,  but  in  tuberculous 
cases  the  lesion  is  of  a  more  chronic  type,  and  then  adhesions  may 
form,  allowing  an  intraperitoneal  abscess  to  develop,  and  should  it 
open  externally,  a  faecal  fistula  follows.  In  not  a  few  cases  the 
process  of  cicatrization  may  lead  to  a  spontaneous  closure  of  the 
fistula,  and  no  operation  should  be  undertaken  until  sufficient  time 
has  elapsed  to  determine  whether  or  not  this  will  occur. 

In  the  lower  portion  of  the  ileum,  typhoid  fever  is  the  most  usual 
cause  of  perforation.  Occasionally  in  cases  of  the  so-called  '  ambula- 
tory typhoid  '  it  is  the  first  evidence  of  the  presence  of  the  disease,  but 
it  generally  occurs  about  the  end  of  the  second  or  in  the  third  week, 
and  rarely  more  than  one  perforation  is  present.  It  is  most  com- 
monly seen  in  bad  cases  associated  with  meteorism  and  haemorrhage, 
but  is  not  limited  to  such.  The  symptoms  are  usually  those  of 
sudden  collapse,  as  indicated  by  a  falling  temperature  and  a  quick 
and  feeble  pulse,  whilst  severe  and  persistent  abdominal  pain  followed 
by  increasing  distension  indicates  the  development  of  general  peri- 
tonitis. Even  when  the  patient  is  already  collapsed  by  the  disease, 
some  slight  fall  of  temperature  with  acceleration  of  the  pulse  may 
occur,  followed  by  abdominal  pain  and  meteorism.  Early  rigidity 
of  the  belly  wall  is  an  important  diagnostic  sign,  whilst  there  may  be 
some  irritability  of  the  bladder.  The  only  treatment  -'hich  holds  out 
any  prospect  of  saving  the  patient  is  operation,  but  owing  to  his 
depressed  condition  the  outlook  is  not  particularly  bright.    Obviously, 


1624  ^  MANUAL  OP  SURGERY 

when  he  is  moribund,  it  is  useless  to  interfere ,  but  the  facts  that  of 
some  300  cases  operated  on  and  reported  27  per  cent,  have  recovered, 
and  that  the  death-rate  has  gradually  fallen  from  90  to  69  per  cent., 
indicate  that  in  cases  diagnosed  early  a  fair  proportion  of  success 
may  be  anticipated.  The  abdomen  should  be  opened  in  the  middle 
line  below  the  umbilicus,  or  directly  into  the  right  iliac  fossa,  and  if 
the  lesion  is  not  at  once  obvious,  the  ileum  is  sought  for  at  its  junc- 
tion with  the  caecum,  and  the  bowel  brought  up  and  carefully 
examined  inch  by  inch  till  the  perforation  is  found ;  it  may  then 
either  be  closed  by  sutures  introduced  so  as  to  close  the  wound  in 
the  transverse  axis  of  the  gut  and  thus  diminish  the  risks  of  a  sub- 
sequent stenosis,  or  the  edges  of  the  ulcer  stitched  to  the  margins  of 
the  wound  so  as  to  create  a  temporary  fistula.  The  peritoneum  is 
cleansed  and  drained  in  the  usual  way,  after  determining  that  no 
second  perforation  is  present  or  imminent. 

In  the  large  intestine  the  most  common  cause  of  perforation  is 
ulceration  due  to  chronic  obstruction  or  malignant  disease.  Masses 
of  faeces  accumulate  within  the  bowel,  and  by  their  pressure  give 
rise  to  inflammation  of  the  walls,  which  runs  on  either  to  ulceration 
or  to  actual  necrosis.  Most  usually  the  peritoneum  is  by  this  means 
laid  open,  either  just  above  the  growth,  or  as  a  consequence  of  its 
local  extension  ;  sometimes,  however,  the  bowel  gives  way  at  a 
higher  level,  where  fasces  mainly  accumulate,  and  then  generally  in 
the  caecum.  In  many  cases  acute  perforative  peritonitis  follows, 
but  occasionally  the  mischief  is  limited,  and  an  intraperitoneal 
abscess  forms,  followed  by  a  faecal  fistula. 

Foreign  Bodies  in  the  intestine  are  of  three  types  : 

1.  Gallstones  give  rise  to  no  symptoms  unless  they  are  of  large 
size ;  the  smaller  ones  enter  the  canal  through  the  common  bile-duct 
after  an  attack  of  biliary  colic,  and  are  voided  in  the  stools.  Larger 
stones  usually  gain  entrance  to  the  intestine  by  ulceration  from  the 
gall-bladder  into  the  duodenum.  A  coating  of  faecal  matter  is  likely 
to  form  around  them,  and  thus  they  increase  in  size  as  they  pass 
downwards,  whilst  the  intestine  gradually  diminishes  in  calibre 
from  the  duodenum  to  the  ileum,  so  that  they  are  likely  to  become 
impacted  in  the  lower  ileum.  Women  over  fifty  are  most  often  the 
subjects  of  this  condition,  and  there  may  be  only  a  history  of  some 
inflammatory  condition  in  the  region  of  the  gall-bladder,  and  none  of 
biliary  colic. 

2.  Enteroliths  are  of  three  classes  :  (a)  Calculi  of  phosphate  of  lime 
or  inspissated  faeces  form  around  some  foreign  body  as  a  nucleus. 
(b)  Masses  of  indigestible  vegetable  material  may  be  matted  together 
with  inspissated  faeces,  mucus,  etc. ;  they  are  said  to  be  not  uncom- 
mon in  Scotland  (the  so-called  avenolith),  consisting  largely  of  the  husks 
of  coarse  oatmeal.  They  have  also  been  known  to  consist  of  hair,  or 
of  cocoanut  fibre  in  a  patient  engaged  in  mat-making.  (-:)  Calculi 
have  been  found  consisting  of  insoluble  mineral  salts^^.^.,  carbonate 
of  magnesia  or  chalk,  taken  as  medicine.  Whatever  their  origin, 
such  enteroliths  are  likely  to  become  impacted  near  the  caecum,  and 


ABDOMINAL  SURGERY  1025 

may  cause  acute  obstruction.     In  thin  persons  their  presence  may  be 
detected  by  palpation  of  the  abdomen. 

3.  Foreign  Bodies  accidentally  or  intentionally  swallowed  occasionally 
pass  through  the  stomach  and  become  lodged  in  the  intestinal  canal. 
Lunatics  and  children  are  most  frequently  affected,  and  in  the  former 
the  most  astonishing  collections  are  occasionally  found. 

The  Symptoms  caused  by  such  conditions  will  be  either  those  of 
intestinal  obstruction  (p.  1133)  or  of  perforation.  In  the  latter  the 
process  is  usually  gradual,  rather  than  sudden,  giving  time  for  adhe- 
sions to  form,  thereby  limiting  the  mischief.  Suppuration  follows, 
and  possibly  the  foreign  body  may  be  extruded  naturally  or  removed 
by  the  surgeon  through  the  abscess  cavity,  with  or  without  the  forma- 
tion of  a  faecal  fistula. 

Small  spiculated  foreign  bodies— !?.§■.,  fragments  of  glass  or  metal, 
the  husks  of  cereals,  etc. — may  sometimes  lodge  in  the  pouches  of  the 
colon,  and  give  rise  to  localized  inflammatory  phenomena,  perhaps  in 
one  or  more  of  the  appendices  epiploicse.  The  symptoms  will  very 
closely  resemble  those  of  a  localized  appendix  abscess,  and  similar 
operative  treatment  will  be  required.  In  other  cases  a  chronic  in- 
flammatory mass  may  be  produced  which  simulates  a  neoplasm  of  the 
intestinal  wall,  and  may  disappear  spontaneously  or  after  exploration. 
The  supposed  cure  of  certain  cases  of  intestinal  cancer  by  quack 
remedies  may  be  explained  in  'this  way. 

Enteritis,  or  inflammation  of  the  mucous  membrane  of  the  intestine, 
is  a  condition  usually  treated  by  the  physician  ;  occasionally  it 
complicates  surgical  cases  and  needs  effective  treatment.  Thus  it 
may  follow  the  exposure  of  a  coil  of  intestine  in  the  depths  of  a  wound 
which  has  to  be  packed  for  drainage  purposes.  Severe  diarrhoea  may 
result,  and  the  inflammation  may  even  spread  through  the  whole 
thickness  of  the  gut  wall,  and  lead  to  the  establishment  of  a  faecal 
fistula.  Enteritis  also  occurs  as  a  post-operative  complication  of 
strangulated  hernia  (p.  1124).  Whatever  its  origin,  it  is  always 
characterized  by  diarrhoea  of  varying  type,  and  by  pain  or  abdominal 
discomfort  and  perhaps  vomiting.  Treatment  consists  in  the  use  of  a 
bland  diet — e.g.,  milk — and  the  administration  of  soothing  astringent 
drugs,  such  as  bismuth  and  perhaps  opium.  It  must  not,  however, 
be  checked  without  ascertaining  so  far  as  possible  that  the  causative 
irritant  has  been  removed,  and  not  uncommonly  the  best  treatment 
to  start  with  is  the  administration  of  a  good  dose  of  castor  oil. 

Colitis  is  an  affection  occasionally  needing  surgical  treatment. 
The  cause  is  usually  chronic  constipation,  but  bacteria  of  various 
types  or  the  Amoeba  coli  may  be  present.  In  the  simpler  cases 
{rnucous  conns')  the  patient  complains  of  griping  pains  in  the  course  of 
the  colon,  diarrhoea,  the  passage  of  mucus  in  the  stools,  perhaps 
in  membranous  flakes,  and  definite  tenderness  of  the  colon  on 
palpation.  The  appendix  is  not  unfrequently  inflamed  at  the  same 
time,  and  one  of  the  most  tender  spots  may  be  over  this  organ. 
Treatment  of  this  form  consists  in  emptying  the  bowel  by  enemata, 
keeping  the  patient  quiet  in  bed  on  a  milk  diet,  and  possibly  ordering 

65 


1026  A  MANUAL  OF  SURGERY 

bismuth  or  a  little  chlorodyne.  When  the  patient  is  convalescent 
and  all  tenderness  has  disappeared,  the  causative  chronic  constipation 
must  be  treated.  Purgatives  usually  cause  irritation  and  pain,  and 
must  be  as  far  as  possible  avoided.  Abdominal  massage  and  the 
methodical  use  of  the  so-called  Swedish  exercises,  which  increase 
the  power  of  the  abdominal  muscles,  and  thereby  give  tone  to  the 
relaxed  colon,  will  often  work  wonders  in  these  cases.  The  use  of 
medicinal  waters  and  of  irrigation  of  the  colon,  as  practised  at 
Harrogate  and  Plombieres,  often  gives  excellent  results. 

The  graver  cases  (^ulcerative  colitis)  are  associated  with  the  discharge 
of  pus  and  the  exfoliation  of  patches  of  mucous  membrane.  The 
patient's  health  may  be  profoundly  affected  in  this  disease,  pus  of 
a  most  offensive  type  pouring  out  from  the  rectum,  or  fever  of 
a  marked  hfectic  character  being  present.  The  nutrition  is  necessarily 
impaired,  and  the  patient  wastes  to  a  shadow.  Under  such  circum- 
stances, and  especially  when  rectal  irrigation  has  failed,  the  surgeon 
may  be  asked  to  make  an  artificial  opening  into  the  caecum  in  order 
to  permit  of  more  thorough  irrigation,  and  also  perhaps  to  divert  the 
intestinal  contents.  For  the  method  of  operating,  see  p.  1034.  The 
fluid  employed  for  irrigation  must  be  bland,  non-toxic,  and  unirritating. 
Warm  saline  solution  should  be  first  used,  and  subsequently  a  weak 
boric  acid  solution,  or  possibly,  with  great  care,  a  i  in  5,000  solution 
of  nitrate  of  silver.  The  patient  sits"  over  a  bed-pan,  and  the  fluid 
is  injected  through  the  fistula  from  an  irrigator  ;  distension  of  the 
bov/el  must  be  avoided,  and  to  this  end  the  introduction  of  a  rectal 
speculum  to  keep  the  anus  open  during  the  irrigation  is  desirable. 
Latterly  the  vermiform  appendix  has  been  used  for  this  purpose  ;  it 
is  stitched  into  the  wound  and  opened  {appendicostomy),  and  the  bowel 
irrigated  through  it.  The  escape  of  intestinal  contents  is  less  than 
if  the  bowel  is  opened,  and  subsequent  closure  of  the  fistula  after  the 
disease  is  cured  is  more  easily  affected.  It  is  probable  that  some  amount 
of  stenosis  of  the  bowel  may  result  from  the  cicatrization  of  the  ulcers 
in  the  colon,  and  then  the  fistula  may  have  to  remain  permanently. 

Tuberculous  Disease  of  the  Intestine  usually  occurs  in  the  ileo- 
caecal  region,  and  manifests  itself  in  two  main  varieties  : 

I.  Tuberculoas  Ulcers  are  generally  multiple,  though  occasionally 
single.  They  are  of  the  usual  tuberculous  type,  with  undermined 
margins,  and  extend  along  the  course  of  the  bloodvessels  and  lym- 
phatics— viz.,  around  the  gut,  so  that  if  they  heal  stricture  is  almost 
certain  to  follow.  In  their  early  stages  they  do  not  require  surgical 
assistance,  but  later  on  obstructive  phenomena  may  supervene,  and 
these  may  be  due  not  only  to  the  stenosis,  but  also  to  associated  peri- 
tonitis; neighbouring  mesenteric  glands  are  usually  infected,  and 
together  with  the  bowel  and  omentum  may  form  a-  palpable  mass, 
in  the  midst  of  which  suppuration  may  occur.  Should  the  abscess 
burst  externally,  a  faecal  fistula  may  result.  Operation  may  be 
needed  for  the  relief  of  the  obstructive  phenomena,  or  for  the  sup- 
puration, and  some  form  of  anastomosis,  or  even  excision  of  the 
mass,  may  be  sometimes  required. 


ABDOMINAL  SURGERY  1027 

2.  The  disease  is  sometimes  of  a  hyperplastic  type,  and  is  then 
chiefly  limited  to  the  caecum,  producing  a  well-marked  tumour,  which 
can  be  palpated  from  outside,  known  as  the  Tuberculous  Caecal 
Tumour  ;  the  disease  is  liable  to  extend  along  the  ascending  colon  for 
some  distance,  and  less  frequently  along  the  ileum.  The  intestinal 
wall  is  thick,  congested,  and  infiltrated  with  a  tuberculous  deposit ; 
the  outer  coat  is  rough  and  nodulated  ;  the  mucous  lining  is  ulcerated 
and  often  presents  vegetations  and  polypi  of  a  granulomatous  type ; 
the  mass  is  firm,  but  not  hard  to  the  touch.  The  neighbouring 
mesentery  is  occupied  by  enlarged  glands,  and  these  may  also  be 
found  on  the  inner  border  of  the  ascending  colon.  Adhesions  may 
be  present,  and  lead  to  kinking  or  twisting  of  loops  of  bowel,  which 
may  assist  in  producing  intestinal  obstruction.  The  symptoms  vary 
a  good  deal,  but  in  the  early  stages  constipation  and  diarrhoea  may 
alternate,  whilst  later  on  obstructive  phenomena  may  supervene, 
or  even  well-marked  pyrexia  of  a  hectic  type.  The  diagnosis  from 
a  caecal  carcinoma  is  not  always  easy ;  the  chief  points  in  favour  of 
tubercle  are  the  earlier  age  (under  forty  years),  the  longer  duration 
of  symptoms  (two  or  three  years),  the  associated  pyrexia,  and  the 
presence  of  tuberculous  lesions  .elsewhere.  The  diagnosis  is,  however, 
not  uncommonly  made  on  the  operating-table.  Treatment  consists 
in  short  circuiting,  or  excising  the  mass.  The  latter  may  involve 
an  extensive  procedure,  but  even  when  enlarged  glands  have  to  be 
left  behind,  the  case  may  do  well. 

Stenosis  of  the  Intestine  arises  from  two  main  causes — the  contrac- 
tion of  cicatrices  or  adhesions,  and  the  development  of  tumours, 
usually  malignant. 

Simple  or  cicatricial  stricture  usually  results  (i)  from  the  healing 
of  ulcers  which  have  extended  more  or  less  circularly  around  the 
bowel,  or  have  involved  its  walls  extensively.  Hence,  tuberculous 
ulcers  lend  themselves  to  its  development  more  than  the  typhoid 
lesion,  and  it  is  a  little  doubtful  whether  it  has  ever  occurred  as  a 
sequela  of  the  latter.  Syphilitic  ulceration  is  followed  by  it,  especi- 
ally when  involving  the  rectum  ;  but  the  upper  part  of  the  jejunum 
is  also  occasionally  affected.  In  the  large  intestine  dysentery  is  the 
most  common  cause,  and  the  stenosis,  like  the  ulceration,  may  be 
irregular  and  extensive.  (2)  It  may  follow  strangulated  hernia  as 
the  result  of  ulceration  along  the  actual  site  of  constriction  ;  and, 
similarly,  it  may  develop  after  the  separation  of  an  intussusception. 
(3)  An  end-to-end  anastomosis  of  the  gut  may  lead  to  stenosis 
unless  considerable  care  is  taken  not  to  tuck  in  too  much  of  the 
gut  wall.  (4)  The  contraction  of  adhesions  outside  the  intestine  is  by 
no  means  an  uncommon  cause ;  thus  it  may  be  due  to  many  forms 
of  localized  peritonitis,  and  frequently  ensues  after  pelvic  cellulitis. 

Owing  to  the  contents  of  the  small  intestine  being  of  a  somewhat 
liquid  nature,  a  stricture  in  this  situation  often  exists  for  some  time 
before  symptoms  of  any  urgency  arise.  The  patient  may  complain 
of  a  certain  amount  of  indigestion  and  discomfort,  but  sooner  or  later 
the  narrowed  aperture  of  the  gut  becomes  blocked  either  by  a  fold 


I028  A  MANUAL  OF  SURGERY 

of  mucous  membrane  or  by  a  portion  of  undigested  food,  and  thus  an 
attack  of  obstruction  is  induced.  In  the  early  stages  of  the  disease 
this  can  be  overcome  and  remedied  by  purgatives,  but  each  recur- 
rence is  likely  to  increase  in  severity,  until  finally  an  acute  attack 
supervenes,  which  kills  the  patient,  unless  relieved  by  prompt 
surgical  interference. 

In  the  layge  intestine  very  similar  phenomena  appear,  but  the  attacks 
of  obstruction  are  of  a  somewhat  different  character,  since  there  is 
less  pain  and  vomiting ;  and  aperients,  instead  of  relieving  the  patient, 
as  they  often  do  in  the  earlier  attacks  in  the  small  gut,  always  aggra- 
vate the  symptoms  ;  there  is  also  much  greater  distension  of  the 
abdomen.  The  diagnosis  of  stricture,  though  strongly  suggested  by 
the  symptoms,  can  only  be  confirmed  absolutely  by  an  exploratory 
operation,  except  when  the  lower  part  of  the  rectum  is  involved. 

The  Treatment  in  the  earlier  stages  consists  of  suitable  dieting,  and 
the  administration  of  purgatives  or  of  larger  enemata,  and  for  a  time 
such  will  be  successful.  Sooner  or  later,  however,  a  more  than  usually 
serious  attack  of  obstruction  will  call  for  something  more  radical,  and 
readers  are  referred  to  the  chapter  on  obstruction  for  details  of  the 
treatment  to  be  adopted.  If  on  operating  the  stricture  is  found  and 
recognised,  enteroplasty  or  enterectomy  should  be  undertaken  if  the 
small  gut  is  involved.  For  stricture  of  the  caecum  or  ascending 
colon,  some  short-circuiting  method,  whereby  the  ileum  is  implanted 
into  the  colon  below  the  stricture  (ileo-colostomy),  is  perhaps  the  best 
plan  to  adopt ;  in  the  transverse  colon  excision  is  possible,  as  also  in 
the  sigmoid  flexure.  Failing  any  of  these  measures,  the  establish- 
ment of  an  artificial  anus  will  be  required  to  give  relief.  It  must  be 
remembered,  however,  that  no  permanent  opening  of  this  nature  can 
be  made  in  the  small  intestine  since  the  absorption  of  nourishment  is 
thereby  so  interfered  with  that  death  from  asthenia  is  certain  to 
follow  in  a  comparatively  short  time,  whilst  the  intestinal  contents 
are  fluid  and  extremely  irritating  to  the  skin. 

Tumours  of  the  Intestinal  Wall  may  be  simple  or  malignant, 
primary  or  secondary.  Simple  tumours  are  unusual,  and  consist  of 
papilloma,  adenoma,  myoma,  lipoma,  and  a  few  other  varieties. 
They  may  cause  irritation  and  irregular  action  of  the  gut,  resulting, 
perchance,  in  intussusception  (p.  1140)  ;  haemorrhage,  sometimes  of  a 
serious  character,  is  associated  with  multiple  papilloma  or  adenoma  ; 
and  obstruction  occasionally  ensues.  It  is  unusual  for  a  diagnosis 
to  be  made  apart  from  an  exploratory  laparotomy,  unless  the  rectum 
is  affected.  The  treatment  is  governed  by  the  location  of  the  growth 
and  by  the  symptoms  it  causes. 

Sarcoma  of  the  intestine  is  not  common ;  it  may  involve  the  ileum 
or  caecum,  and  give  rise  to  a  localized  tumour  or  diffuse  infiltration. 
Obstruction  may  ensue,  or  considerable  peritoneal  irritation  resulting 
in  an  abundant  blood-stained  exudation  which  leads  to  abdominal 
distension,  and  may  be  recognised  as  due  to  a  new  growth  on  tap- 
ping. Treatment  consists  in  removal  of  the  affected  coil  of  gut  if  the 
disease  has  not  progressed  too  far. 


ABDOMINAL  SURGERY 


1029 


Cancer  of  the  Eowel  is  almost  always  primary  in  nature,  and  is 
then  usually  a  columnar  carcinoma,  to  which  colloid  degeneration  is 
sometimes  added.  The  small  intestine  is  rarely  involved,  but  any 
part  of  the  colon  may  be  affected,  and  even  the  vermiform  appendix. 
Secondary  growths  are  occasionally  met  with,  and  are  necessarily  of 
the  same  nature  as  the  original  tumour.  The  physical  characters  of 
the  growth  vary  considerably,  but  usually  conform  to  one  of  two 
types — viz.,  (i.)  the  hypertrophic,  in  which  a  large  mass  forms,  perhaps 
occupying  the  whole  lumen  of  the  bowel.  It  is  a  fairly  rapid 
growth,  and  usually  associated  with  ulceration  and  haemorrhage, 
whilst  obstructive  phenomena  are 
late  in  appearing.  (ii.)  In  the 
sclerosing  form  the  tumour  develops 
as  an  annular  constriction  around 
the  bowel,  the  lumen  of  which  is 
contracted  so  that  it  may  be  al- 
most impossible  to  pass  a  crow's 
quill  or  a  probe  through  it  (Fig. 
457).  It  is  an  astonishing  feature 
of  these  cases  that  the  function  of 
the  bowel  is  carried  on  without 
much  pain  or  difEculty  until  the 
lumen  is  almost  obliterated,  and 
then  suddenly  a  serious  attack  of 
obstruction  occurs.  Sometimes 
the  bowel  looks  from  outside  as  if 
a  piece  of  string  had  been  tied 
round  it,  so  great  is  the  constric- 
tion. Above  the  growth  the  bowel 
is  hypertrophied  and  dilated ;  the 
mucous  membrane  is  often  con- 
gested, inflamed,  and  even  ulcer- 
ated ;  the  latter  lesion  is  usually 
due  to  the  irritation  of  stagnant 
faeces,  and  the  ulcers  are  termed 
'  stercoral.'  Bacteria  may  find 
their  way  into  and  through  the 
intestinal  wail  from  these  foci,  and 

lead  to  peri-intestinal  suppuration,  and  as  a  sequela  a  faecal  fistula 
may  develop.  The  bowel  below  the  growth  is  often  distended 
('ballooned')  from  paralysis  of  its  walls,  and  the  development  of 
gases  from  the  faecal  material  which  may  accumulate  from  the  loss 
of  the  vis  a  tergo ;  this  can  often  be  remarked  in  cancer  of  the 
rectum. 

The  irritation  of  the  tumour  leads  sooner  or  later  to  the  formation 
of  adhesions,  which  may  assist  in  hampering  the  action  of  the  bowel. 
Secondary  deposits  occur  in  the  mesenteric  glands  and  omentum, 
and  less  commonly  in  the  liver  or  distant  regions ;  but  there  can  be 
no  question  that  the  growth  is  often  much  less  malignant  in  type 


Fjg.  457. 


—  Carcinoma   of    the    De- 
scending Colon. 


The  growth  was  of  the  sclerosing  type, 
and  had  given  rise  to  no  symptoms 
except  a  little  diarrhoea  until  the 
onset  of  a  fatal  attack  of  obstruction. 


I030  A  MANUAL  OF  SURGERY 

than  cancer  elsewhere,  and  both  adhesions  and  secondary  deposits 
are  usually  late  developments. 

The  Symptoms  are  at  first  vague  in  the  extreme,  and  the  disease 
is  likely  to  have  progressed  for  some  time  before  a  diagnosis  is 
reached.  The  patient  complains  of  indigestion  of  an  intestinal  type  ; 
there  may  be  some  pain  of  a  colicky  character,  and  either  constipa- 
tion or  diarrhoea  may  be  present ;  not  unfrequently  they  alternate, 
the  constipation  being  primary,  and  the  diarrhoea  resulting  from  the 
decomposition  of  retained  faeces,  or  a  catarrhal  enteritis  set  up 
thereby.  A  discharge  of  mucus  or  blood  may  be  noticed  in  the 
stools,  and  the  patient's  nutrition  begins  to  suffer,  although  wasting 
is  at  first  slow. 

The  conditions  which  may  require  and  justify  interference  by  the 
surgeon  areas  follows:  (i)  Repeated  attacks  of  slight  obstruction, 
especially  if  localized  resistance  of  the  abdominal  wall  or  an  in- 
definite sense  of  fulness  in  some  region  is  associated  therewith  ;  (2)  an 
acute  attack  of  obstruction,  the  nature  and  symptoms  of  which  vary 
with  the  site  of  the  lesion ;  (3)  the  existence  of  a  tumour,  which, 
though  at  first  readily  moveable,  becomes  fixed  after  a  while,  owing 
to  the  formation  of  adhesions ;  and  (4)  the  development  of  a  peri- 
intestinal  abscess.  On  the  other  hand,  if  it  is  evident  that  secondary 
deposits  are  present  in  the  omentum  or  elsewhere,  and  the  primary 
growth  is  so  large  or  fixed  that  its  removal  is  doubtful,  it  is  useless 
to  undertake  merely  an  exploratory  operation.  In  these  cases  it  will 
suffice  to  interfere  when  obstructive  phenomena  make  their  appear- 
ance. The  mere  handling  of  such  a  growth,  the  inner  surface  of 
which  is  probably  ulcerated,  is  sometimes  sufficient  to  determine 
increased  activity  of  the  bacteria,  and  the  development  of  an  abscess 
around  the  growth,  which  may  be  followed  by  diffuse  or  localized 
peritonitis,  and  even  by  a  faecal  fistula. 

Treatment. — Except  under  the  circumstances  just  mentioned, 
whenever  a  diagnosis  of  malignant  disease  of  the  bowel  has  been 
made  or  is  suspected,  an  exploratory  laparotomy  is  justifiable  in 
order  to  confirm  or  disprove  the  fact.  Unfortunately,  cases  are 
usually  left  until  the  progress  of  the  disease  has  settled  the  question, 
and  then  palliative  treatment  may  alone  be  possible.  If  found  early 
enough,  the  growth,  together  with  a  good  margin  of  healthy  tissue 
on  either  side,  should  be  removed,  and  the  intestinal  canal  restored 
by  enterorrhaphy.  Affected  mesenteric  glands  are  included  in  the 
part  excised,  if  possible,  but  the  total  removal  of  the  growth  is  quite 
justifiable,  even  if  glands  have  to  be  left,  inasmuch  as  it  restores  the 
functional  activity  of  the  tube.  It  must  be  remembered,  however, 
that  unless  the  bowel  has  been  thoroughly  emptied  previously  it  is 
always  wiser  to  make  a  temporary  artificial  anus,  and  restore  the 
continuity  of  the  canal  at  a  later  date.  Hence  excision  should  never 
be  undertaken  when  obstruction  is  present. 

Should  excision  be  impracticable  owing  to  the  extent  or  fixity  of  the 
tumour,  the  following  plans  of  treatment  may  be  considered,  and  that 
which  best  suits  the  requirements  of  the  particular  case  undertaken. 


ABDOMINAL  SURGERY 


1031 


1.  The  growth  m.iy  be  short -circuited  by  uniting  portions  of  gut 
above  and  below  it.  This  is  usually  accomplished  by  one  of  the 
forms  of  lateral  anastomosis  described  hereafter  ;  thus,  the  caecum 
may  be  attached  to  the  sigmoid  flexure  in  a  case  of  cancer  of  the 
transverse  colon. 

2.  The  bowel  may  be  entirely  divided  above  the  tumour,  and  the 
upper  end  implanted  into  the  gut  below  it,  the  lower  end  of  the 
divided  bowel  being  closed  (Fig.  458).  This  lateral  implantation  is 
the  best  plan  of  treatment  to  employ  for  cancer  of  the  caecum  which 
cannot  be  extirpated  ;  the  ileum  is  divided  above  the  valve,  and  its 
upper  end  implanted  into  the  ascending  or  transverse  colon  well 
beyond   the    growth   (ileo-colos- 


tomy),  whilst  the  lower  end   is 
totally  closed. 

3.  The  affected  coil  of  gut  has 
been  excluded  from  the  intestinal 
tube  by  dividing  the  bowel  above 
and  below,  and  uniting  the  upper 
and  lower  segments.  One  end 
of  the  diseased  coil  is  closed,  and 
the  other  is  brought  to  the  sur- 
face and  fixed  there  so  as  to 
establish  a  fistulous  track.  There 
is  always  a  certain  amount  of 
discharge  from  the  cancerous 
growth,  and  the  mucous  mem- 
brane itself  secretes,  so  that 
total  closure  of  the  excluded 
loop  would  be  accompanied  by 
danger. 

4.  Finally,  if  none  of  these 
measures  are  applicable,  or  if 
the  patient's  condition  is  such  as  to  make  it  unwise  to  attempt  them, 
and  if  the  growth  is  situated  in  the  colon,  an  artificial  anus  may  be 
established. 

Idiopathic  Dilatation  of  the  Colon  (Hirschsprung's  Disease)  is  a 
rare  affection  met  with  in  infancy,  but  occasionally  lasting  on  till 
young  adult  life.  The  cause  in  many  cases  is  unknown,  but  con- 
genital contraction  of  the  rectum  has  been  found  in  some.  It  is 
characterized  by  enormous  distension  of  the  colon,  and  usually  of  the 
sigmoid  flexure  ;  possibly  on  opening  the  abdomen  nothing  but  the 
colon  is  seen.  The  walls  are  hypertrophied,  and  stercoral  ulcers  may 
be  present.  The  abdomen  is  distended,  but  soft  and  free  from 
rigidity  ;  the  child  does  not  complain  of  pain  and  tenderness,  and 
vomiting  is  unusual.  The  most  prominent  symptom  is  constipation, 
and  that  generally  of  a  most  obstinate  character,  purgatives  having  no 
effect  but  to  cause  pain  and  vomiting.  Enemata  are  often  retained, 
and  even  gas  cannot  easily  be  passed  ;  the  introduction  of  a  long 
flatus-tube  is  followed  by  the  escape  of  very  putrid  gas   in   large 


Implantation  of 
Ileum    into    the 


Fig.    458.  —  7.ATERAL 

DivjDED    End    of 

Transverse    Colon    for    Irremove- 

ABLE  Cancer  of  the  Cjecvm  (Ileo- 

colostomy). 


I032  '  A  MANUAL  OF  SURGERY 

quantities.  Death  results  from  cachexia,  perforative  peritonitis,  or 
obstruction.  Treatment. — Purgatives  must  be  avoided,  but  massage 
and  electricity  may  do  good,  together  with  the  routine  use  of  enemata.. 
Excision  of  the  distended  portion,  followed  by  a  lateral  anastomosis, 
is  probably  the  best  surgical  treatment.  In  one  case,  operated  on  by 
Sir  F.  Treves,  excision  of  the  rectum,  sigmoid  flexure,  and  descend- 
ing colon  was  performed,  and  the  transverse  colon  was  dragged  down 
and  fixed  in  the  perineal  opening. 

Enteroptosis,  or  Glenard's  disease,  is  a  condition  not  uncommonly 
met  with  in  which  there  is  a  general  displacement  downwards  of  the 
viscera.  The  small  intestine,  transverse  colon,  kidneys,  and  stomach 
are  the  organs  chiefly  involved,  but  any  of  the  viscera  may  be  affected. 
The  cause  varies  and  cannot  always  be  ascertained  ;  sometimes  it 
commences  after  an  acute  illness,  more  usually  it  is  chronic  and 
develops  gradually.  The  relaxed  abdominal  wall  which  follows 
repeated  pregnancies  is  often  present,  and  tight -lacing  may  be  an 
important  causative  factor.  Women  are  much  more  frequently 
affected  than  men.  The  condition  ^er  $e  is  not  necessarily  associated 
with  symptoms,  but  in  a  considerable  number  of  cases  marked  neuras- 
thenia is  present,  possibly  from  the  drag  of  the  viscera  upon  the 
sympathetic  plexuses  in  the  posterior  abdominal  wall.  The  amount 
of  displacement  is  no  measure  of  the  severity  of  the  symptoms.  The 
stomach  may  be  well  below  the  costal  arch,  and  when  inflated  stands 
out  prominently,  both  curvatures  being  visible ;  it  is  usually  dis- 
tended atonically,  and  succussion  sounds  may  be  heard.  The  relaxa- 
tion of  the  small  intestines  is  alluded  to  in  connection  with  the 
aetiology  of  hernia  (p.  1088).  The  transverse  colon  may  sag  down- 
wards almost  into  the  pelvis,  and  the  kinking  of  the  splenic  and 
hepatic  flexures  thereby  induced  may  be  an  important  element  in 
the  production  of  constipation.  The  spleen  and  liver  may  also  slip 
downwards.  Displacement  of  the  kidneys  is  referred  to  under  the 
heading  '  Moveable  Kidney.' 

Treatment  must  be  wisely  modified  according  to  circumstances,  and 
due  allowance  made  for  the  neurasthenic  element.  A  course  of  Weir 
Mitchell  treatment  {i.e.,  rest  and  feeding)  is  often  valuable,  both  for 
its  influence  on  the  nervous  state  and  also  in  assisting  to  increase  the 
deposit  of  fat.  Electricity  and  massage  to  the  abdominal  walls,  to- 
gether with  suitable  gymnastic  exercises,  help  to  restore  their  tone 
and  to  improve  the  condition  of  the  underlying  viscera.  An  ab- 
dominal belt  or  bandage  will  do  much  to  relieve  symptoms,  especially 
if  applied  with  the  patient  in  the  Trendelenburg  position.  Operation 
is  not  to  be  lightly  undertaken  ;  but  if  a  fair  test  has  been  given  to 
the  above  measures,  it  may  be  justifiable  to  open  the  abdomen  and 
stitch  up  into  place  organs  like  the  stomach,  liver,  or  spleen,  or  to 
brace  up  the  abdominal  wall  by  some  plastic  operation,  such  as 
that  suggested  on  p.  11 12.  For  treatment  of  moveable  kidney,  see 
p.  1 182.  The  question  of  removing  or  short-circuiting  the  kinked 
colon  may  also  have  to  be  considered. 


ABDOMINAL  SURGERY 


1033 


Operations  on  the  Intestines. 

1.  Enterotomy  is  a  term  which  is  only  correctly  applied  to  an  in- 
cision made  into  the  intestine  either  for  the  removal  of  a  foreign  body 
or  for  the  examination  of  its  interior.  The  wound  should  always  be 
placed  in  the  longitudinal  axis  of  the  gut,  and  along  its  anti-mesenteric 
border ;  it  is  closed  by  a  row  of  Lambert,  Czerny-Lembert,  or  Hal- 
stead  stitches. 

2.  Enterostomy,  or  the  formation  of  an  artificial  opening  into  the 
bowel,  may  be  undertaken  for  several  reasons,  and  any  part  of  the 
gut  may  be  opened,  [a)  The  jejunum  may  be  brought  to  the  surface 
and  opened  (jejunostoniy)  in  cases  of  cancer  of  the  stomach  where 
gastro-enterostomy  and  pylorectomy  are  impossible  and  the  patient 

.  is  dying  of  inanition  ;  he  can  subsequently  be  fed  by  the  fistula  in 
this  way  produced,  {h)  The  ileum  may  need  to  be  opened  and 
drained  in  cases  of  obstruction  not  lower  than  the  caecum  or  ascend- 
ing colon,  when  the  small  gut  is  much  distended  and  the  patient's 
general  condition  so  bad  that  no  prolonged 
search  for  the  cause  and  no  attempt  to  deal 
directly  with  it,  even  if  obvious,  are  possible. 
The  abdomen  is  opened  either  in  the  middle 
line  or  in  the  right  iliac  region ;  a  suitable 
distended  coil  is  withdrawn  and  opened  after 
carefully  protecting  the  peritoneal  cavity 
from  fsecal  infection.  A  large  trocar  and 
cannula  are  first  introduced,  so  as  to  allow 
the  first  gush  of  flatus  and  fluid  contents  of 
the  gut  to  escape ;  the  opening  is  then  en- 
larged and  a  Paul's  (glass)  tube  tied  in 
(Fig.  459)  by  means  of  a  purse-string  suture 
passing  in  and  out  through  the  whole  thick- 
ness of  the  bowel  wall,  and  the  affected  coil 
of  intestine  fixed  to  the  abdominal  wall.  A  thin  tube  of  rubber  is 
attached  to  the  other  end  of  the  glass  tube,  and  through  this  the 
intestinal  contents  are  temporarily  allowed  to  escape  without  con- 
tamination of  the  peritoneal  cavity  or  of  the  wound. 

If  the  patient  recovers  from  the  acute  symptoms,  a  second  opera- 
tion will  be  needed  in  order  to  re-establish  the  continuity  of  the 
intestinal  canal.  Life  is  not  likely  to  be  of  long  duration  if  an 
artificial  opening  exists  above  the  caecum,  as  the  exclusion  of  the 
absorbing  mucous  surface  of  the  large  intestine  seriously  hampers 
nutrition. 

{c)  Colostomy,  or,  as  it  is  more  usually  termed,  '  colotomy,'  is 
frequently  employed  in  dealing  with  diseases  of  the  lower  bowel, 
and  is  an  extremely  successful  proceeding. 

The  character  of  the  artificial  opening  varies  considerably  accord- 
ing to  whether  or  not  it  is  intended  to  be  a  permanent  condition.  If 
merely  a  temporary  opening  is  required,  the  smaller  the  portion  of 
bowel   secured   to   the   parietes   the    better,   since   the   subsequent 


Fig.  459. — Paul's  Tudes 
(Glass),  Large  and 
Small  Sizes. 


1034  A  MANUAL  OF  SURGERY 

operation  for  its  closure  is  so  much  simpler  (Fig.  460).  But  where 
a  permanent  aperture  has  to  be  established,  the  surgeon's  aim  should 
be  to  divert  totally  the  course  of  the  faeces ;  and  hence  it  is  desirable 
to  withdraw  a  portion  of  the  gut  from  the  abdominal  cavity,  and  to 
cut  away  a  complete  segment,  including  also,  if  possible,  a  portion 
of  the  mesentery.  By  this  means  the  upper  and  lower  openings  are 
brought  to  the  surface  of  the  skin,  and  separated  from  one  another 
by  an  area  of  cicatricial  tissue  representing  the  section  of  the  mesen- 
tery, and  constituting  the  best  form  of  '  spur '  that  can  be  developed 
(Fig.  461).  .  .       „ 

The  ascending  colon,  or  preferably  the  ccBcum,  is  occasionally  opened 
in  cases  of  membranous  or  ulcerative  colitis  where  there  is  an  abun- 
dant secretion  of  pus,  and  the  patient's  life  is  threatened  by  pyrexia 
and  toxic  exhaustion.  The  object  of  the  operation  is  twofold — viz., 
to  prevent  the  irritation  caused  by  the  passage  of  the  faeces  over  the 
ulcerated  mucous  membrane,  and  to  permit  the  colon  to  be  irrigated. 
Inasmuch  as  the  contents  of  the  bdwel  at  this  level  are  fluid  and  very 
acid,  it  is  wise  to  make  the  opening  as  small  as  possible,  and  this  may 
be  done  by  stitching  firmly  into  the  bowel  a  piece  of  rubber  drainage- 
tube  as  in  Witzel's  operation  for  gastrostomy  (p.  1013)  and  then  fixing 
the  bowel  to  the  skin  and  abdominal  muscles.  It  is  possible,  how- 
ever, that  in  spite  of  every  precaution  the  skin  will  become  irritated. 
If  the  opening  has  to  remain  for  some  time,  the  patient  must  be 
provided  with  an  abdominal  belt  to  which  is  fitted  an  elastic  pad 
carrying  a  solid  rubber  plug  which  fits  into  the  opening. 

Intestinal  obstruction  at  the  hepatic  flexure  sometimes  necessitates 
a  caecal  colostomy,  which  is  performed  as  for  the  small  intestines,  a 
Paul's  tube  being  tied  in.  A  secondary  operation  is  usually  required 
in  order  to  excise  the  cause  of  the  obstruction,  or  to  short-circuit  it. 

The  transverse  colon  is  most  likely  to  require  opening  for  obstruc- 
tion located  in  the  splenic  flexure,  as  by  carcinoma  or  adhesions.  In 
all  probability  the  source  of  the  trouble  has  not  been  recognised  prior 
to  operation ;  the  abdomen  is  explored  through  an  incision  in  the 
middle  line,  and  in  order  to  relieve  the  urgent  symptoms  the  dis- 
tended transverse  colon  has  to  be  opened  at  once  and  a  Paul's  tube 
tied  in.  If  the  case  is  less  urgent,  and  yet  a  considerable  amount  of 
faecal  material  is  present  in  the  gut,  a  small  portion  should  be  stitched 
to  the  surface,  and  after  adhesions  have  formed,  it  may  be  opened 
and  drained  for  a  few  days.  Necessarily  the  situation  is  not  a 
desirable  one  for  an  artificial  anus,  and  therefore  it  should  be  only 
of  a  temporary  character.  When  the  bowel  has  been  satisfactorily 
emptied,  the  abdomen  should  be  again  opened,  and  some  form  of 
anastomosis  performed  to  short-circuit  the  obstruction  if  excision  of 
the  growth  is  impossible. 

The  descending  colon  or  sigmoid  flexure  is  the  most  frequent  situa- 
tion for, colostomy.  Two  chief  methods  have  been  employed^viz., 
the  lumbar  operation,  in  which  the  upper  part  of  the  descending  colon 
is  reached  behind  or  through  the  peritoneum,  and  the  iliac,  in  which 
the  upper  part  of  the  sigmoid  flexure  or  lower  end  of  the  descending 
colon  is  brought  to  the  surface  after  opening  the  peritoneal  cavit}'. 


ABDOMINAL  SURGERY 


I03S 


Uses  of  Left  Lumbar  ov  Iliac  Coloslomy.- — The  operation  is  required 
under  the  following  conditions:  (i)  For  congenital  absence  of  the 
rectum,  when  a  perineal  incision  has  failed  to  discover  it;  (2)  for 
chronic  obstruction  of  the  lower  end  of  the  large  intestine,  which 
cannot  be  relieved  by  enemata  or  medical  means,  such  as  that  arising 
from  simple  or  malignant  stricture,  or  from  the  pressure  of  pelvic 
tumours  ;  (3)  for  carcinoma  of  the  rectum  or  sigmoid  flexure,  whether 
obstruction  is  present  or  not,  if  a  radical  operation  is  impracticable, 
or  as  a  preliminary  to  excision  ;  (4)  for  some  cases  of  syphilitic  and 
other  forms  of  ulceration  of  the  rectum,  which  cannot  heal  as  long  as 
they  are  irritated  by  the  passage  of  faeces  ;  (5)  for  irremediable  cases 
of  recto  -  vesical  and  recto  -  vaginal  fistula,  whatever  their  origin  ; 
(6)  for  volvulus  of  the  sigmoid  flexure,  the  iliac  operation  being 
needed  not  only  to  relieve  the  obstruction,  but  also  to  prevent 
recurrence. 

Left  Lumbar  Colostomy  (Amussat's  Operation)  has  been  much 
neglected  of  recent  years,  and  practically  replaced  by  its  iliac  rival. 


,./       .--- 

/  {(  V"'' 

•¥■;..,„ 

•  *^ 

^           / 

"^    -, 

,f 

.         ,vi».. 

Fig.  460. — Diagram  of  Temporary  Fig.  461. — Diagram  of  Permanent  Colo- 
CoLosTOMY,  SHOWING  THE  Single  stomy,  showing  the  Two  Openings 
Opening  on  a  Level  with  the  separated  One  from  the  Other  by  a 
Skin,  the  Passage  TO  the  Lower  Section  of  the  Mesentery. 
Bowel  being  merely  blocked  by  ^he  dotted  portion  indicates  the  amount  of 
a  Spur  of  Mucous  Membrane.  ^f  ^owel  cut  away  ;  but,  of  course,  such 

an  extensive  resection  is  only  practicable 
when  there  is  a  very  long  mesentery, 
which  is  unusual. 

Performed  as  it  was  in  the  old  days  without  opening  the  peritoneal 
cavity,  this  operation  was  certainly  not  a  desirable  one ;  but  if  the 
method  described  below  is  adopted,  it  will  probably  be  found  as 
efficient  as  the  iliac  proceeding.  The  patient  lies  on  the  right-  side, 
with  a  sandbag  beneath  the  loin,  so  as  to  increase  the  space  between 
the  last  rib  and  the  crest  of  the  ilium.  The  position  of  the  colon  is 
indicated  by  a  vertical  line  drawn  upwards  from  a  point  \  inch 
behind  the  centre  of  another  line,  passing  from  the  anterior  to  the 
posterior  superior  iliac  spine. 


1036  A  MANUAL  OF  SURGERY 

The  centre  of  the  incision  should  correspond  to  this  line  midway 
between  the  last  rib  and  the  crest  of  the  ilium.  It  should  be  made 
parallel  to  the  last  rib,  and  for  practical  purposes  may  commence  at 
the  outer  border  of  the  erector  spinae,  and  pass  outwards  for  about 
4  or  5  inches  (Fig.  507,  A,  p.  11 79).  This  incision  is  carried  through 
the  layers  of  the  abdominal  muscles,  dividing  the  latissimus  dorsi 
and  a  small  portion  of  the  external  oblique,  and  beneath  this  the 
posterior  attachments  of  the  internal  oblique  and  transversalis 
muscles,  constituting  the  fascia  lumborum.  The  last  dorsal  nerve 
and  first  lumbar  artery  are  often  divided,  and  the  outer  fibres  of  the 
quadratus  lumborum  are  notched,  if  necessary.  The  deeper  portions 
of  the  wound  are  now  held  apart  by  spatulge,  and  the  loose  fatty 
subperitoneal  tissue  gently  torn  through  with  the  fingers  and 
forceps. 

If  the  gut  is  distended,  it  may  at  once  come  into  view  ;  but  if 
collapsed,  it  is  not  recognised  at  first.  In  about  20  to  30  per  cent. 
of  individuals  a  true  peritoneal  descending  meso-colon  is  present. 
Under  any  circumstances  the  peritoneum  is  opened  in  the  anterior 
portion  of  the  wound,  and  the  colon  definitely  looked  for  and 
identified.  The  highest  portion  that  can  be  reached  is  secured,  so 
that  there  shall  be  no  slack  intestine  above  the  opening  to  give  rise 
later  on  to  prolapse ;  for  choice,  one  fixes  the  end  of  the  transverse 
colon  to  the  skin. 

If  the  case  is  not  urgent,  the  loop  of  bowel  is  withdrawn  and 
secured  to  the  skin  by  sutures  through  the  seromuscular  coats  ;  the 
rest  of  the  parietal  incision  is  closed.  After  a  few  days  the  bowel  is 
opened.  It  is  well  to  fix  it  as  far  back  in  the  wound  as  possible,  so 
as  not  to  leave  a  pocket  behind  in  which  discharges  can  accumulate. 
If,  however,  urgent  obstruction  is  present,  requiring  immediate 
relief,  the  bowel  is  drawn  out  of  the  wound  and  opened  with  the 
same  precautions  as  in  the  iliac  procedure.  A  trocar  and  cannula  is 
introduced  to  give  exit  to  the  first  gush  of  flatus  and  fluid  faecal 
matter,  and  then  a  Paul's  tube  is  tied  in,  the  bowel  stitched  to  the 
skin,  and  the  rest  of  the  wound  closed. 

Lumbar  colostomy  is  not  much  in  favour  at  the  present  day,  but 
there  are  eminent  and  up-to-date  surgeons  w'ho  maintain  that  in 
reality  a  lumbar  opening  is  more  comfortable  and  convenient  than 
one  in  the  iliac  fossa,  and  that  it  is  much  easier  to  control  the  escape 
of  faeces  than  in  the  latter  proceeding. 

Iliac  Colostomy,  or  Littr^'s  Operation,  consists  in  opening  the  lower 
portion  of  the  colon  or  sigmoid  flexure  through  the  anterior  abdominal 
walk  An  incision  2  or  3  inches  in  length  is  made  at  right  angles  to 
a  line  extending  from  the  anterior  superior  spine  to  the  umbilicus, 
the  centre  of  the  incision  corresponding  to  the  junction  of  the  outer 
and  middle  thirds  (Fig.  449,  D).  The  abdominal  parietes  are  divided, 
either  in  the  line  of  the  cutaneous  incision,  or  by  McBurney's  method 
of  splitting  the  muscles  in  the  line  of  the  fibres ;  the  latter  is  only 
desirable  when  there  is  but  little  distension,  and  when  it  is  not  neces- 
sary to  make  an  extensive  exploration  of  the  viscera.     The  sigmoid 


ABDOMINAL  SURGERY 


1037 


flexure  is  sought  for,  and  recognised  by  the  presence  of  the  appen- 
dices epiploicae  and  the  longitudinal  bands  of  muscle  fibres.  It  is 
gently  drawn  out,  and  the  upper  part  is  selected  for  fixation  in  the 
wound,  so  as  to  diminish  the  risk  of  subsequent  prolapse.  Many 
different  plans  of  fixing  it  are  in  vogue,  but  probably  the  simplest 
and  most  effective  is  to  pass  a  strong  silk  thread  through  the  parietes 
and  parietal  peritoneum  on  either  side  of  the  wound,  the  stitch 
traversing  the  mesentery  en  route.  It  is  then  passed  through  the  same 
structures  once  more  in  the  same  way,  but  at  a  distance  of  about 
^  inch  from  the  former  (Fig.  462).  The  loose  ends  are  tied  together, 
so  as  to  bring  the  parietal  peritoneum  and  sigmoid  meso-colon  into 
close  apposition.  A  few  additional  stitches  should  be  inserted, 
uniting  the  skin  to  the  longitudinal  muscular  bands  at  each  end 
of  the  incision,  thereby  preventing  any  subsequent  retraction  of  the 
exposed  bowel  or  escape  of  sm.ali  intestine.     Some  surgeons  pass 


Fig.  462. — Iliac  Colostomy  to  show  Fixation  Stitch  passing  through 
Mesentery  and  Abdominal  Parietes. 

a  glass  rod  through  the  mesentery  and  stitch  the  peritoneum  to  the 
skin,  whilst  it  has  also  been  suggested  to  make  a  hole  through 
the  mesentery  and  suture  the  two  edges  of  the  incision  through  it — 
i.e.,  beneath  the  bowel — a  most  excellent  proceeding  when  practic- 
able. The  projecting  portion  of  gut  is  then  covered  with  purified 
protective,  and  an  antiseptic  dressing  applied.  At  the  end  of  two  or 
three  da.ys  the  bowel  is  opened,  no  anaesthetic  being  generally  neces- 
sary for  this  proceeding.  About  the  eighth  day  a  portion  of  the 
whole  lumen  of  the  gut  should  be  removed,  down  to  and  even  in- 
cluding the  mesentery,  so  as  to  separate  completely  the  upper  from  the 
lower  end,  and  thus  establish  an  efficient  spur  (Fig.  461).  The  deep 
stitch  is  removed  about  the  twelfth  day.  Should  it  be  necessary  to 
open  the  bowel  at  the  time  of  operation,  the  distended  coil  is  first 
withdrawn  and  the  deep  trans-mesenteric  stitch  passed  and  tied. 
The  margins  of  the  wound  are  then  carefully  protected  by  antiseptic 
compresses,  and  the  bowel  is  tapped  with  a  trocar  and  cannula. 
When  the  first  gush  of  flatus  and  faeces  has  escaped,  the  opening  is 
enlarged  and  a  large-sized  Paul's  tube  tied  in  by  means  of  a  purse- 
string  suture.  The  skin  is  then  carefully  sutured  all  round  to  the 
bowel  and  mesentery,  and  a  collar  like  pad  of  gauze  protects  the 


,038  "  /''   MANUAL  OF  SURGERY 

junction.  The  tube  is  probably  set  free  about  the  fourth  day  by 
sloughing  of  the  portion  of  bowel  grasped  by  the  ligature,  but  the 
wound  is  by  that  time  well  protected,  and  no  risk  of  intraperitoneal 
infection  exists.  If  a  Paul's  tube  is  not  to  hand,  a  large  drainage- 
tube  without  lateral  openings  can  be  stitched  into  the  bowel  in  its 
stead. 

When  cicatrization  of  the  wound  is  complete,  a  protective  apparatus 
is  required  in  order  to  keep  the  patient  clean.  This  should  consist 
of  a  hollow  oval  cup,  made  of  plated  metal,  vulcanite,  or  celluloid, 
with  a  rolled  edge,  and  kept  in  position  either  by  a  truss  spring  or 
an  abdominal  belt.  This  hollow  cup  should  be  large  enough  to 
include  a  2-inch  margin  of  skin  all  round  the  opening,  and  in  the 
concavity  a  small  portion  of  antiseptic  dressing  is  placed.  Such  an 
apparatus  enables  the  patient  to  go  about  in  comparative  comfort ; 
the  bowels  are  encouraged  to  act  thoroughly  every  morning  by 
means  of  an  enema,  so  that  no  further  disturbance  need  occur  during 
the  day. 

Comparison  of  the  Two  Operations.  —  At  the  present  time  the 
methodical  and  deliberate  opening  of  the  peritoneal  cavity  obviates 
nearly  all  the  difficulties  which  were  formerly  experienced  in  con- 
nection with  the  lumbar  operation,  and  the  advantages  of  the  iliac 
operation  are  not  nearly  so  pronounced  as  formerly,  {a)  One  great 
advantage  is  the  closer  proximity  to  a  pelvic  growth,  which  can  be 
carefully  examined,  as  also  the  lymphatic  glands  in  the  meso-rectum 
or  lumbar  region,  and  valuable  indications  as  to  the  advisability  or 
not.  of  excision  of  the  rectum  can  be  thereby  obtained,  (h)  An 
artificial  anus  situated  in  tlie  iliac  region  can  be  attended  to  by  the 
patient  himself  without  assistance,  and  is  more  easily  cleansed  and 
protected,  [c)  It  is  occasionally  possible  for  a  certain  amount  of 
sphincteric  control  to  be  developed  after  the  abdominal  operation, 
owing  to  the  muscles  of  the  abdominal  parietes  becoming  adherent 
to  the  coats  of  the  gut.  Of  course  this  can  only  be  attained  when 
these  structures  are  brought  into  accurate  apposition,  as  b}'  the  fixa- 
tion stitch  described  above,  or,  better  still,  by  uniting  the  margins  of 
the  abdominal  wound  through  a  hole  in  the  meso-colon,  or  by  the 
employment  of  McBurney's  method  of  muscle-splitting. 

It  is  sometimes  desirable  to  close  a  colostomy  wound  after  a  shorter 
or  longer  interval.  The  plan  usually  adopted  at  the  present  day  is 
to  dissect  up  the  margins  of  the  wound,  freeing  the  gut  from  its 
attachments  to  surrounding  parts,  and  excising  the  affected  segment ; 
in  this  way  the  continuity  of  the  canal  can  be  restored  without  leaving 
parietal  adhesions.  Occasionall}"  it  ma}'  seem  desirable  to  close  the 
opening  without  encroaching  on  the  peritoneal  cavit}^  This,  of  course, 
is  only  possible  when  the  whole  circumference  of  the  bowel  has  not 
been  encroached  on,  and  the  spur  consists  of  a  valve  or  flap  of  mucous 
membrane  (Fig.  460).  It  is  then  necessary  to  efface  or  remove  the 
spiur,  which  would  otherwise  hinder  the  onward  passage  of  the  faeces. 
This  may  be  effected  by  stitching  a  piece  of  drainage-tubing  of  large 
calibre  into  the  bowel  so  as  to  reach  above  and  below  the  opening ; 


ABDOMINAL  SURGERY  1039 

the  margins  can  then  be  pared  and  closed  in  some  suitable  way  ; 
after  a  tmie  the  stitches  in  the  drainage-tube  (catgut  by  choice)  will 
be  absorbed,  and  it  will  pass  on  doMoi  the  canal.  This  latter  method 
of  dealing  with  an  artificial  anus  is  extremely  unsatisfactorv^  as  it 
leaves  an  adherent  coil  of  intestine,  w^hich  is  certain  to  hamper 
peristalsis  and  may  cause  recurrent  colic,  or  may  even  determine  an 
attack  of  obstruction ;  the  open  operation  is  usually  very  successful. 

3.  Enteroplasty  is  a  plan  of  treatment  which  has  been  devised  for 
dealing  with  cicatricial  strictures  of  the  intestine,  and  is  based  on  the 
same  idea  as  the  operation  of  pyloroplasty  for  fibrous  stenosis  of 
the  pylorus  (p.  loi-i).  A  longitudinal  incision  is  made  through  the 
stenosed  gut  along  the  anti-mesenteric  border ;  this  is  opened  out, 
and  converted  into  a  transverse  cleft,  which  is  carefully  sutured,  the 
lumen  of  the  bowel  being  thereby  considerably  increased. 

4.  Enterectomy,  or  excision  of  a  portion  of  the  bowel,  is  required 
in  the  following  conditions  :  (a)  For  the  removal  of  gangrenous  gut 
after  strangulation,  whether  internal  or  external ;  (b)  in  the  treatment 
of  multiple  penetrating  wounds,  as  after  a  stab  or  gunshot  injury; 
(c)  for  the  closure  of  an  artificial  anus  or  faecal  fistula;  (d)  for  the 
removal  of  simple  or  malignant  strictures  ;  and  (e)  in  some  cases 
of  intussusception.  Naturally,  the  results  vary  largely  with  the 
condition  for  which  it  is  performed,  with  the  site  of  the  lesion,  and 
with  the  experience  and  skill  of  the  operator  ;  a  m.uch  higher  rate 
of  mortality  follows  when  the  excision  is  done  for  malignant 
disease,  for  gangrene  following  strangulation,  or  for  intussuscep- 
tion, than  when  performed  for  other  causes.  Operations  on  the 
large  intestine  are  also  much  less  favourable  than  those  directed  to 
the  small  gut. 

Whenever  practicable,  the  bowel  should  be  thoroughly  emptied 
prior  to  operation,  and  rendered  as  sterile  as  possible  by  the  use  of 
such  drugs  as  calomel  (gr.  i.  daily),  salol,  /3-naphthol,  naphthalene, 
bismuth  subnitrate,  etc.,  for  a  few  days  previously.  Should  this  be 
impossible  and  when  the  bowel  is  distended,  it  is  usually  wise  to 
open  and  drain  it  for  a  few  days,  and  then  subsequently  perform  the 
anastomosis. 

The  abdomen  is  opened  by  any  suitable  incision,  and  the  portion 
to  be  removed  clearly  defined,  the  general  peritoneal  cavity  being 
protected  by  a  careful  packing  with  abdominal  cloths  or  gauze. 
The  bowel  must  then  be  clamped  on  either  side  of  the  seat  of 
operation,  so  as  to  prevent  the  escape  of  intestinal  secretions  or 
faeces.  Any  of  the  forms  of  clamp  figured  in  surgical  instrument 
catalogues  will  effect  this  purpose  ;  but  if  they  are  not  obtainable, 
the  same  result  can  be  obtained  by  passing  a  piece  of  drainage- 
tube  through  the  mesenteric  attachment,  and  tying  or  clamping  it 
around  the  gut. 

The  affected  portion  is  now  removed  by  scissors,  cutting  through 
the  bowel  and  taking  away  a  V-shaped  portion  of  the  mesentery, 
after  securing  as  far  back  as  possible  the  main  nutrient  vessels  to 
the  diseased  area,  according  to  Murphy's  recommendation.     It  must 


I040 


A  MANUAL  OF  SURGERY 


be  remembered  that  the  terminal  vessels  run  circularly  round  the 
gut,  and  have  but  few  lateral  anastomoses,  and  therefore  it  is 
desirable  that  the  incisions  should  diverge  slightly  from  the  mesen- 
teric attachment,  otherwise  the  projecting  edge  of  the  anti-mesenteric 
border  is  certain  to  slough,  and  septic  peritonitis  will  result.  Some 
operators  recommend  that  the  mesentery  should  not  be  cut  into,  but 
that  the  gut  should  be  detached  from  the  mesenteric  junction  ;  such 
practice  will  suffice  when  merely  a  small  segment  of  bowel  is  to  be 
removed  ;  but  if  a  large  portion  needs  resection,  it  would  take  a  much 
longer  time  to  secure  all  the  bleeding-spots.  The  wound  in  the 
mesentery  is  subsequently  secured  by  sutures,  and  the  divided  ends  of 
the  bowel  united  by  either  an  end-to-end  or  a  lateral  anastomosis. 


Fig.  463. — End-to-End  ANASTOwrtMS  by  Simple  Suturing. 

For  clearness'  sake,  the  first  row  of  stitches  in  the  mucous  membrane  has  been 
omitted,  and  the  sero-muscular  sutures  of  the  Lembert  type  are  represented 
as  interrupted.     In  practice  one  would  use  a  continuous  stitch. 


For  end  to-end  union  the  following  are  the  chief  plans  that  have 
been  adopted  : 

A.  Entero-anastomosis  by  simple  suturing.  In  this  the  surgeon 
utilizes  no  special  apparatus,  but  trusts  to  the  deftness  of  his  fingers 
and  the  accuracy  of  his  stitches. 

The  mesenteric  and  anti-mesenteric  borders  are  first  united  by 
stitches  which  are  left  long  for  the  assistant  to  hold  ;  the  gut  is  there- 
by steadied  (Fig.  463).  The  mucous  membrane  is  then  sutured  by 
catgut  or  silk  stitches,  which  should  not  be  continuous  all  round  the 
junction,  as  thereby  it  might  be  drawn  in  too  closely  and  contracted  ; 
it  is  best  taken  up  in  two  or  three  portions.  The  sero-muscular  coats 
are  now  united  all  round  by  one  or  two  continuous  stitches  of  the 
Lembert  or  Gushing  type.  Extreme  care  must  be  taken  in  dealing 
with  the  mesenteric  attachment,  as  the  peritoneal  coats  separate 
there  in  order  to  enclose  the  bowel,  and  the  muscular  coat  retracts 
considerably ;  leakage  is  more  likely  to  occur  at  this  point  than 
at  any  other. 


ABDOMINAL  SURGERY 


1041 


Some  surgeons  advise  that  the  first  row  of  stitches  should  include 
the  whole  thickness  of  the  gut,  and  that  the  second  row  should  be  of 
the  Lembert  type.  This  is  unnecessary  and  undesirable  as  a  routine 
procedure,  as  it  involves  too  great  an  infolding 
of  the  gut  wall,  and  thereby  the  lumen  at  the  site 
of  anastomosis  is  unduly  encroached  on,  and 
some  amount  of  stenosis  may  result. 

In  the  large  intestine  this  type  of  anastomosis 
is  not  always  easy  to  accomplish,  owing  to  the 
greater  complexity  of  the  peritoneal  relations. 
It  is  often  necessary  to  introduce  the  sero- 
muscular stitches  first  on  the  posterior  aspects 
of  the  section,  and  subsequently  those  for  the 
mucous  membrane  ;  but  it  is  probably  wiser  to 
employ  a  lateral  anastomosis  in  dealing  with  the 
colon.  One  thing  is  quite  certain — viz.,  that 
unless  the  colon  is  satisfactorily  empty,  no  anas- 
tomosis should  be  attempted,  and  hence  a  tem- 
porary colostomy  is  often  necessary. 

B.  A  vast  amount  of  ingenuity  has  been  expended  in  the  pro- 
duction of  a  variety  of  bobbins  and  buttons,  with  the  idea  of 
facihtating  entero-anastomosis  and  making  it  safer,  but   they  have 


F  I  G.    464.  M  A  YO 

Robson's  Bobbin. 
(Down  Brothers.) 


Fig.  465. — Entero-anastomosis  over  a  Robson's  Bobbin. 

A,  A'  is  the  internal  suture  for  approximating  the  edges  of  the  mucous  mem- 
brane ;  B,  B^  is  the  external  continuous  sero-muscular  stitch  introduced 
according  to  Cushing's  method. 


been  almost  entirely  discarded  at  the  present  day  in  favour  ot 
simple  suturing.  The  methods  of  attaining  their  object  vary,  but 
according  to  the  underlying  principle  one  may  divide  them  into 
two  groups  : 

(i.)  Those  which  aim  merely  at  providing  an  internal  splint,  which 
shall  serve  as  a  firm  support  to  facilitate  the  introduction  and  tying 

66 


I042 


A  MANUAL  OF  SURGERY 


of  the  stitches,  and  shall  subsequently  protect  the  line  of  union  for  a 
time.  A  hollow  tube  of  turnip  or  potato  will  do  quite  well,  but 
Rohson's  bobbin  (Fig.  464),  made  of  decalcified  bone,  is  perhaps  more 
convenient  in  that  it  can  be  kept  ready  for  use  in  a  variety  of  si^es. 
Two  continuous  sutures  should  be  employed,  one  to  unite  the  divided 

ends  of  the  mucous  membrane,  and 
the  other  to  approximate  the  serous 
and  muscular  coats  (Fig.  465).  The 
sero-muscular  suture  is  first  intro- 
duced for  the  posterior  half  of  the 
incision,  each  stitch  taking  a  firm 
grip  of  the  sero-muscular  coats  up 
to  about  half  a  centimetre  from 
the  margin.  The  muco- mucous 
suture  is  then  put  in  for  the  same 
extent.  The  bobbin  is  now  placed 
in  position  ;  the  muco  -  mucous 
suture  is  first  finished  and  tied, 
and  finally  the  anterior  half  of  the 
ssro-muscular  suture  is  similarly 
completed.  Each  of  these  sutures 
must  be  firmly  tied  around  the  bob- 
bin, so  that  no  slipping  is  possible. 
The  material  of  which  it  is  com- 
posed (decalcified  bone)  is  such  as 
to  do  no  subsequent  harm  to  the 
mucous  membrane,  since  it  becomes 
soft  and  pulpy  in  the  course  of  a 
few  days. 

(ii.)  The  majority  of  buttons  aim 
at  the  approximation  and  apposition 
of  the  divided  segments.  Murphy's 
button,  of  which  illustrations  and 
descriptions  were  given  in  former 
editions,  may  be  looked  on  as  the 
type  of  all  these  contrivances,  but 
it  has  so  many  disadvantages  that 
it  is  now  seldom  employed. 

5.  Lateral  Anastomosis  of  the 
intestine  is  usually  undertaken  in 
order  to  affect  the  short-circuiting 
of  some  malignant  growth,  or  of 
a  stricture  which  cannot  otherwise  be  dealt  with.  It  is  frequently 
employed  instead  of  end-to  end  anastomosis  to  unite  divided  segments 
of  intestine.  The  open  ends  are  first  entirely  closed  by  Lem- 
bert  or  Czerny-Lembert  stitches,  and  the  portions  of  bowel  made  to 
overlap.  The  actual  anastomosis  is  performed  as  for  gastro-enteros- 
tomy  (Fig.  466).  Robson's  or  other  suitable  clamps  are  applied,  and 
the  coils  are  brought  into  suitable  apposition. 


Fig.  466. — Lateral  Anastomosis 
OF  Bowel  after  Complete  Divi- 
sion. 

The  divided  ends  are  closed  by 
sutures  and  approximated  by  a 
sero-muscular  continuous  stitch 
(A,  Ai) ;  the  incisions  in  the  bowel 
are  then  made,  and  the  mucous 
membranes  united  by  a  continuous 
stitch  (B,  Bi)  ;  and,  finally,  the 
sero-muscular  suture  is  carried 
round  the  whole  opening.  Only 
the  deep  layer  of  sutures  is  shown 
here,  and  they  have  not  been 
drawn  tight,  so  as  to  indicate  their 
relative  positions. 


Longitudinal  incisions 


ABDOMINAL  SURGERY  1043 

are  made  through  the  sero-muscular  coats,  and  these  are  then  united 
on  the  posterior  aspsct  of  the  proposed  junction.  The  segments  of 
bowel  are  then  opened,  and  any  fluid  or  solid  contents  carefully 
mopped  up  and  removed.  A  continuous  stitch  unites  the  mucous 
membrane  all  round,  and  finally  the  external  sero-muscular  stitch 
secures  the  anastomosis.  The  operation  is  completed  by  securing  the 
divided  edges  of  the  overlapping  segments  of  the  mesentery  so  as  not 
to  leave  an  aperture  through  which  internal  strangulation  might  occur. 
6.  Lateral  Implantation  is  a  procedure  not  uncommonly  required 
in  order  to  short-circuit  a  malignant  growth  (Fig.  458).  It  is  perhaps 
employed  most  frequently  for  irremoveable  cancer  of  the  caecum 
or  ascending  colon ;  the  ileum  is  divided  well  above  the  growth  ;  the 
lower  end  is  closed,  and  the  upper  united  to  the  transverse  colon. 
The  junction  may  be  made  by  simple  suturing,  two  rows  of  stitches 
being  introduced,  but  it  is  probably  wiser  to  close  the  end  of  the 
ileum  and  perform  a  lateral  anastomosis,  as  described  above,  inas- 
much as  it  is  possible  thereby  to  secure  a  larger  opening. 

Appendicitis  (Syn.  :  Perityphlitis,  Epityphlitis,  etc.). 

Appendicitis  is  an  affection  which  may  appear  at  any  time  of  life, 
but  it  is  most  common  in  young  adults,  and  the  male  sex  is  more  fre- 
quently attacked  than  the  female.  The  disease  is  sometimes  of  but 
slight  significance,  but  occasionally  runs  such  a  virulent  course  as  to 
destroy  life  in  a  few  hours.  Its  importance  lies  in  the  fact  that  it  is 
an  infective  process,  and  inasmuch  as  the  peritoneal  envelope  is 
generally  involved,  a  certain  degree  of  peritonitis  is  almost  necessarily 
a  consequence. 

.ZEtiology. — Many  different  conditions  contribute  either  directly  or 
indirectly  in  determining  an  attack  of  appendicitis,  (i)  The  appendix 
is  to  be  looked  on,  not  as  an  actively  functional  structure,  but  as  a 
degenerated  relic  or  remnant,  which  is  apparently  of  little  value  or 
importance.  Hence,  as  in  other  similar  structures,  it  often  has  but 
a  poor  blood-supply,  derived  from  the  posterior  ileo  csecal  branch  of 
the  ileo-colic  artery.  The  main  nutrient  vessels  traverse  or  run 
along  the  free  border  of  the  meso  appendix,  but  a  second  twig  often 
runs  down  the  base  of  the  mesentery,  and  is  more  or  less  independent 
of  the  others.  Some  authorities  join  issue  with  the  above-mentioned 
view  as  to  the  inutility  of  the  appendix,  and  maintain  that  it  secretes 
a  fluid  which  stimulates  the  peristalsis  of  the  caecum  or  colon 
(MacEwen).  This  may  be  so,  but  the  fact  remains  that  a  vast 
number  of  people  who  have  lost  their  appendixes  by  operation 
get  on  quite  as  well  without  it.  (2)  A  large  amount  of  lymphoid 
tissue  is  present  in  the  mucous  membrane,  especially  in  younc»- 
people,  so  much,  in  fact,  that  the  title  of  '  abdominal  tonsil '  has  been 
applied  to  it.  The  lymphoid  follicles  have  a  tendency  to  atrophy 
with  advancing  age.  Inflammatory  processes  are  readily  set  up 
within  its  walls  as  a  result  of  the  absorption  of  toxins  or  organisms, 
which  are  almost  constantly  present  within  it.     It  is  interesting  to 


I044  A  MANUAL  OF  SURGERY 

note  here  that  some  look  on  appendicitis  as  an  outcome  of  rheuma- 
tism, and  the  association  of  that  disease  with  tonsilhtis  is  suggestive. 
(3)  Its  length  and  direction  vary  considerably  in  different  individuals. 
In  length  it  may  measure  anything  between  1^  and  11  or  12  inches, 
but  is  usually  3  to  4  inches  long,  whilst  as  to  direction,  it  may  lie  in 
any  axis,  and  the  clinical  picture  is  largely  influenced  by  its 
anatomical  position.  The  commonest  situation  is  behind  the  caecum 
in  relation  with  the  lowest  end  of  the  mesentery,  pointing  towards 
the  spleen  ;  but  it  is  not  unusual  for  it  to  lie  deeply  behind  the  caecum, 
pointing  down  towards  the  pelvis,  and  then  pelvic  complications 
almost  always  accompany  an  attack  of  appendicitis.  At  other 
times  the  appendix  lies  to  the  outer  side  of  the  caecum,  arid 
the  inflammatory  reaction  then  may  be  more  localized.  The  position 
of  the  appendix  also  governs  the  facility  with  which  the  intestinal 
contents  find  their  way  into  its  lumen,  and  it  seems  probable  that 
appendicitis  is  more  commonly  met  with  where  it  is  so  placed  as 
readily  to  admit  material  which  is  with  difhculty  expelled — i.e., 
when  it  is  transverse,  or  directed  downwards.  A  longer  appendix 
is  also  more  liable  to  become  twisted  and  kinked  on  itself.  (4)  The 
extent  to  which  the  meso-appendix  is  attached  is  also  an  important 
element,  since  the  portion  which  projects  beyond  its  free  border  is 
less  well  supplied  with  blood.  As  a  matter  of  fact,  the  mesentery 
often  does  not  extend  beyond  the  junction  of  the  middle  with  the 
distal  third,  and  perforation  not  unfrequently  occurs  about  this  spot. 
The  vessels  often  run  in  the  free  border  of  the  mesentery,  and  kink- 
mg  of  the  appendix  may  result  in  thrombosis  of  the  vessels  and 
gangrene.  (5)  The  communication  with  the  caecum  is  usually  a 
small  one,  and  is  guarded  by  an  insignificant  fold  of  mucous  mem- 
brane, known  as  the  valve  of  Gerlach.  Sometimes  this  aperture 
becomes  blocked,  or  the  orifice  stenosed,  as  the  result  of  a  preceding 
attack  of  typhlitis  or  inflammation  of  the  mucous  lining  of  the  caecum, 
so  that  an  accumulation  of  mucus  occurs  within  the  appendix,  leading 
to  its  dilatation  into  a  cyst-like  pouch.  (6)  The  contents  of  the  normal 
appendix  consist  of  a  little  mucus  and  a  certain  number  of  bacteria, 
similar  to  those  found  in  the  neighbouring  intestine ;  they  do  no 
harm  unless  the  mucous  lining  is  so  damaged  as  to  permit  them  to 
invade  the  living  tissues,  and  then  they  become  virulent.  A 
generalized  sepsis  of  the  intestinal  canal,  perhaps  the  result  of  oral 
sepsis,  will  obviously  be  a  favourable  condition  for  determining 
infection  of  the  appendix.  Foreign  bodies,  such  as  pips,  pins,  etc.,  are 
occasionally  found  within  it,  and  by  their  presence  and  irritation 
may  light  up  an  attack  of  inflammation.  They  are  much  less 
common  than  was  formerly  imagined,  and  the  fact  that  the  opening 
into  the  intestine  is  generally  not  larger  than  to  admit  a  No.  8 
catheter  will  explain  this  rarity.  Fiscal  coiicretiom  are  comparatively 
common ;  they  are  oval  bodies,  varying  from  i  to  i  inch  in  length, 
and  usually  laminated,  consisting  of  dried  faecal  material  mixed  with 
myriads  of  bacteria,  and  perhaps  with  a  pip  or  foreign  body  as  a 
nucleus.     They  are  not  very  hard,  and  can  easily  be  cut  with  a 


ABDOMINAL  SURGERY 


I04S 


knife,  or  even  crushed  between  the  fingers.  Occasionally  they  can 
be  recognised  in  a  radiograph  of  the  pelvis  taken  for  other  reasons 
(Fig.  467).  They  are  sometimes  the  result  of  a  preceding  attack 
which  has  left  the  tube  contracted,  and  thus  determined  stasis  and 
retention  of  its  contents,  which  have  become  inspissated.  (7)  Ap- 
pendicitis is  not  unfrequently  associated  with  a  true  typhlitis  or 
with  a  more  generalized  colitis,  probably  due  to  chronic  constipation  ; 
the  continuity  of  the  mucous  lining  of  the  caecum  and   appendix 


Fig.  407. — Skiagraph  of  Right  Iliac  Fl  ssa.   showing  the  Presence  of  an 
Elongated  F.ecal  Concretion  in  the  Appendix.      (A.  D.  Reid.)' 


explains  this  fact,  which  must  always  be  taken  into  consideration  in 
estimating  the  benefits  which  may  be  expected  from  removal  of  the 
appendix  in  a  quiescent  stage.  JNIuch  disappointment  in  the  non- 
relief  of  symptoms  has  arisen  from  the  persistence  of  a  typhlitis  or 
colitis  after  the  appendix  has  been  removed.  Dysenteric  ulceration 
may  involve  the  appendix,  or  lead  to  stenosis  of  its  orifice,  but  it  is 
rarely  implicated  in  typhoid  fever.  (8)  Injury  in  the  shape  of  a 
strain  or  sudden  twist  is  not  unfrequently  mentioned  as  the  cause  of 
an  outbreak,  and  probably  acts  by  displacing  a  long  appendix  in 
such  a  way  as  to  lead  to  kinking  and  possibly  to  obstruction  of  the 


1046  A  MANUAL  OF  SURGERY 

nutrient  vessels.  When  a  concretion  is  present,  it  is  easy  to  under- 
stand that  the  final  attack  is  determined  by  some  traumatism  which 
modifies  the  vascular  conditions  around  it.  When  an  appendix  is 
filled  with  muco-pus  as  a  result  of  stenosis,  either  at  the  orifice  or  in 
the  tube  itself,  a  blow  may  lead  to  its  rupture  and  cause  an  outbreak 
of  fatal  peritonitis. 

There  can  be  no  question  as  to  the  greatly  increased  frequency  of 
appendicitis  at  the  present  day,  especially  amongst  those  who  live  in 
large  towns  or  cities.  It  is  difficult  to  assign  any  one  cause  for  this, 
but  possibly  many  conditions  may  be  at  work — e.g.,  (a)  dental 
disease  and  degeneration,  and  consequent  oral  and  intestinal  sepsis ; 
(b)  the  bolting  and  non-mastication  of  meals  associated  with  the 
hurry  and  scurry  of  modern  life,  leading  to  chronic  irritation  of 
stomach  and  bowel,  (c)  Chronic  constipation  is  a  most  important 
factor.  (^)  The  presence  of  minute  foreign  bodies  in  imported  corn 
and  other  food-supplies,  and  the  chips  derived  from  enamelled 
cooking  utensils  have  been  suggested  as  causes,  but  there  has  been 
no  proof  of  any  connection  forthcoming,  (e)  The  greatest  dietetic 
change  of  recent  years  consists  in  the  increased  amount  of  meat  that 
is  eaten.  The  cheapness  of  imported  frozen  meat  has  made  it 
generally  available,  and  it  is  quite  possible  that  meat  which  has  been 
frozen  for  some  time  is  more  putrescible  than  that  which  is  fresh, 
and  hence  intestinal  sepsis  may  be  favoured.  In  favour  of  this  idea 
is  the  fact  that  races  that  live  on  fish  or  vegetables  are  largely 
immune,  whilst  members  of  the  same  race  transported  to  other 
regions  and  put  on  a  meat  diet  develop  the  disease. 

Pathological  Anatomy. — Whatever  the  assigned  cause  may  be,  it 
must  ever  be  kept  in  mind  that  appendicitis  is  an  infective  malady, 
due  to  invasion  of  the  walls  of  the  appendix  by  organisms,  especially 
the  Streptococcus  pyogenes,  the  B.  coli,  and  other  anaerobic  intestinal 
bacteria.  These  find  an  entrance  into  the  wall  of  the  appendix  either 
through  an  eroded  area  of  the  mucous  membrane  due  to  the  impac- 
tion of  a  foreign  body  or  of  a  faecal  concretion,  or  else  they  are 
absorbed  into  the  lymphoid  tissue  so  abundantly  present,  and  at  once 
commence  to  develop  and  multiply.  The  results  may  be  best  de- 
scribed under  the  following  headings  : 

(i)  Changes  in  the  Appendix  itself. — These  vary  considerably  in 
intensity  and  character  according  to  the  cause  and  the  power  of 
resistance  of  the  individual. 

In  the  simpler  forms  a  mere  catarrh  of  the  appendix  results.  The 
organ  looks  red  and  swollen,  and  its  peritoneal  surface  may  be 
smooth,  or  roughened  by  loss  of  endothelium  and  deposit  of  lymph. 
It  feels  stiff  from  effusion,  and  has  lost  its  natural  flexibility.  The 
muscular  coats  are  often  infiltrated  with  leucocytes,  and  this  is 
especially  noticed  around  the  hiatus  muscularis  through  which  the 
vessels  enter.  The  mucous  membrane  is  thickened,  engorged,  and 
infiltrated  with  polynuclear  leucocytes,  and  here  and  there  erosion 
or  ulceration  is  present.  If  the  process  goes  no  further,  healing 
occurs  after  a  time,  and  this  is  often  associated  with  fibrosis,  which 


ABDOMINAL  SURGERY 


1047 


may  show  itself  (a)  as  a  more  or  less  generalized  sclerosis  of  the 
whole  appendix,  which  may  remain  stiff  and  hard,  and  is  perhaps 
twisted  on  itself  (Fig.  468);  or  (b)  as  a  stricture  of  the  tube,  which 
leads  to  retention  of  secretion,  possibly  to  the  formation  of  a  faecal 
concretion  distal  to  the  stricture,  and  frequently  to  a  recurrence, 
which  is  often  of  a 
severer  type  than  the 
original  attack  ;  or 
(c)  obliteration  of  the 
appendix  may  occur 
from  the  union  across 
its  lumen  of  granu- 
lating surfaces.  This 
usually  commences  at 
the  tip  and  works  up 
towards  the  gut,  but 
is  not  completed  until 
the  patient  has 
suffered  from  many 
attacks. 

When  ulceration  oc- 
curs, the  loss  of  sub- 
stance of  the  mucous 
membrane  may  be 
slight  or  extensive ; 
it  may  be  a  simple 
erosion  associated 
with  a  mild  catarrhal 
attack,  or  a  deeper 
loss  of  substance  due 
to  the  presence  and 
impaction  of  a  fsecal 
concretion ;  or  it  may  result  from  a  specific  infection^  as  from 
typhoid  fever  or  tuberculous  disease.  The  appendix  is  then  likely 
to  be  more  seriously  invaded  with  micro-organisms,  and  suppiivation 
of  many  types  may  ensue.  It  may  contain  muco-pus  in  its  lumen,  or 
the  whole  wall  of  the  tube  may  be  yellow  with  a  diffuse  purulent 
infiltration.  The  ulcer  may  gradually  spread  through  the  walls  and 
lay  open  the  peritoneal  cavity,  giving  rise  to  a  local  or  diffuse  sup- 
purative peritonitis  ;  but  the  peritoneum  may  only  be  slightly 
affected,  resulting  in  the  formation  of  fibrous  adhesions. 

Necrosis  or  sloughing  of  the  appendix  occurs  in  the  more  severe  forms. 
It  is  due  to  an  acute  interstitial  inflammation  spreading  from  an 
impacted  concretion,  or  from  an  ulcer  of  the  mucosa ;  or  results  from 
kinking  and  thrombosis  of  the  appendicular  vessels  in  the  meso- 
appendix.  The  whole  appendix  may  slough,  or  merely  a  portion, 
and  then  usually  the  tip  or  the  part  immediately  opposite  the 
distal  end  of  the  meso-appendix.  The  necrotic  tissue  is  soft  and 
easily   torn,   of   a   blackish,   brown,    or   green    colour,   and    usually 


Fig.  468. — Vermiform  Appendix  tied  down  both 
TO  C^cuM  AND  Ileum,  and  doubled  on  Itself 
BY  Old-standing  Adhesions. 

The  appearances  in  this  illustration  are  very  charac- 
teristic of  what  is  frequently  seen ;  but  the  case 
from  which  it  was  taken  was  a  very  unusual 
one.  It  occurred  in  a  baby  of  seven  days,  who 
was  operated  on  for  acute  obstruction  due  to 
the  adhesions,  which  were  old-standing,  and  evi- 
dently ante-natal.  The  child  died,  and  the  caecum 
was  subsequently  removed. 


1048  A  MANUAL  OF  SURGERY 

extremely  offensive.  It  may  be  associated  with  a  perforation, 
through  which  the  concretion  may  escape  (Fig.  469).  In  all  ther.e 
cases  a  grave  peritoneal  infection  follows. 

(2)  Changes  in  the  Cascum  often  accompany  appendicitis.  In  the 
catarrhal  variety  a  generalized  typhlo-colitis  is  often  present,  and 
perhaps  it  would  be  more  correct  to  speak  of  appendicitis  as  a 
complication  of  that  condition.  It  is  in  these  cases  where  the  caecum 
and  colon  are  inflamed  and  tender,  as  well  as  the  appendix,  that  most 
careful  discrimination  is  needed  in  order  to  prevent  needless  oper- 
ation which  will  not  improve  the  patient's  condition.  In  suppurative 
appendicitis  the  caecum  is  generally  inflamed  and  infiltrated,  but 
rather  from  the  peritoneal  aspect  than  from  within  ;  operative  treat- 
ment will  in  these  cases  be  quickly  followed  by  resolution.  Rarely 
does  the  inflammation  become  so  severe  as  to  lead  to  suppuration  or 
necrosis  of  the  wall  of  the  caecum  ;  should  this  occur,  it  usually  in- 
volves the  origin  of  the  appendix,  and  may  be  followed  by  a  faecal 
fistula. 


Fig.  469.  — Perforation  of  the  Appendix  from  an  Impacted  Concretion, 
CAUSING  AN  Acute  Abscess  (Semi-diagrammatic). 

(3)  The  Peritoneal  Phenomena  associated  with  appendicitis  are  of 
the  utmost  importance. 

In  the  milder  cases  the  peritonitis  is  protective  in  type.  The 
serous  coat  of  the  appendix  becomes  inflamed,  sheds  its  endothelium, 
and  becomes  roughened  by  a  deposit  of  lymph,  and  this  results  either 
in  a  thickening  of  the  wall,  or  in  a  formation  of  adhesions  which  tie  down 
the  appendix  in  various  directions  and  positions.  Most  commonly 
it  is  simply  fixed  to  the  caecum  along  part  of  its  length,  but  some- 
times it  is  firmly  united  to  it  for  its  whole  extent.  Adhesions  may 
pass  between  the  appendix  and  the  omentum,  the  mesentery,  or 
ovary,  etc. ;  in  fact,  the  appendix  may  be  united  to  almost  any  of 
the  viscera,  and   may  thereby  hamper  their   action  or  give  rise  to 


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ABDOMINAL  SURGERY  1049 

some  form  of  acute  obstruction.  It  may  also  contract  adhesions  to 
the  fasciae — e.g.,  over  the  psoas  sheath  or  iliac  vessels,  and  various 
symptoms  may  be  caused  thereby. 

In  the  graver  cases  an  infective  peritonitis  occurs,  and,  according 
to  the  virulence  of  the  organisms,  the  defensive  powers  of  the  patient, 
and  the  character  of  the  infection,  the  process  may  be  localized  or 
not.  A  localized  intraperitoneal  abscess  is  by  no  means  uncommon ; 
its  extension  is  limited  by  the  formation  of  adhesions  between  the 
omentum,  the  parietes,  and  neighbouring  coils  of  intestine.  Its 
exact  anatomical  relations  depend  on  the  original  situation  of  the 
appendix.  Frequently  it  is  located  below  and  behind  the  caecum ; 
sometimes  it  burrows  down  into  the  pelvis ;  in  other  cases  it  passes 
inwards  amongst  the  intestines ;  it  may  track  up  towards  the  liver 
either  on  the  inner  or  outer  side  of  the  ascending  colon.  The  abscess 
may  burst  externally,  and  its  approach  to  the  surface  will  be  heralded 
by  brawny  swelling,  redness,  and  cedema  ;  the  most  frequent  sites  for 
external  pointing  are  the  outer  part  of  the  iliac  fossa  and  the  lumbar 
region  (Petit's  triangle).  It  may  burst  into  any  of  the  viscera,  and 
then  most  commonly  into  the  caecum  or  bladder.  Finally,  it  may 
break  through  the  peritoneal  adhesions,  and  involve  the  general 
serous  cavity,  causing  acute  diffiuse  peritonitis  ■  in  other  cases  a 
serous  effusion  into  the  peritoneal  cavity  is  found,  resulting  from  the 
irritation  of  the  abscess,  and  disappearing  when  it  is  opened.  The 
pus  contained  in  the  abscess  is  usually  of  a  stinking  character,  and 
in  cases  of  sloughing  of  the  appendix  the  foetor  may  be  intense ;  but 
it  must  be  remembered  that  the  amount  of  smell  is  no  gauge  of  the 
virulence  of  the  process.  Sometimes  the  debris  of  a  broken-down 
concretion  can  be  recognised  in  the  pus,  and  sometimes  a  portion  of 
the  appendix  as  a  slough.  Gas  is  also  present  in  some  cases,  having 
escaped  from  the  bowel,  or  been  generated  by  the  activity  of  gas- 
producing  organisms.  It  is  not  always  possible  to  distinguish  the 
appendix  in  these  abscesses,  even  when  it  has  not  sloughed  off, 
it  may  be  firmly  adherent  to  the  caecum,  and  unrecognisable  to  the 
examining  finger. 

In  the  w'orst  cases,  associated  with  perforation  or  necrosis  of  the 
appendix,  a  spreading  septic  peritonitis  is  frequently  observed,  with  but 
little  tendency  to  limitation  ;  an  abundant  sero-purulent  effusion 
occurs  due  largely  to  the  presence  of  streptococci,  and  later  to 
invasion  by  the  B.  coli.  The  line  of  diffusion  is  governed  by  the 
anatomical  relations  of  the  appendix  ;  most  commonly  the  effusion 
involves  the  pelvis,  and  after  filling  Douglas's  pouch,  spreads  up  on 
the  left  side  to  the  inner  aspect  of  the  sigmoid  meso-colon.  If  the 
appendix  is  situated  above  the  brim  of  the  pelvis,  the  effusion  will 
extend  to  the  right  kidney  pouch,  and  a  subphrenic  abscess  be 
thereby  determined.  If  it  spreads  beyond  these  limits,  the  whole 
peiitoneal  cavity  will  be  affected,  and  operative  treatment  is  little 
likely  to  be  successful.  The  effusion  in  the  first  place  is  serous,  but 
soon  becomes  turbid,  and  finally  fibrino-purulent  or  frankly  purulent. 
Experience  proves  that  as  long  as  the  exudate  is  serous  or  merely 


I050  A  MANUAL  OF  SURGERY 

sefo-purulent,  operative  treatment  holds  out  good  prospects  of  re- 
covery. In  later  stages  the  intestines  become  matted  together  by 
lymph,  and  paralyzed,  and  a  cure  is  almost  hopeless. 

(4)  Extra -peritoneal  suppuration  occasionally  follows,  and  is  then 
usually  due  to  extension  backwards  through  adhesions  formed 
between  the  appendix  and  the  peritoneum  on  the  posterior  wall  of 
the  abdomen  or  pelvis,  thereby  leading  to  infection  of  the  retro- 
peritoneal connective  tissue.  The  pus  may  collect  in  the  iliac  fossa 
and  point  anteriorly  ;  or  may  track  downwards  into  the  pelvis  and 
open  into  the  rectum  ;  or  may  travel  along  the  psoas  tendon  and 
open  into  the  thigh  ;  or  burrow  upwards  into  the  loin,  forming  a 
perinephritic  collection,  or  a  retroperitoneal  subphrenic  abscess, 
and  then  may  extend  even  into  the  thorax. 

(5)  Various  complications  may  be  associated  with  any  of  these 
different  types  of  appendicitis,  (a)  The  veins  in  the  meso-appendix 
may  become  thrombosed  and  infected  with  pyogenic  organisms  ; 
detachment  of  emboli  may  lead  to  the  occurrence  of  pylephlebitis  and 
pyaemia,  (b)  Thrombosis  of  the  femoral  veins  may  develop  ;  if  on  the 
right  side,  it  is  probably  due  to  implication  of  the  right  iliac  vein  in  the 
inflammatory  process  ;  but  if  it  happens,  as  is  much  more  common, 
on  the  left  side,  it  must  be  due  to  general  toxic  causes  ;  or,  if  it 
occurs  after  operation,  to  spreading  thrombosis  from  vessels  divided 
in  the  anterior  abdominal  wall  (p.  346).  (c)  Chronic  or  subacute 
ovaritis  often  accompanies  appendicitis  in  women  ;  it  is  probably  due 
to  the  position  of  the  appendix  which  hangs  over  into  the  pelvis. 
{d)  Various  renal  complications  may  supervene,  usually  from  pressure 
of  the  inflammatory  mass  on  the  renal  vein,  or  on  the  ureter  as 
it  crosses  the  pelvis  brim,  resulting  either  in  haematuria  or  in  renal 
colic,  [e)  Inflammation  of  an  appendix  located  in  a  hernial  sac 
is  referred  to  hereafter  (p.  logo).  (/)  Lastly,  intestinal  obstruction 
may  be  induced  by  the  acute  inflammatory  attack  leading  to  paralysis 
of  the  intestinal  wall,  or  it  may  develop  subsequently  as  a  result  of 
kinking  or  strangulation  by  bands  or  adhesions. 

Clinical  History. — (i.)  The  mild  variety  of  the  disease,  known  as  a 
simple  catarrhal  appendicitis,  to  which  is  added  merely  a  localized 
plastic  peritonitis,  usually  commences  somewhat  suddenly,  the  patient 
being  seized  with  pain,  which  is  at  first  referred  to  the  umbilicus  or 
to  any  part  of  the  abdomen,  but  at  the  end  of  twenty-four  to  forty- 
eight  hours  localizes  itself  in  the  right  iliac  fossa.  It  is  often  of  a 
sharp,  cutting  character,  but  varies  much  in  intensity  and  duration. 
Fever  is  usually  present,  and  the  attack  may  start  with  a  rigor.  The 
patient  may  complain  of  nausea  and  vomiting,  but  the  latter  symptom 
does  not  last  long.  Constipation  results  from  the  intestinal  paralysis 
due  to  the  inflammatory  lesion,  but  in  children  it  is  sometimes 
replaced  by  diarrhoea,  and  that  even  blood-stained,  so  that  the 
diagnosis  may  need  to  be  made  from  typhoid  fever. 

On  examination  the  abdomen  is  found  to  be  held  more  rigid  than 
usual ;  the  ri<;ht  leg  is  often  drawn  up  to  relax  the  muscles,  and  in 
bad  cases  all  abdominal  respiratory  movements  are  abolished.     Even 


ABDOMINAL  SURGERY  1051 

in  mild  cases  the  muscles  over  the  right  iliac  fossa  are  held  tense  and 
rigid  so  as  to  guard  the  underlying  structures.  Definite  tenderness 
is  noted  on  pressure,  and  the  patient  will  often,  but  by  no  means 
constantly,  refer  it  to  a  spot  about  i-|  inches  from  the  anterior 
superior  iliac  spine  along  a  line  drawn  to  the  umbilicus  (McBurney's 
spot ;  Fig.  456,  A).  In  many  cases,  when  the  appendix  is  directed 
backwards,  there  is  marked  tenderness  in  the  lumbar  region  ;  but  if 
it  points  downwards  into  the  pelvis,  the  pain  and  tenderness  may  not  be 
evident  except  on  rectal  or  vaginal  examination,  which  should  never  be 
neglected.  A  definite  swelling  may  sometimes  be  detected  by  palpa- 
tion, usually  above  the  outer  half  of  Poupart's  ligament,  but  varying  in 
its  position  with  the  site  of  the  appendix  ;  it  may  be  dull  on  percussion, 
but  is  frequently  tympanitic,  since  it  consists  of  coils  of  intestine  and 
omentum  matted  together  around  the  appendix.  The  absence  of  a 
definite  lump  is  due  to  the  non-development  of  protective  adhesions, 
and  hence  is  noted  in  the  worse  cases  of  perforative  appendicitis  ;  or 
it  may  be  caused  by  the  inflamed  mass  lying  deep  in  the  abdomen, 
and  being  covered  over  by  distended  and  uninflamed  intestine. 

This  simple  form  of  the  disease  usually  lasts  three  or  four  days, 
and  then,  if  properly  treated,  resolves  satisfactorily  without  abscess 
formation.  It  is  exceedingly  common,  and  the  prognosis  is,  on  the 
whole,  favourable.  Tofft,  of  Copenhagen,  found  adhesions  in  the 
neighbourhood  of  the  appendix  in  35  per  cent,  of  all  bodies  subjected 
to  post-mortem  examination. 

(ii.)  The  more  serious  variety,  commonly  resulting  in  a  localized 
abscess,  may  commence  in  a  similar  way,  but  with  more  acute  symp- 
toms. There  may  be  an  initial  rigor,  and  the  temperature  soon 
runs  up,  even  to  104°  F.  Some  general  abdominal  tenderness  and 
distension  follow  ;  constipation  is  often  absolute,  and  faecal  vomiting 
may  occur,  although  diarrhoea  is  not  unknown,  especially  in  children. 
The  muscles  on  the  right  side  of  the  abdominal  wall  are  held  tense 
and  rigid,  and  a  well-marked  fulness  can  sometimes  be  detected  in 
the  iliac  fossa.  In  other  cases  a  distinct  swelling  can  be  seen  as 
well  as  felt,  and  is  not  necessarily  limited  to  the  right  fossa,  but 
may  appear  in  the  middle  line  of  the  abdomen  or  elsewhere. 
Under  a  careful  regime  this  may  disappear,  and  the  symptoms 
gradually  abate  in  their  severity,  the  temperature  and  the  pulse 
falling  concurrently  ;  but  it  is  very  common  for  suppuration  to  ensue, 
and  such  is  indicated  by  the  temperature  persisting  at  its  original 
hiffh  level,  or  by  the  pulse-rate  increasing  in  rapidity,  whilst  the 
temperature  falls.  Fluctuation  is  rarely  to  be  detected  in  the  early 
stages,  and,  indeed,  it  is  bad  practice  to  wait  for  it  before  interfering, 
since  there  is  a  considerable  probability  that  the  tension  within  the 
abscess  may  be  sufficient  to  break  down  the  wall  of  newly-formed 
and  not  too  strong  adhesions,  and  the  general  peritoneal  cavity  may 
be  thus  infected.  The  abscess  develops  at  first  round  the  appendix, 
and  is,  of  course,  primarily  intraperitoneal.  Not  unfrequently  it 
bursts  into  the  bowel,  and  thereby  relief  is  gained  without  the  assist- 
ance of  surgery ;  some  authorities,  indeed,  maintain  that  this  occurs 


IOS2  A  MANUAL  OF  SURGERY 

in  every  case  of  the  more  severe  type  which  resolves.  In  other 
instances  it  may  point  externally,  either  through  the  anterior  abdo- 
minal wall,  which  becomes  congested  and  oedematous  as  the  pus 
approaches  the  surface,  or  through  the  loin.  Not  unfrequently  it 
tracks  up  along  the  inner  or  outer  side  of  the  ascending  colon,  and 
then  may  get  into  relation  with  the  under  surface  of  the  liver.  In 
other  patients,  and  especially  when  the  tip  of  the  appendix  lies  over 
the  brim  of  the  pelvis,  the  pus  travels  downwards  and  forms  a 
collection  in  front  of  the  rectum  ;  the  surgeon  must  never  omit 
a  rectal  examination  in  appendicitis,  where  the  temperature  is  of  such 
a  nature  as  to  suggest  the  existence  of  an  abscess,  and  yet  no 
evidence  of  one  can  be  found.  Should  it  burst  into  the  peritoneal 
cavity,  all  the  phenomena  of  acute  perforative  peritonitis  supervene, 
probably  indicated  by  severe  pain,  sudden  fall  of  temperature,  rapid 
collapse  and  toxaemia,  and  a  fatal  issue,  preceded  by  increasing 
abdominal  distension,  unless  surgical  assistance  can  be  obtained  at  a 
very  early  period. 

In  not  a  few  cases  the  patient's  general  symptoms  improve  after 
the  first  outbreak ;  the  temperature  may  become  normal,  the  pam 
decrease,  and  the  vomiting  cease.  It  is  often  difficult  to  be  certain 
whether  this  improvement  is  merely  temporary,  or  is  the  commence- 
ment of  a  true  convalescence.  Under  the  former  circumstances — 
i.e.,  if  it  is  merely  an  interval  of  quiescence — careful  examination  will 
probably  reveal  some  disturbing  factor  ;  either  the  abdominal  disten- 
sion persists,  or  perhaps  hiccough  is  present,  or  a  well-marked 
tenderness  continues,  perhaps  only  to  be  detected  per  rectum,  or  the 
pulse-rate  may  remain  unduly  high.  After  a  few  days  the  tempera- 
ture begins  to  rise  once  more,  the  focal  symptoms  become  more 
urgent,  and  a  localized  abscess  forms. 

It  is  often  by  no  means  a  simple  matter  to  make  certain  that  pus  is 
present ;  but  considerable  assistance  can  be  derived  from  a  blood 
count,  which  is  advisably  made  each  day  that  the  uncertainty  persists. 
Readers  are  referred  back  to  p.  53  for  a  full  consideration  of  letico- 
cytosis ;  it  will  suffice  here  to  state  that  a  leucocyte  count  under 
20,000  is  merely  indicative  of  an  inflammatory  attack  well  resisted  ; 
if  suppuration  is  present,  the  leucocytes  are  usually  over  20,000.  In 
the  early  stages,  however,  a  high  leucocyte  count  means  compara- 
tively little;  but  a  maintained  leucocytosis  is  a  valuable  sign  of 
suppuration. 

A  complication  likely  to  occur  in  the  more  severe  t}'pes  of  the 
disease  is  pylephlebitis,  or  infective  thrombosis  of  the  branches  of  the 
portal  vein  in  the  liver.  Such  would  be  indicated  by  recurrent  rigors, 
and  possibly  by  pain  and  tenderness  in  the  hepatic  area.  Necessarily 
it  is  almost  invariably  fatal. 

(iii.)  In  the  graver  forms  of  diffuse  or  generalized  peritonitis,  the 
onset  is  usually  sudden,  the  patient  becoming  collapsed  with  the 
severity  of  the  pain  ;  vomiting  often  accompanies  the  outbreak  and 
occasionally  a  rigor.  These  symptoms  sometimes  pass  over  directly 
into  those  of  generalized  peritonitis,  as  described  on  p.  983,  death 


ABDOMINAL  SURGERY  1053 

ensuing  in  two  or  three  days ;  the  temperature  in  such  cases  may  be 
low,  and  the  absence  of  reactive  phenomena  is  indicated  by  a  leuco- 
penia.  More  frequently  the  course  is  not  quite  so  acute  ;  the  pain 
which  at  first  is  referred  to  the  umbilicus  becomes  localized  to  the 
right  iliac  fossa ;  the  abdominal  wall  on  that  side  is  held  rigid,  and 
the  rigidity  gradually  spreads  across  the  abdomen  tc  the  left  iliac 
region  and  upwards  towards  the  liver  ;  vomiting  and  absolute  consti- 
pation are  present,  and  the  temperature  is  usually  raised  three  or  four 
degrees;  the  pulse  varies  from  100  to  120,  and  the  amount  of  urine 
passed  is  diminished  in  quantity.  If  surgical  treatment  is  not 
undertaken  early,  the  typical  phenomena  of  acute  diffuse  peritonitis 
are  soon  developed. 

(iv.)  Relapsing  Appendicitis  is  the  term  applied  to  a  condition 
when  an  attack  passes  off,  but  not  quite  satisfactorily.  There  may 
be  a  slight  persistent  rise  of  temperature  at  night ;  or  the  appendix 
remains  palpable  and  tender ;  or  some  amount  of  appendicular  pain 
often  of  a  colicky  character  may  be  noted.  In  many  of  these 
cases  the  symptoms  are  due  to  unhealed  ulceration  of  the  mucous 
lining  or  to  stenosis  of  the  tube.  If  left  alone,  a  more  acute  outbreak 
may  supervene,  or  bacterial  invasion  of  the  vessels  in  the  meso- 
appendix  may  follow,  and  serious  consequences  develop.  If  an 
attack  of  appendicitis  has  not  cleared  up  completely  at  the  end  of  a 
week  or  ten  days,  an  operation  is  always  advisable  for  the  removal 
of  the  organ. 

(v.)  Recurrent  Appendicitis  is  characterized  by  repeated  attacks 
of  varying  gravity  m  an  individual  who  has  been  once  the  subject  of 
the  disease.  They  may  occur  only  at  prolonged  intervals,  or  be  so 
frequent  as  entirely  to  incapacitate  the  patient,  and  are  usually  asso- 
ciated with  the  presence  of  some  abnormal  adhesion  or  constriction 
of  the  appendix.  It  is  not  uncommon  for  the  appendix  to  become 
fixed  to  the  sheath  of  the  psoas  muscle,  and  then  any  excessive 
movements  of  the  limb  may  light  up  an  attack.  Where  stenosis 
exists,  secretions  containing  bacteria  may  be  pent  up  behind  the  con- 
striction, and  from  time  to  time  the  patient  suffers  from  severe  pain 
of  a  colicky  nature  without  fever,  supposed  to  be  due  to  an  attempt 
to  get  rid  of  the  excess  of  mucus.  Such  attacks  have  been  named 
appendicular  colic.  In  a  few  cases  the  appendix  becomes  totally 
obliterated  after  a  time  and  incorporated  in  a  mass  of  adhesions,  a 
natural  cure  being  thus  established ,  but  more  frequently,  if  these 
occurrences  are  allowed  to  continue,  the  patient  finally  develops  an 
abscess,  possibly  from  the  infection  of  some  unobliterated  portion  of 
the  tube,  or  succumbs  to  diffuse  peritonitis. 

Recurrences  are  more  common  after  the  simpler  forms  of  the 
disease,  and  it  has  been  calculated  that  over  30  per  cent,  of  the 
subjects  of  a  mild  catarrhal  attack  suffer  in  this  way.  In  the  more 
acute  forms  recurrence  is  less  common,  and  it  is  unusual  for  a  case  to 
recur  when  suppuration  has  existed  ;  we  have,  however,  seen  cases 
where  an  abscess  has  developed  two  and  even  three  times  in  con- 
nection with  attacks  which  were  separated  by  intervals  of  complete 
disappearance  of  symptoms. 


1054  A  MANUAL  OF  SURGERY 

(vi.)  Appendicular  Gastralgia  is  the  name  applied  to  cases  in  which 
all  the  signs  and  symptoms  of  the  disease  are  referred  to  the 
epigastrium,  and  closely  mimic  those  of  a  gastric  or  duodenal  ulcer. 
The  patients  are  usually  women,  and  a  test-meal  examination  reveals 
a  hypersecretion  of  gastric  juice,  in  which  the  hydrochloric  acid  may 
be  increased  or  diminished.  Laparotomy  shows  no  lesion  in  the 
stomach  or  duodenum,  but  chronic  appendicitis  is  usually  present. 
That  the  previous  symptoms  were  due  to  the  condition  of  the 
appendix  is  proved  by  the  relief  to  the  symptoms  and  the  changes 
in  the  gastric  secretion  after  appendicectomy.  The  probable  ex- 
planation is  that  the  condition  of  the  appendix  causes  intestinal 
stasis,  and  this  in  turn  sets  up  a  toxaemia  which  reacts  on  the 
gastric  mucous  membrane.  The  condition  is  important  clinically, 
as  it  emphasizes  the  importance  of  finding  definite  evidence  of  a 
lesion  in  the  stomach  or  duodenum  before  performing  gastro- 
enterostomy for  supposed  gastric  or  duodenal  ulcer. 

Diagnosis.— In  a  well-marked  case  the  symptoms  of  appendicitis 
are  so  typical  that  the  diagnosis  can  never  be  in  doubt.  The  pain, 
tenderness,  fever,  vomiting,  constipation,  abdominal  rigidity,  and 
perhaps  tumour,  constitute  a  picture  that  is  quite  characteristic. 
The  disease,  however,  often  presents  symptoms  so  varied,  and  mani- 
festations so  protean,  that  one  is  never  surprised  to  meet  with  it  in 
all  sorts  of  diverse  settings,  and  many  mistakes  of  diagnosis  are  made, 
even  by  the  most  skilled  clinicians. 

The  early  stage  of  pneumonia  is  sometimes  associated  with  severe 
pain  and  tenderness  in  the  iliac  fossa,  especially  in  children,  and  the 
resemblance  to  appendicitis  is  the  more  marked  when  the  onset  is 
sudden,  and  abdominal  rigidity  and  vomiting  are  present.  A  careful 
examination  of  the  lungs  should  never  be  omitted  in  the  case  of 
children  with  suspected  appendicitis.  Cases  which  commence  with 
diarrhoea  may  be  mistaken  for  enteric  fever,  but  the  absence  of  the 
rash  and  a  negative  Widal's  reaction  should  guard  the  practitioner 
from  error.  Recurrent  appendicular  pain  may  be  mistaken  for  that 
of  renal  colic  or  for  the  painful  attacks  associated  with  displacement 
of  a  floating  kidney  {Dietl's  crises),  or  vice  versa  ;  and  the  difficulty  is 
increased  if  hsematuria  or  irritation  of  the  bladder  are  caused  by  an 
appendicitic  effusion  or  abscess.  Biliary  colic  may  be  simulated, 
whilst  a  distended  and  inflamed  gall-bladder  may  closely  resemble  an 
appendix  abscess  which  has  travelled  upwards. 

Perforation  of  the  duodenum,  or  even  of  the  stomach,  may  lead  to 
symptoms  very  similar  to  those  of  appendicitis,  due  to  the  inflam- 
matory mischief  tracking  downwards.  The  initial  pain  will  usually 
be  referred  to  the  upper  part  of  the  abdomen,  and  there  may  be 
evidence  of  free  gas  in  the  peritoneal  cavity.  If  gas  escapes  from 
the  abdomen  on  operation,  and  it  is  free  from  odour,  the  probability  is 
that  the  lesion  is  gastric  or  duodenal.  Mucous  colitis  simulates  chronic 
appendicitis,  and  the  appendix  is  indeed  often  involved  in  the  mischief. 
The  distinction  is  made  by  the  tenderness  being  located  over  the 
whole  course  of  the  colon,  and  by  the  passage  of  mucus  in  the  stools. 


ABDOMINAL  SURGERY  1055 

Tubal  and  ovarian  diseases  are  recognised  on  pelvic  examination  ;  but 
the  fact  must  not  be  overlooked  that  chronic  appendicitis  is  often 
associated  with  inflammation  of  the  right  ovary,  and  then  attacks  of 
pain  may  occur  at  each  menstrual  period.  A  small  ovarian  dermoid 
with  a  twisted  pedicle  may  resemble  appendicitis  very  closely  in  the 
absence  of  a  vaginal  or  rectal  examination. 

A  considerable  swelling  in  the  right  iliac  fossa  may  result  from 
repeated  attacks  due  to  a  matting  of  the  parts  together,  and  a 
diagnosis  from  tuberculous  or  malignant  disease  is  sometimes  difficult 
apart  from  operation.  The  history  may  be  spread  over  a  longer  time, 
hov/ever,  in  appendicitis. 

In  abdominal  abscesses  the  possibility  of  an  appendicular  origin 
must  always  be  kept  in  mind,  as  they  may  occur  in  any  part  of  the 
abdomen ;  and  it  is  often  only  by  a  careful  exploration  of  the  cavity 
that  we  can  trace  the  cause  to  the  appendix. 

The  diagnosis  from  acute  obstruction  is  noted  hereafter  (p.  11 15). 

The  Prognosis  is  never  absolutely  certain,  for,  as  has  been  well 
pointed  out  by  many  acute  observers,  the  initial  symptoms  are 
frequently  alike  in  all  the  varieties,  and  hence  one  can  never  know 
what  course  the  case  is  going  to  take  ;  as  R.  Morris,  of  New  York, 
says,  '  The  infected  appendix  is  a  cap  which  sometimes  snaps,  some- 
times flashes,  and  sometimes  causes  an  explosion,  and  none  of  us 
can  tell  in  advance  just  what  is  going  to  happen.'  As  particularly 
bad  signs  may  be  mentioned  a  continued  high  temperature,  in  spite 
of  rest  and  careful  dietetic  measures,  or  a  fall  of  temperature  with 
increased  rate  of  the  pulse.  Persistent  hiccough  is  also  a  bad  sign. 
The  existence  of  a  swelling  in  the  iliac  fossa  is  not  a  bad  sign,  but 
rather  the  reverse.  Absence  of  a  localized  swelling  is  due  either  to  a 
defective  formation  of  protective  adhesions,  and  hence  is  likely  to  be 
noted  in  the  most  acute  cases,  or  to  the  appendix  being  placed  behind 
the  caecum  in  a  position  less  favourable  to  operative  measures. 

Treatment. — So  much  has  been  written  on  this  subject  during  the 
last  twenty  years,  that  it  is  extremely  difficult  to  compress  even  a 
brief  summary  of  the  many  facts  observed  into  a  necessarily  limited 
space.  Formerly  perityphlitis  was  the  exclusive  property  of  the 
physician  ;  but  a  great  change  has  occurred,  and  many  authorities 
consider  that  appendicitis  is  more  justly  within  the  realm  of  the 
surgeon,  or,  at  any  rate,  that  a  surgeon  should  always  share  the 
responsibility  of  treatment  with  the  physician.  At  any  moment 
complications  may  develop  even  in  cases  which  appear  to  be  simple, 
when  immediate  surgical  assistance  will  alone  hold  out  any  hopes 
of  saving  the  patient.  In  America  surgery  is  the  recognised  treat- 
ment for  almost  every  case  of  the  disease,  as  soon  as  it  is  diagnosed ; 
in  this  country  conservative  ideas  still  persist,  but  a  more  healthy 
opinion  is  gaining  ground,  and  surgical  interference  is  becoming 
recognised  as  the  most  appropriate  means  of  treatment  in  most 
instances. 

I.  In  the  mild  catarrhal  type  of  appendicitis,  where  the  tempera- 
ture does  not  run  above  101°  F.  and  the  symptoms  are  not  severe,  all 


ios6  A  MANUAL  OF  SURGERY 

that  is  required  in  the  majority  of  cases  is  to  put  the  patient  to 
bed,  and  apply  fomentations  locally  ;  the  lower  bowel  should  be 
emptied  by  an  enema  after  a  rectal  examination  has  determined  that 
no  abscess  or  serious  pelvic  complication  is  present ;  if  it  seems 
likely  that  there  is  an  accumulation  of  irritating  faeces  within  the 
intestine,  one  dose  of  castor  oil  or  of  calomel  may  be  administered,  but 
not  without  due  consideration.  A  fluid,  unstimulating  diet  is  all  that 
is  permitted,  and  should  there  be  much  vomiting,  rectal  alimentation 
may  be  resorted  to.  Possibly  morphia  may  be  given  with  advantage 
to  quiet  the  patient  and  check  peristalsis,  thereby  facilitating  the 
formation  of  protective  adhesions  ;  but  the  less  the  better,  since  it 
tends  to  mask  symptoms. 

The  question  of  operation  for  this  mild  type  of  disease  can  be 
readily  compressed  into  the  three  following  propositions  : 

{a)  If  the  condition  is  not  showing  signs  of  improvement  at  the 
end  of  forty-eight  hours — i.e.,  on  the  third  day — in  spite  of  appro- 
priate treatment,  the  case  should  be  looked  on  with  suspicion  as 
probably  one  in  which  suppuration  is  occurring,  and  operation  is 
desirable. 

(&)  If  the  appendix  remains  tender  and  palpable  after  an  attack, 
and  especially  if  the  temperature  rises  slightly  at  night,  the  organ 
should  be  removed  without  delay. 

ic)  As  soon  as  the  attack  is  really  quiescent — i.e.,  generally  in  nine 
to  ten  days — the  appendix  should  be  removed.  This  proposition 
may  not  be  generally  accepted ;  but  it  is  absolutely  logical,  and  daily 
experience  is  emphasizing  the  conviction  as  to  its  accuracy.  In  the 
first  place,  recurrence  is  common,  and  the  figures  given  above  (viz., 
30  per  cent.)  probably  underestimate  its  frequency.  Then,  too,  it  is 
impossible  to  tell  which  cases  will  recur  and  which  escape,  whilst  the 
recurrent  attack  is  frequently  more  severe  than  the  first,  and  often 
accompanied  by  suppuration.  Moreover,  each  recurrent  attack  is 
likely  to  add  to  the  adhesions  present,  so  that  whilst  removal  after  a 
first  attack  is  an  easy  proceeding,  removal  after  many  recurrences 
may  necessitate  a  long  incision  and  a  troublesome  or  dangerous  dis- 
section, complicated,  perhaps,  by  unintentional  perforation  of  the 
bowel,  or  even  enterectomy.  Finally,  it  may  be  necessary  to  keep 
the  patient  very  quiet  and  to  limit  his  diet  and  his  activities  consider- 
ably if  recurrence  is  to  be  avoided  ;  and  such  practice  in  a  bread- 
winner may  be  a  serious  matter.  By  removing  the  appendix,  either 
during  or  immediately  after  the  attack,  this  period  of  disability  will 
probably  be  reduced  to  a  minimum. 

Operation  in  the  Quiescent  Period. — The  muscle-splitting  plan 
suggested  by  McBurney  may  well  be  adopted  when  it  is  probable 
that  but  few  adhesions  are  present.  The  incision  is  an  oblique  one, 
about  2  to  3  inches  long,  crossing  McBurney's  spot  or  a  little  below 
it,  and  parallel  to  the  outer  end  of  Poupart's  ligament,  somewhat 
similar  to  that  for  ligaturing  the  external  iliac  artery  (Fig.  449,  C). 
The  external  oblique  is  exposed,  and  incised  in  the  course  of  its 
fibres  ;  the  divided  segments  are  held  well  aside  by  retractors,  so  that 


ABDOMINAL  SURGERY 


1057 


about  2  inches  of  the  internal  obHque  muscle  come  into  view.  The 
exposed  fibres  of  this  muscle  run  nearly  in  the  same  direction  as  those 
of  the  transversalis  muscle,  and  the  two  can  be  split  together  by  a 
transverse  incision.  The  introduction  of  large  deep  retractors  wil 
expose  a  square  or  diamond-shaped  area  of  subperitoneal  fat  or  p>3ri- 
toneum  about  i^  to  2  inches  in  diameter.  The  peritoneum  is 
divided  transversely,  and  the  margins  grasped  for  identification 
purposes  by  Spencer  Wells  forceps.  The  caecum  probably  presents, 
and  is  gently  withdrawn.  The  anterior  longitudinal  muscular  band 
conducts  to  the  appendix,  which  is  freed  from  adhesions  and 
removed.  The  meso-appendix  is  first  divided  after  securing  the 
vessels  in  it  by  a  ligature  (Fig,  470,  A),     The  serous  and  muscular 

coats    are    then    divided    by    a 

circular  incision  (B)  and  peeled 

back    like    a    cuff,    leaving    the 

mucous  membrane  as  a  narrow 

tube.     The  retraction  is  carried 

back  so  as  to  enable  a  ligature 

to  be  placed  around  the  tube  of 

mucous    membrane    flush    with 

the    caecum/ (Fig.    471).      The 

distal     end     is     grasped     with 

WW  WW  '/7/i  %'-v-.j^r'  Spencer  Wells  forceps,  and  cut 

ylyV^         \\   -^^w^^^^^^-TTTr^  away  after  protecting  the  parts 

Vv^-v"  ;...-•    •;-^ ^- y\' •  ■>.-  ■  '-^^ , , ,Ti?i7j^        below  with  a  strip  of  sterilized 

gauze.  The  protruding  portion 
of  mucous  membrane  is  carefully 
curetted,  and  the  sero-muscular 
cuff  replaced  over  it.  A  purse- 
string  suture  is  then  introduced 
through  the  serous  and  muscular 
coats  all  round  it ;  the  appendix 
stump  is  gently  invaginated  into 
the  caecum  by  a  pair  of  forceps, 
and  the  suture  tied ;  by  this 
means  the  site  of  the  appendix 
is  puckered  up,  and  a  peritoneal  surface  left  (Fig.  472).  The  site  of 
detachment  of  the  meso-appendix,  or  of  the  position  from  which  the 
appendix  itself  has  been  detached,  may  require  a  few  sutures  in  order 
to  ensure  a  complete  peritoneal  coating,  and  thus  minimize  the  risk 
of  subsequent  adhesions. 

All  bleeding-points  having  been  secured,  the  caecum,  which  has 
been  protected  during  the  operation  by  a  warm  wet  sterilized  cloth, 
is  returned  into  the  abdomen,  and  finally  in  the  female  the  right  ovary 
and  tube  are  carefully  examined.  The  abdominal  wound  is  then 
closed,  layer  by  layer,  without  drainage. 

If,  however,  it  seems  probable  that  many  adhesions  are  present,  the 
muscle-splitting  operation  should  be  avoided,  and  the  abdominal 
parietes  divided  in  the  line  of  the  cutaneous  incision,  so  as  to  allow 

67 


Fig.  470. — Appendicectomy. 

A.  indicates  _the  ligature  placed  on  the 
meso-appendix ;  B,  the  situation  of 
the  circular  incision  through  the 
sero-muscular  coat ;  C,  the  lower 
end  of  the  ileum  ;  D  is  placed  on 
the  anterior  muscular  band  of  the 
caecum  which  leads  directly  to  the 
base  of  the  appendix. 


tp58 


A  Manual  op  surgery 


the  wound  to  be  enlarged  up  or  down  as  may  be  desired.  The 
severance  of  these  adhesions  may  be  a  most  tedious  and  troublesome 
procedure,  but  when  once  it  is  effected  the  appendix  is  amputated 
as  described  above.  In  some  of  these  more  serious  and  prolonged 
operations,  it  may  be  desirable  to  drain  the  iliac  fossa  by  a  tube  or 
gauze  wick  for  a  short  time. 

Under  any  circumstances  the  patient  remains   in    bed  for  three 


Fig.  471. 


Fig. 


472. 


ASlPUTATION    OF    THE    APPENDIX. 


In  Fig.  471  the  cuff  of  sero-muscular  tissue  has  been  dissected  up,  exposing  the 
tube  of  mucous  membrane,  to  which  a  pair  of  Spencer  Wells  forceps  is 
applied  distally,  whilst  a  ligature  is  placed  on  its  proximal  end.  The  purse- 
string  suture  has  been  introduced  around  its  base. 

In  Fig.  472  the  purse-string  suture  has  been  tied  after  tucking  in  the  sero-muscular 
cuff,  thereby  burying  the  stump  of  the  appendix. 

weeks,  to  allow  the  bond  of  union  to  become  firm,  and  should  avoid 
all  needless  strain  for  some  months. 

2.  In  the  gravest  variety  oi  fnhninating  appendicitis,  associated  with 
diffuse  septic  peritonitis,  there  can  be  no  question  that  the  only 
hope  of  recovery  lies  in  immediate  operation.  When  the  peritonitis 
is  extensive  and  the  exudate  purulent,  this  hope  is  but  slender  in  the 
extreme  ;  if,  however,  the  effusion  is  mainly  pelvic,  and  still  of  a  sero- 
purulent  type,  it  is  possible  that  a  considerable  percentage  of  the  cases 
may  be  saved.  Hence,  whenever  the  attack  starts  with  severe  pain 
and  collapse,  and  if  the  abdomen  shows  any  signs  of  rigidity  or  dis- 
tension in  twenty-four  hours,  and  if  vomiting  is  present,  no  time  should 


ABDOMINAL  SURGERY  -  1059 

be  lost  in  operating.  The  abdomen  is  opened,  either  through  the 
middle  line  or  in  the  right  iliac  fossa  ;  the  appendix  is  looked  for  and 
removed,  and  the  effusion  is  swabbed  or  washed  away  with  sterilized 
salt  solution  at  108°  F.  Drainage  must  then  be  provided  by  tubes 
or  gauze  wicks;  one  tube  passes  into  Douglas's  pouch,  and  one 
through  the  lumbar  region  ;  gauze  wicks  are  inserted  as  required. 

3.  When  an  abscess  is  evidently  present,  being  indicated  either 
by  fluctuation  or  by  a  commencing  oedema  of  the  abdominal  wall, 
there  should  be  no  hesitation  in  cutting  down.  An  incision  is  made 
over  the  oedematous  spot,  and  deepened  carefully,  since  the  tissues 
are  probably  matted  together,  and  cut  like  bacon  or  brawn.  The 
knife  or  index-finger  may  suddenly  sink  into  the  abscess  cavity,  and 
a  gush  of  foetid  pus  follows.  The  cavity  is  gently  explored,  so  as 
to  ascertain  whether  or  not  the  appendix  can  be  felt ;  no  undue  force 
should  be  used,  for  fear  of  breaking  down  adhesions  and  thus  open- 
ing the  general  peritoneal  sac.  If  the  appendix  cannot  be  readily 
found,  it  is  best  left  alone  ;  the  abscess  may  be  gently  irrigated, 
drainage  is  provided  for,  and  the  incision  partly  closed.  Probably 
the  case  will  go  on  well,  the  discharge  losing  its  smell  about  the 
third  day,  and  the  remaining  sinus  will  gradually  heal  by  granula- 
tion. Should  the  appendix,  however,  present  itself,  it  should  be 
removed. 

4.  There  is  still,  however,  a  large  group  of  cases  in  which  neither 
of  the  above  conditions  is  manifest,  and  yet  the  symptoms,  both  local 
and  general,  indicate  that  a  lesion  of  considerable  gravity  is  present. 
The  attack  may  have  commenced  more  or  less  acutely,  but  has 
progressed  steadily.  Much  difference  of  opinion  has  existed  as  to  the 
desirability  of  operation  in  such  cases,  and  especially  as  to  the  most 
favourable  time  for  such  a  procedure.  It  must  be  admitted  that  in 
many  instances  conservative  or  medical  treatment  will  suffice  to  bring 
about  a  satisfactory  result,  but  this  can  never  be  depended  on,  and, 
unfortunately,  the  experience  of  all  surgeons  is  that  only  too  fre- 
quently have  they  been  called  in  to  operate  on  patients  who  have 
been  brought  into  the  gravest  jeopardy  of  their  lives  through  undue 
delay.  Either  they  are  suffering  from  generalized  peritonitis,  or  are 
profoundly  toxaemic  by  absorption  from  a  large  abscess,  or  exhausted 
by  previous  suffering  ;  possibly  other  complications  have  arisen  due 
to  extension  of  thrombosis  or  dissemination  of  emboli.  Operation 
under  such  circumstances  is  always  risky,  and  even  if  the  local 
conditions  are  effectively  dealt  with,  the  patient  may  subsequently 
succumb  to  toxaemia,  septicaemia,  pulmonary  embolus,  or  other  mani- 
festations of  blood-poisoning,  perhaps  aggravated  by  the  operation. 

The  objections  usually  raised  to  early  operation  are  that  it  involves 
the  removal  of  the  appendix  from  a  certain  number  of  people  who 
might  get  well  without  operation,  and  that  it  is  not  the  best  time  to 
operate  when  inflaimmatory  phenomena  are  present.  The  answer  to 
these  objections  is  quite  obvious,  viz.,  that  the  prognosis  in  any  case 
is  so  hopelessly  uncertain  that  the  risks  involved  in  waiting  for 
a  quiescent  interval  on  the  one  hand,  or  for  the  development  of  un- 


lo6o  A  MANUAL  OF  SURGERY 

doubted  indications  of  the  presence  of  pus  on  the  other,  are  much 
greater  than  those  of  an  operation  undertaken  at  an  early  date  by  a 
skilful  surgeon.  Moreover,  an  appendix  that  has  once  been  inflamed 
is  of  no  service,  and  may  be  a  source  of  grave  danger  to  its  possessor, 
and  the  sooner  he  is  rid  of  it  the  better.  Extensive  experience  of  the 
early  operation  proves  that  pus  is  frequently  present  at  quite  an 
early  stage  of  the  alTection — ?.^.,  within  thirty-six  hours — and  one  rarely 
operates  on  any  case  where  the  symptoms  are  at  all  severe  without 
finding  cause  for  gratification  that  delay  had  not  been  counselled. 
The  chief  advantages  of  an  early  operation  may  be  indicated  as 
follows  •  (a)  That  the  patient  is  not  in  a  state  of  collapse  from  toxaemia, 
and  hence  can  easily  stand  the  shock  of  an  intraperitoneal  explora- 
tion ;  {b)  that  the  amount  of  pus  likely  to  be  present  is  small,  and 
hence  can  be  easily  dealt  with  and  safely  removed  with  but  little  risk 
of  infecting  the  general  peritoneal  cavity ;  {c)  that  the  appendix  can 
usually  be  found,  isolated,  and  removed  without  much  difficulty ;  in 
the  later  stages  where  a  large  abscess  exists  this  may  be  impractic- 
able, and  a  second  operation  for  its  removal  may  be  required  later 
on,  and  then  the  appendix  may  have  to  be  '  dug  out '  of  a  mass 
of  adhesions,  and  serious  risks  taken  ;  and  (d)  that  a  smaller  incision 
will  be  required,  and  hence  there  will  be  less  likelihood  of  the  subse- 
quent developm.ent  of  a  hernia.  One  would  therefore  claim  that  the 
following  rule  is  both  reasonable  and  justifiable,  and  that  its  obser- 
vance will  be  beneficial,  viz.,  that  in  cases  of  moderate  severity  if  in 
spite  of  suitable  rest  and  medical  treatment  the  symptoms,  both  general  and 
local,  are  not  commencing  to  abate  at  the  end  of  forty -eight  hours,  operation 
should  be  undertaken,  and  still  more  so  if  any  of  the  following  conditions, 
indicative  of  the  formation  of  an  intraperitoneal  abscess  are  existent, 
viz.,  a  steady  rise  in  the  leucocyte  count,  or  one  above  20,000,  especi- 
ally if  maintained  for  twenty-four  hours  ;  persistent  distension  of  the 
abdomen,  a  maintained  high  temperature,  hiccough,  or  a  continued 
high  pulse  rate,  in  spite  of  a  falling  temperature.  Of  course, 
a  localized  swelling  which  persists  or  increases  in  size  and  becomes 
more  tender,  will  aJso  indicate  operation. 

5.  Not  a  few  cases  will  be  observed  in  which  the  initial  symptoms 
quiet  down  at  the  end  of  twenty-four  or  forty -eight  hours,  but 
after  an  interval  of  quiescence  of  varying  length  the  phenomena 
suggestive  of  suppuration  show  themselves.  In  such  patients  opera- 
tion should  be  advised  immediately,  as  an  abscess  is  obviously 
developing. 

Operation  for  Suppurative  Appendicitis. — Ether  should  always  be  the 
anesthetic,  if  possible ;  the  mortality  after  operation  when  chloroform 
is  employed  is  decidedly  higher.  The  incision  will  vary  with  the 
physical  signs  and  the  site  of  maximum  tenderness.  The  whole 
thickness  of  the  abdominal  wall  is  divided,  and  it  is  well  to  make  a 
sufficiently  large  opening  ;  an  extra  inch  of  incision  may  make  all  the 
difference  between  blindly  groping  in  the  dark  and  seeing  clearly  what 
one  is  doing.  The  general  arrangement  of  the  parts  is  noted,  and  the 
peritoneal  cavity   protected   from  purulent  infection  by  packing  in 


ABDOMINAL  SURGERY  1061 

sterilized  gauze ;  one  strip  is  usually  passed  upwards  along  the  as- 
cending colon,  one  downwards  into  the  pelvis,  and  one  internally  to 
protect  the  small  intestines  and  general  serous  cavity.  The  caecum 
is  then  gently  lifted  from  its  bed,  and  the  abscess  will  usually  be 
found  behind  it.  Every  effort  must,  of  course,  be  made  to  prevent 
soiling  of  the  unaffected  peritoneum.  Whenever  possible,  the 
appendix  should  be  removed ;  it  is  first  freed  from  adhesions,  and 
the  meso-appendix  ligatured.  If  sufficiently  healthy,  a  formal 
amputation,  as  in  the  chronic  cases,  should  be  undertaken,  but 
.  such  a  procedure  is  often  impracticable.  A  ligature,  and  preferably 
of  catgut,  which  can  be  absorbed,  is  then  tied  around  the  base 
about  ^  inch  from  the  caecum,  and  the  appendix  cut  away  ;  the 
stump  is,  if  practicable,  buried  by  the  insertion  of  two  or  three 
sutures  into  the  serous  membrane  covering  the  caecum.  Not 
unfrequently,  however,  the  appendix  does  not  appear,  and  then  it  may 
be  better  to  leave  it  alone  ;  in  many  cases,  however,  an  experienced 
surgeon  will  be  able  to  detach  and  remove  it.  The  cavity  is  emptied 
of  pus  by  swabbing  it  out,  and  a  careful  but  thorough  exploration  of 
the  pelvis  and  right  kidney  pouch  made  to  ensure  that  pus  is  not 
shut  up  in  these  regions.  Finally,  the  cavity  is  packed  in  such  a 
way  as  to  drain  it  thoroughly,  and  yet  to  protect  the  surrounding 
parts.  It  may  be  desirable  to  introduce  a  drainage-tube  through 
a  counter-opening  in  the  loin.  The  abdominal  incision  is  partially 
closed. 

The  packing  is  gradually  removed  in  the  next  two  or  three  days, 
and  after  the  general  cavity  has  been  shut  off  by  the  development  of 
adhesions,  irrigation  with  salt  solution  or  peroxide  of  hydrogen  is 
permissible.  The  wound  heals  by  granulation,  and  when  nearly  flush 
with  the  surface  may  be  drawn  together  by  strapping,  so  as  to  limit 
the  chances  of  development  of  a  ventral  hernia. 

Sequelae. — A  FcBcal  fistula  may  result  from  a  perforative  appendi- 
citis when  the  abscess  has  been  merely  opened,  and  no  radical 
treatment  undertaken  at  the  same  time,  or  it  may  follow  an  amputa- 
tion of  the  appendix  from  sloughing  or  yielding  of  the  stump.  It 
is  usually  small  in  size,  and  sinuous  in  its  course,  and  in  the  majority 
of  cases  closes  of  itself.  Occasionally  it  is  necessary  to  deal  with  it  by 
laying  bare  the  caecum  in  the  iliac  fossa,  and  removing  the  appendix 
or  suturing  the  opening.  Failing  that,  it  may  be  necessary  to  short- 
circuit  the  caecum. 

A  Ventral  Hernia  sometimes  follows  from  the  yielding  of  the 
cicatrix  in  the  abdominal  wall  after  an  abscess  has  been  opened  and 
drained.  Both  omentum  and  bowel,  perhaps  matted  together  and 
adherent  to  the  cicatrix,  are  found  in  the  protrusion.  In  some 
cases  it  may  suffice  to  protect  and  restrain  it  with  a  truss,  but  in 
others  operation  is  required  ;  adhesions  must  be  divided  or  broken 
down,  and  often  the  opportunity  can  be  taken  for  removing  the 
appendix,  if  this  has  not  already  been  accomplished.  The  margins 
of  the  divided  muscles  are  then  sought  for,  and  united  by  a  row  of 
buried  sutures  in  the  ordinary  way. 


io52  A  MANUAL  OF  SURGERY 

Tuberculosis  of  the  Appendix  is  found  not  uncommonly  in  patients 
who  have  died  of  other  manifestations  of  the  disease,  especially 
phthisis  (30  per  cent,  Keen)  ;  it  is  not  often  seen  as  an  independent 
condition,  but  most  frequently  comes  under  observation  in  men 
between  the  ages  of  twenty  and  forty,  who  are  the  subject  of  urino- 
genital  tuberculous  disease.  The  affection  may  develop  as  an 
ulceration  of  the  mucous  membrane,  which  slowly  spreads  from  the 
tip  and  destroys  -the  walls  of  the  organ,  giving  rise  finally  to  a  large 
pericsecal  abscess,  which  opens  into  the  bowel  or  discharges  externally. 
In  other  cases  the  condition  is  merely  an  element  in  the  evolution  of 
the  hyperplastic  tuberculous  growth  of  the  caecum  described  else- 
where (p.  1027).  Occasionally  the  appendix  is  involved  in  a  tuber- 
culous peritonitis,  and  then  the  trouble  may  either  have  started  in 
the  appendix,  or  have  reached  it  secondarily  from  the  serous  coat. 
The  symptoms  of  these  conditions  are  in  no  ways  peculiar,  and 
correspond  to  those  of  a  chronic  appendicitis. 

Actinomycosis  attacks  the  appendix  more  frequently  than  any 
other  abdominal  organ.  The  disease  originates  usually  from  the 
ingestion  of  infected  material,  and  the  result  is  the  production  of  a 
hard,  slowly  enlarging  mass,  infiltrating  the  tissues  in  the  right  iliac 
fossa.  Sooner  or  later  the  skin  gives  way,  and  then  the  discharge  of 
glairy  pus  and  of  the  yellow  sulphur-like  granules,  together  with  the 
musty  smell,  is  pathognomonic.  Pyococcal  infection  of  the  sinuses  is 
only  too  likely  to  follow,  sometimes  originating  from  within  the  bowel, 
and  the  case  then  becomes  complicated  bya  suppurating  element  which 
has  an  important  bearing  on  the  result  Secondary  foci  are  common, 
especially  in  the  liver.  Treatment  consists  in  the  excision  of  the 
appendix  and  even  of  the  caecum,  if  such  be  practicable,  or  in  the 
exhibition  of  large  doses  of  iodide  of  potassium  with  curettage  and 
drainage  ;  but  even  when  the  organisms  have  been  destroyed  by  the 
drug,  the  discharge  of  pus  may  continue,  and  the  afi~ection  m_ay  prove 
fatal. 

Primary  Carcinoma  of  the  appendix  is  noteworthy  on  account  of 
its  slight  malignancy.  The  case  presents  the  history  of  a  chronic 
appendicitis,  in  no  ways  peculiar,  and  on  operation  the  growth  is 
discovered.  Removal  is  usually  followed  by  freedom  from  recur- 
rence. The  condition  is,  however,  very  uncommon.  Sarcoma  has 
also  been  known  to  occur  in  connection  with  the  appendix,  but  the 
prognosis  is  less  favourable. 

Affections  of  tlie  Liver. 

Displacements  of  tlie  Liver  are  obviously  not  likely  to  be  common, 
since  the  organ  is  well  supported,  both  by  ligaments  and  attachments 
to  deep  structures,  and  by  the  intra-abdominal  pressure.  Should, 
however,  the  abdominal  parietes  be  relaxed  and  the  intra-abdominal 
pressure  lessened,  it  is  possible  for  the  liver  to  sink,  and  thus  hepato- 
ptosis  becomes  an  element  in  the  syndrome  known  as  Glenard's 
disease  (p.  1032).     The  displaced  liver  is  rotated  forwards  so  that  its 


ABDOMINAL  SURGERY  1063 

upper  wall  presents  anteriorly,  with  obvious  resulting  physical  signs. 
An  enlarged  liver  may  manifest  somewhat  similar  phenomena,  but 
dulness  is  then  found  over  the  normal  hepatic  area  ;  in  hepatoptosis 
the  normal  site  is  resonant.  Some  amount  of  dragging  pain  and 
discomfort  may  be  complained  of,  but  this  is  not  generally  great 
enough  to  demand  treatment  other  than  the  support  of  a  belt, 
together  with  such  measures  as  shall  assist  in  the  restoration  of  the 
abdominal  wall  to  a  state  of  normal  tonicity.  In  the  worst  cases  it 
is  justifiable  to  expose  the  liver  by  an  incision  parallel  to  the  costal 
margin,  and  fix  it  to  the  parietal  peritoneum  by  sutures.  The  opera- 
tion is  conducted  in  the  Trendelenburg  position,  and  the  patient  must 
remain  with  the  lower  end  of  the  bed  raised  for  some  weeks  after 
operation. 

Riedel's  lobe  is  the  name  applied  to  a  linguiform  enlargement  of 
the  right  lobe,  which  projects  downwards  into  the  loin,  and  is  likely 
to  be  mistaken  for  a  floating  kidney.  It  is  sometimes  stated  to  be 
the  result  of  tight  lacing,  but  this  is  not  invariable,  and  more 
frequently  it  is  associated  with  an  enlarged  gall-bladder,  probably 
containing  stones,  which  is  covered  in  by  the  projection.  The  lobe 
may  have  a  broad  base  of  attachment  to  the  liver,  or  may  be  almost 
severed  from  it,  and  then  its  mobility  is  considerable,  and  may  be 
independent  of  the  liver.  A  little  care  in  examination  should  enable 
the  surgeon  to  differentiate  between  this  condition  and  a  floating 
kidney;  if  the  patient  be  laid  over  on  the  left  side,  the  examining 
hand  can  be  insinuated  between  the  lobe  and  the  kidney.  Treat- 
ment is  not  required,  except,  perhaps,  for  the  condition  of  the  gall- 
bladder. 

Rupture  of  the  Liver  is  produced  by  injuries  to  the  abdominal 
walls,  such  as  blows,  kicks,  or  crushes,  or  it  may  be  torn  by  the 
broken  end  of  a  rib.  Penetrating  injuries  also  occur,  as  from  sword 
or  dagger  thrusts,  and  the  organ  may  be  involved  in  a  gunshot 
wound.  The  resulting  lesion  varies  considerably' ;  the  gland  may  be 
merely  torn  or  contused  from  a  non-penetrating  blow,  or  freely 
incised  by  a  sharp-cutting  implement,  in  which  case  some  of  the 
larger  venous  trunks  are  likely  to  be  divided  ;  a  bullet  sometimes 
produces  almost  total  disorganization.  The  amount  of  injury 
depends,  to  some  extent,  on  the  condition  of  the  organ  ;  if  it  is  firm 
and  sclerosed,  it  may  receive  little  damage  from  a  blow  which  would 
otherwise  do  it  considerable  harm,  whilst  if  it  is  enlarged  and  fatty, 
it  is  readily  torn. 

The  chief  Symptoms  are  shock,  which  is  often  not  very  excessive, 
pain  and  tenderness  in  the  right  hypochondrium,  and  the  evidences 
of  loss  of  blood.  The  last  is,  perhaps,  the  most  important,  and 
upon  its  severity  depends  to  a  large  extent  the  result.  Should  the 
capsule  remain  intact,  there  is  considerable  intraglandular  ecchy- 
mosis  and  laceration,  but  no  free  blood  escapes  into  the  peritoneal 
cavity.  Such  a  lesion  is  not  unlikely  to  be  followed  by  an  abscess 
of  the  liver.  When  the  capsule  is  torn,  intraperitoneal  haemorrhage 
is  sure  to  ensue  ;  if  slight,  the  patient,  though  suffering  from  al] 


io64  A   MANUAL  OF  SURGERY 

the  phenomena  characteristic  of  loss  of  blood,  may  recover,  the 
blood  being  absorbed,  and  the  wound  in  the  liver  cicatrizing.  This 
process  is  usually  attended  by  a  certain  amount  of  jaundice  and 
some  vomiting,  whilst  the  urine  is  also  tinged  with  bile-pigment. 
Well-marked  pyrexia  may  follow  the  initial  shock,  and  the  abdominal 
wall  is  held  rigid.  In  other  cases,  the  blood  collects  at  first  in  the 
upper  part  of  the  abdomen,  but  gradually  extends  downwards ;  if  the 
bowel  is  uninjured,  recovery  may  ensue,  but  not  uncommonly  there 
is  some  associated  contusion  of  the  gut  wall,  through  which  intestinal 
bacteria  find  their  way,  giving  rise  to  a  localized  or  general  peritonitis. 
Of  course,  in  the  more  severe  lesions,  where  perhaps  the  left  lobe 
is  entirely  torn  off  or  a  portion  hopelessly  contused,  death  from 
haemorrhage  is  almost  certain  to  ensue  in  a  very  short  time. 

The  Diagnosis  of  hepatic  rupture  turns  mainly  on  the  history  of  the 
accident,  the  situation  of  the  blow,  and  the  resulting  symptoms. 
Evidences  of  intraperitoneal  bleeding,  associated  with  pain  in  the 
right  side,  are  extremely  suggestive.  It  must  not,  however,  be  for- 
gotten that  the  passage  of  a  hansom  cab  or  other  vehicle  over  the  body 
may  give  rise  to  much  shock,  and  to  considerable  local  pain  and  ten- 
derness, and  yet  no  serious  mischief  need  have  happened  to  the  liver. 

The  Treatment  in  the  more  simple  cases  consists  merely  in  careful 
expectancy,  the  surgeon  holding  himself  in  readiness  to  interfere 
should  any  untoward  symptoms  supervene.  The  patient  is  kept 
quietly  in  bed ;  ice  may,  if  necessary,  be  applied  to  the  side,  the  diet 
is  limited  to  fluids,  and  the  bowels  emptied  by  enemata.  In  the 
more  serious  cases,  where  the  diagnosis  of  ruptured  liver  is  tolerably 
certain,  an  exploratory  laparotomy  should  be  undertaken,  and  an 
attempt  made  to  deal  with  the  wound.  Possibly  a  median  incision  is 
as  good  as  any,  since  the  left  half  of  the  liver  often  bears  the  brunt 
of  the  injury.  Outlying  ragged  portions  of  the  gland  may  be  totally 
removed,  preferably  by  the  cautery,  though  one  usually  has  to  depend 
upon  plugging  the  wound  with  gauze  in  order  to  effect  hsemostasis. 
Clean  linear  cuts  may  be  sutured  with  silk,  but  there  is  considerable 
difficulty  in  preventing  the  stitches  from  tearing  out  of  the  friable 
hepatic  tissue  ;  it  is  wise  to  insert  all  the  stitches  first,  taking  up  a 
wide  margin  of  the  gland  substance  before  attempting  to  tie  any. 
The  wound  is  then  carefully  closed  by  the  fingers,  and  the  sutures 
slowly  and  gently  tightened.  A'ery  shallow  wounds  which  it  is  impos- 
sible to  stitch  or  plug  satisfactorily  may  be  seared  with  the  cauter} 
so  as  to  stop  bleeding,  and  then  a  gauze  drain  is  placed  over  them, 
and  brought  out  of  the  external  wound. 

Abscess  of  the  Liver  is  due  to  a  variety  of  causes. 

I.  Multiple  Abscesses  develop  in  cases  of  pyaemia,  whether  the 
emboli  are  carried  by  the  hepatic  artery  or  by  the  portal  vein.  In 
the  former  case,  the  condition  arises  as  a  complication  of  general 
pyaemia  of  systemic  origin  ;  in  the  latter,  the  originating  focus  of 
mischief  is  located  in  the  area  of  distribution  of  the  portal  vein— z'.^., 
in  the  intestinal  canal.  Thus,  pylephlehitis,  as  it  is  termed,  is  not 
uncommonly  met  with  in   appendicitis,  and   sometimes  in  typhoid 


ABDOMINAL  SURGERY  1065 

fever,  whilst  suppurating  piles  may  also  lead  to  it.  It  is  character- 
ized clinically  by  high  fever,  rigors,  vomiting  and  abdominal  disten- 
sion ;  the  liver  is  enlarged  and  tender,  and  the  spleen  may  also  be 
engorged  with  blood. 

2.  Suppurative  Cholangitis  is  another  cause  of  multiple  abscess  of 
the  liver.  It  consists  of  an  inflammatory  affection  of  the  biliary 
duct  and  passages,  and  is  due  to  the  spread  of  organisms  from  the 
intestine,  or  occasionally  from  the  gall-bladder  after  an  operation. 
The  biliary  ducts  in  the  liver  become  enormously  dilated,  and  filled 
with  a  mixture  of  bile  and  pus  which  closely  resembles  yellow  ochre. 
It  is  accompanied  by  pain  over  the  gland  and  the  general  phenomena 
of  pyrexia,  but  rigors  are  not  present.  The  patient  is  not  usually 
jaundiced,  but  bile  may  be  found  in  the  urine.  Treatment  is  of  little 
avail,  but  if  a  diagnosis  can  be  made,  and  the  gall-bladder  has  not 
been  already  incised,  it  may  relieve  tension  to  open  and  drain  it. 

3.  Hydatid  cysts  may  suppurate,  and  require  treatment  as  for  an 
abscess  of  the.  liver. 

4.  The  more  important  abscesses,  from  a  surgical  standpoint,  are 
those  which,  from  their  size,  demand  operative  treatment.  They 
may  result  from  traumatism  in  the  way  stated  above,  or  may  arise 
in  connection  with  hydatid  cysts,  but  more  commonly  are  of  the  type 
known  as  tropical  abscess.  The  latter  usually  occurs  in  men  who 
have  travelled  in  the  tropics,  and  75  per  cent,  of  the  cases  are  attri- 
buted to  dysentery.  It  is  probable  that  unwise  indulgence  in  alcohol 
is  a  predisposing  factor,  and  that  the  abscess  itself  is  embolic  in 
origin.  A  large  proportion  of  the  cases  are  stated  (by  Dr.  Leonard 
Rogers*)  to  be  free  from  ordinary  pyogenic  organisms  when  first 
opened,  but  to  contain  in  abundance  the  Amceha  coli,  which  is  looked 
on  as  being  an  important  factor  in  the  aetiology  of  dysentery.  In  the 
less  acute  cases  the  pus  becomes  sterile  after  a  time,  the  organisms 
apparently  dying.  It  is  probable  that  in  the  more  acute  cases 
ordinary  pyogenic  cocci  are  usually  to  be  found.  A  tropical  abscess 
is  most  frequently  situated  at  the  back  of  the  right  lobe,  but,  of 
course,  any  part  of  the  viscus  may  be  involved.  Though  often 
single,  the  cavity  is  generally  loculated,  indicating  that  several 
original  foci  of  suppuration  have  united  together.  The  abscess  wall 
consists  of  disintegrating  hepatic  tissue  in  acute  cases,  but  may  have 
a  fibro-cicatricial  wall  in  the  more  chronic  forms,  and  in  an  old- 
standing  abscess  the  limiting  membrane  may  be  as  tough  as  leather. 
The  pus  is  sometimes  of  the  ordinary  type,  but  not  uncommonly 
reddish-brown  in  colour,  somewhat  like  chocolate,  and  of  a  most 
nauseating  odour. 

The  Symptoms  are  in  some  instances  extremely  slight,  the  patient 
perhaps  dying  of  peritonitis  due  to  its  rupture  without  its  presence 
having  ever  been  suspected,  or  retaining  the  pus  encapsuled  for 
years.  The  individual  usually  complains  of  a  sense  of  pain  and 
fulness  in  the  right  hypochondrium,  and  in  the  more  acute  cases  this 
may  be  accompanied  by  severe  pain  and  localized  tenderness  over 

*  British  Medical  Journal,  June  16,  1906. 


o56  A  MANUAL  OF  SURGERY 

the  whole  hepatic  region,  the  pain  being  also  referred  to  the  right 
shoulder.  When  the  pus  encroaches  on  the  upper  surface  of  the 
liver,  a  cough  on  taking  a  deep  breath  is  rather  characteristic.  A 
certain  amount  of  febrile  disturbance  occurs,  the  degree  of  which 
depends  on  the  rapidity  of  formation  of  the  abscess  ;  in  the  mce 
acute  forms  the  temperature  is  high  and  rigors  may  be  present ;  in 
the  more  chronic  variety  there  is  some  fever  in  the  evening,  and 
night  sweats  occur.  The  pyrexial  phenomena  are  associated  with 
loss  of  appetite,  rapid  and  well-marked  emaciation,  and  perhaps  a 
slight  amount  of  icterus.  On  physical  examination  a  more  or  less 
evident  enlargement  of  the  liver  will  be  detected;  but  there  is 
neither  fluctuation  nor  a  sense  of  elastic  tension  unless  the  abscess  is 
very  superficial.  The  dulness  often  extends  up  towards  the  thorax 
rather  than  downwards,  though  the  contrary  obtains  when  the  abscess 
is  situated  not  far  from  the  free  margin  of  the  liver. 

Left  to  itself,  several  distinct  courses  are  open  for  the  abscess  to 
follow  :  it  may  become  adherent  to  the  anterior  abdominal  wall  and 
point  in  the  epigastrium,  its  onward  passage  being  indicated  by  con- 
gestion and  oedema  of  the  parietes ;  it  may  open  into  the  peritoneal 
cavity,  or  into  one  of  the  hollow  viscera,  such  as  the  colon  or  duo- 
denum ;  or,  again,  it  may  travel  upwards,  burrowing  through  the 
diaphragm,  and  either  bursting  into  the  lung,  its  contents  being 
expectorated,  or  into  the  pleural  cavity,  leading  to  an  empyema. 
Occasionally  it  remains  passive  as  a  chronic  encysted  abscess,  and 
then  the  walls  become  very  thick,  as  in  a  case  operated  on  by  one 
of  us,  which  had  been  diagnosed  by  an  exploring  needle  twelve 
years  previously,  and  left  alone.  It  contained  about  2  pints  of  pus, 
and  the  walls  were  fully  ^  inch  thick.  The  patient  came  under 
observation  because  the  swelling  was  becoming  more  prominent,  as 
the  result  of  increased  intra-abdominal  pressure,  due  to  pregnancy. 

In  many  cases  the  diagnosis  of  suppuration  is  by  no  means  easy, 
and  mistakes  are  likely  to  be  made,  the  condition  being  looked  on  as 
one  of  hepatitis.  A  blood  count  may  be  of  some  assistance,  and 
especially  a  differential  count ;  but  sometimes  it  is  of  little  value,  since 
a  leucocyte  count  of  20,000  or  more  can  occur  without  suppuration, 
A  marked  increase  in  the  polynuclear  leucocytes  and  a  diminution 
in  the  small  lymphocytes  is  always  suggestive  of  the  presence  of 
pus,  due  to  pyogenic  organisms  ;  in  a  pure  amcebic  abscess,  leuco- 
cytosis  occurs  with  a  comparatively  small  increase  of  polynuclears. 
A  doubtful  diagnosis  can  sometimes  be  confirmed  by  the  aspirator 
or  exploring  syringe,  but  this  should  not  be  utilized  unless  one  is  jully 
prepared  for  immediate  operation  in  the  case  of  pus  being  found.  Manson 
directs  that  the  aspirator  needle  should  be  introduced  in  the  follow- 
ing situations  :  (i)  In  the  right  axillary  line  through  the  seventh  or 
eighth  costal  interspace ;  (2)  just  below  the  ribs  in  the  right  nipple 
line  ;  (3)  immediately  below  the  lung  in  the  line  drawn  downwarc's 
from  the  angle  of  the  right  scapula. 

Treatment. — It  is  unnecessary  to  discuss  the  medical  treatment  of 
cases  of  suspected  abscess  of  the  liver  ;  but  we  must  refer  in  passing 


ABDOMINAL  SURGERY  1067 

to  the  diagnostic  and  curative  value  of  ipecacuanha  in  the  hepatitis 
that  accompanies  amoebic  dysentery  when  pus  is  not  present.  Doses 
of  20  to  40  grains  are  administered  once  or  twice  a  day  twenty 
minutes  after  a  small  dose  of  tincture  of  opium,  and  if  suppuration 
is  absent  the  symptoms  usually  yield  rapidly,  When  an  abscess  is 
present,  operative  treatment  is  of  course  necessary.  Aspiration, 
repeated  once  or  twice,  has  been  frequently  employed,  but  is  of  little 
value,  and  not  a  few  cases  are  on  record  in  which  septic  peritonitis 
or  pleurisy  followed  the  introduction  of  the  needle  from  the  front  or 
side  respectively.  The  practice  usually  followed  is  in  accordance  with 
the  surgical  law  of  treating  suppuration — viz.,  that  the  abscess  should 
be  opened  and  drained.  If  pointing  in  front  and  adherent  to  the 
parietes,  there  is  no  difficulty  or  danger  in  making  an  incision  over 
the  most  prominent  spot  and  laying  the  cavity  open ;  it  is  then  well 
flushed  out  and  a  drainage-tube  inserted.  If  on  dividing  the  abdominal 
parietes  it  is  found  that  the  liver  is  not  yet  adherent,  it  was  formerly 
thought  best  to  plug  the  wound  with  sterilized  or  antiseptic  gauze,  or 
to  introduce  sutures  between  the  liver  and  the  parietal  peritoneum  so 
as  to  determine  the  formation  of  adhesions  to  such  an  extent  as  to 
shut  off  the  general  peritoneal  cavity ;  in  a  few  days  the  abscess 
could  then  be  opened  with  safety.  At  the  present  time  the  operation 
is  usually  done  at  one  sitting,  with  precautions  similar  to  those  taken 
in  dealing  with  an  intraperitoneal  abscess  connected  with  appendicitis. 
The  general  serous  cavity  must  be  carefully  protected  by  sterilized 
gauze  before  letting  out  the  pus,  which  is  of  course  done  slowly,  and 
the  assistant  must  keep  the  parietes  in  close  contact  with  the  hepatic 
tissue.  It  may  be  possible  to  insert  a  few  stitches  through  the  liver 
substance,  securing  it  thus  to  the  parietal  peritoneum ;  otherwise  one 
must  trust  to  careful  packing.  After  opening  the  abscess,  it  is 
usually  advisable  to  wash  it  out,  and  this  may  with  advantage  be 
repeated  subsequently.  A  large  drainage-tube  is  inserted,  and  packed 
around  with  gauze  to  prevent  purulent  extravasation. 

When  the  abscess  is  in  its  most  common  situation,  viz.,  the  back 
of  the  right  lobe,  it  is  often  most  satisfactory  to  open  it  from  the 
side ;  a  similar  proceeding  is  sometimes  needed  when  an  abscess  has 
been  opened  from  the  front,  and  does  not  drain  properly.  An  incision 
is  made  a  little  behind  the  mid-axillary  line  through  the  ninth  or  tenth 
intercostal  space,  and  a  portion  of  one- of  the  adjacent  ribs  removed. 
The  pleural  cavity  is  opened,  and  the  costal  pleura  stitched  carefully 
to  that  portion  which  covers  the  diaphragm ;  it  will  be  found  that 
this  structure  lies  nearly  vertical  in  this  position,  and  but  little  diffi- 
culty is  experienced  in  shutting  off  the  general  pleural  cavity.  The 
diaphragm  is  then  divided,  and  not  unfrequently  the  peritoneal  cavity 
is  opened ;  it  must  be  carefully  protected  by  gauze  packing,  and  then 
the  liver  incised  ;  less  commonly  adhesions  may  have  already  formed, 
or  a  bare  area  of  the  liver  may  be  found,  through  which  the  pus  can 
be  withdrawn  and  the  abscess  opened. 

Recently,  however,  some  doubt  has  been  thrown  on  this  practice 
by  Dr.  Leonard   Rogers,*  who  finds  that  the  Amceba  coll  is  easily 

*  Op.  cit. 


io68  A  MANUAL  OF  SURGERY 

killed  by  comparatively  weak  solutions  of  quinine,  and  hence  has 
suggested  that  in  amcebic  abscesses  all  that  is  needed  is  to  empty  the 
cavity  by  aspiration,  introduce  30  or  40  grains  of  bi-hydrochlorate  of 
quinine,  and  employ  no  drainage.  The  results  hitherto  reported 
have  been  most  encouraging.  A  rapid  microscopic  examination  of 
the  pus  must  of  course  be  made  at  the  time,  and  if  pyogenic  organisms 
other  than  the  amoeba  are  found,  the  ordinary  operation  can  be 
carried  out. 

Hydatid  Cysts  occur  in  the  liver  more  frequently  than  in  any  other 
part  of  the  body.  For  general  details  as  to  the  life-history  of  the 
Tisnia  echinococcus  and  the  structure  of  hydatid  cysts,  see  p.  227,  They 
produce  a  localized  painless  enlargement  of  the  liver,  the  cysts  vary- 
ing in  size  from  a  small  marble  to  a  child's  head ;  the  outline  is  well 
defined  if  superficial,  but  not  so  if  placed  deeply ;  the  cavity  is 
usually  filled  with  fluid  and  daughter-cells.  Fluctuation  may  be  dis- 
tinguished, and  a  hydatid  fremitus  or  thrill  (arising  from  the  concus- 
sion of  the  contained  daughter-cysts)  may,  it  is  said,  be  elicited  on 
palpation.  The  diagnosis  is  easily  made  if  the  cyst  projects  from  the 
lower  border,  but  when  deeply  embedded  in  the  organ  it  may  be 
exceedingly  difficult,  and  the  tumour  can  only  be  distinguished  with 
certainty  from  carcinoma  or  syphilis  by  the  use  of  the  aspirator,  or 
preferably  by  an  open  exploration.  The  character  of  the  fluid  with- 
drawn from  a  hydatid  cyst  is  at  once  conclusive,  as  it  is  of  low  specific 
gravity,  viz.,  1007  to  1009,  slightly  opalescent,  with  no  albumen, 
and  a  trace  of  salt ;  the  presence  of  scolices  or  booklets  is  the 
pathognomonic  feature. 

Terminations. — The  cyst  may  remain  latent  and  innocuous,  or  may 
actually  dry  up  and  form  a  mass  somewhat  like  wet  mortar,  owing 
to  the  death  of  the  organism  ;  or  it  may  burst  and  be  evacuated  in 
different  directions,  with  or  without  suppuration.  Thus,  it  may  open 
externally  through  the  abdominal  parietes,  or  into  the  peritoneal 
cavity,  causing  fatal  shock  and  in  many  cases  peritonitis  ;  or  into  the 
stomach  or  intestines,  spontaneous  cure  usually  resulting  ;  or  it  may 
penetrate  the  diaphragm,  and  the  contents  be  expectorated,  or  set  free 
in  the  pleural  cavity,  causing  a  rapidly  fatal  pleurisy.  It  has  been 
known  to  open  into  the  pericardium,  or  even  into  the  hepatic  veins, 
the  contents  then  being  impacted  in  the  right  auricle ;  in  both  cases 
immediate  death  resulted. 

Treatment. — The  best  plan  of  dealing  with  a  hydatid  cyst  is  to  lay 
it  open  either  through  the  anterior  abdominal  wall,  or  through  the 
costal  parietes  and  diaphragm,  to  empty  it  of  its  contents,  and  if 
possible  to  enucleate  the  lining  wall  or  endocyst,  which  is  often  but 
loosely  connected  to  the  fibrous  ectocyst.  This  is  usually  accom- 
plished at  one  sitting.  Similar  precautions  as  to  protecting  the  peri- 
toneum are  taken  as  for  an  abscess.  When  the  surface  of  the  liver 
is  exposed,  it  is  advisable  to  puncture  the  cyst  first  with  a  trocar  and 
cannula,  so  as  to  reduce  the  tension  within  it.  It  is  then  incised 
freely  and  the  loose  daughter-cysts  removed.  This  is  facilitated  by 
flushing  out  the  cavity  with  sterilized  salt  solution.     The  endocyst  is 


ABDOMINAL  SURGERY  1069 

removed  either  by  enucleation  with  the  fingers  or  a  blunt  dissector, 
or  it  may  be  possible  to  detach  it  by  irrigation,  the  nozzle  of  the 
irrigator  being  inserted  beneath  it.  If  enucleation  is  completely  suc- 
cessful, the  lesion  in  the  liver  may  be  closed,  and  the  abdominal 
wound  sutured  in  the  ordinary  way  without  drainage  (Hamilton 
Russell),  dependence  being  placed  on  the  aseptic  organization  of  the 
blood-clot  which  fills  up  the  cavity  in  the  liver.  If  for  any  reason 
this  seems  undesirable,  a  gauze  packing  is  introduced  into  the  cavity, 
and  healing  by  granulation  is  allowed  to  proceed.  If,  however,  part 
of  the  lining  wall  is  left,  a  drainage-tube  must  also  be  introduced,  and 
the  cavity  subsequently  irrigated  at  each  dressing. 

No  attempt  should  be  made  to  remove  the  fibrous  ectocyst,  as  it  is 
closely  connected  with  the  liver  substance,  and  grave  haemorrhage 
might  follow  any  interference  with  it. 

Formerly  aspiration  and  electrolysis  were  largely  employed  in  the 
treatment  of  this  affection.  It  has  been  found,  however,  that  although 
a  considerable  percentage  of  cases  could  be  cured  in  this  way  (more 
than  a  half),  yet  it  was  not  unaccompanied  by  risk  of  peritonitis, 
and  that  recurrence  was  often  observed.  Moreover,  some  of  the  fluid 
not  unfrequently  leaked  into  the  peritoneal  cavity,  and  probably  from 
the  absorption  of  some  toxic  product  present  led  to  urticaria,  and 
sometimes  to  even  graver  phenomena  of  poisoning.  Electrolysis 
merely  acts  by  producing  a  puncture  of  the  cyst  wall  and  consequent 
leakage.     Both  of  these  methods  should  be  entirely  discontinued. 

A  suppurating  hydatid  cyst  is  dealt  with  according  to  the  same 
rules  of  treatment  as  hold  good  for  abscess  of  the  liver. 

Tumours  of  the  Liver  are  rarely  primary.  Angiomata,  adenomata, 
and  simple  cysts  have  been  described,  but  primary  growths  are  more 
often  carcinomatous  in  nature,  and  develop  either  as  a  large  well- 
defined  infiltrating  mass,  or  as  a  small  central  tumour,  with  secondary 
nodules  scattered  around.  Sarcomata  are  rare.  Secondary  tumours 
of  the  liver  are  common,  and  either  arise  by  direct  extension  from 
the  gall-bladder,  or  follow  a  carcinoma  of  the  intestinal  canal, 
especially  of  the  stomach  or  large  intestine,  or  perhaps  may  be  a 
sequel  of  cancer  of  the  ovary,  uterus,  or  breast.  The  liver  is  also 
involved  secondarily  in  melanotic  disease  of  the  skin  or  retina.  In 
all  these  cases  the  organ  becomes  enlarged  and  its  surface  irregular, 
due  to  the  projection  of  nodular  masses  of  the  growth  ;  in  cancer 
they  are  frequently  more  or  less  umbilicated.  The  simple  growths 
are  occasionally  pedunculated,  and  may  arise  from  the  left  lobe,  and 
thus  become  amenable  to  surgical  treatment.  Pain  is  not  generally 
a  prominent  symptom,  but  ascites  and  jaundice  develop  in  malignant 
cases  from  pressure  on  the  portal  vein  and  biliary  ducts  in  the  portal 
fissure,  and  oedema  of  the  legs  may  be  caused  by  compression  of  the 
inferior  vena  cava. 

Grummata  are  developed  in  inherited  and  acquired  syphilis,  and  are 
of  sufficient  size  to  need  careful  diagnosis  from  the  more  serious 
growths  which  develop  in  the  liver.  They  are  single  or  multiple,  and 
occur  in  the  form  of  rounded  yellowish  avascular  masses,  tending  U 


tojo  A   MANUAL  OF  SURGERY 

caseate,  and  surrounded  by  much  fibrous  tissue.  Absorption  is 
followed  by  considerable  cicatrization,  which  leads  to  deformity. 
The  diagnosis  from  secondary  carcinoma  is  not  always  easy.  The 
history  of  the  patient  must  be  carefully  considered,  and  if  any  doubt 
arise  a  Wassermann  reaction  is  undertaken.  Carcinomatous  growths 
have  a  hard  umbilicated  surface,  if  it  can  be  felt,  enlarge  rapidly  with 
marked  cachexia,  and  early  produce  jaundice  and  ascites.  Gummata 
are  slower  in  their  progress,  do  not  generally  affect  the  structures 
in  the  portal  fissure,  and  may  be  associated  with  an  enlarged  spleen 
from  lardaceous  or  gummatous  disease.  A  course  of  antisyphilitic 
medicine  will  necessarily  influence  the  case  very  decidedly. 

Actinomycosis  of  the  liver  is  usually  secondary  to  an  aff"ection  of 
the  alimentary  canal,  particularly  the  appendix  or  transverse  colon, 
or  may  be  due  to  a  direct  spread  of  the  infection.  The  liver  is 
enlarged,  and  may  be  covered  with  adhesions.  On  section  the 
affected  area  presents  a  trabeculated  honeycombed  appearance,  which 
has  been  compared  to  a  sponge  soaked  in  pus.  There  is  much 
fibrosis  around,  and  the  trabeculae  are  markedly  fibrous.  The  pus 
contains  the  characteristic  granules  of  the  fungus.  The  clinical 
history  is  that  of  an  hepatic  abscess,  and  the  prognosis  is  bad. 
Treatment  is  as  for  the  disease  elsewhere  (p.  183). 

Affections  of  the  Gall-Bladder  and  Biliary  Passages. 

The  Gall-Bladder  (Fig.  473,  GB),  is  a  pear-shaped  sac  lying  under  cover  of  the 
liver  and  projecting  into  the  peritoneal  cavity.  Its  average  length  is  about  3  to 
4  inches,  and  it  is  normally  capable  of  holding  about  an  ounce  of  fluid.  When 
one  remembers  that  the  liver  secretes  about  an  ounce  of  bile  every  hour,  it  is 
obvious  that  its  function  as  a  biliary  reservoir  must  be  very  limited ;  in  fact,  it  is 
possible  that  in  a  state  of  health  it  does  not  contain  bile  at  all,  and  that  it  merely 
acts  as  a  pressure-gauge  regulating  the  flow  of  bile  into  the  intestine  or  secretes  a 
mucoid  fluid  which  dilutes  the  bile.  An  fw^aro-^^  gall-bladder  projects  downwards 
and  towards  the  umbilicus,  constituting  a  rounded  swelling  which  moves  with 
respiration,  and  is  almost  always  in  close  relation  with  the  anterior  abdominal 
wall ;  it  is  freely  mobile  from  side  to  side,  and  has  attained  such  dimensions  that 
it  has  been  operated  on  in  mistake  for  an  ovarian  cyst.  It  is  attached  to  the  liver 
by  reflections  of  the  peritoneum,  which  vary  somewhat  in  their  insertion  ;  as  a 
rule,  about  a  fifth  of  the  circumference  of  the  gall-bladder  is  in  contact  with  the 
liver.  The  attachment  is  loose,  and  when  once  the  right  layer  has  been  reached, 
it  is  easy  to  strip  the  gall-bladder  from  the  liver.  The  cystic  artery  reaches  it  at 
some  distance  from  the  fundus.  In  a  few  cases  the  gall-bladder  has  a  complete 
peritoneal  investment,  swinging  loose  from  the  liver  on  a  mesentery,  and  in  two 
cases  one  has  seen  serious  colic  develop  apparently  from  this  lax  attachment, 
much  in  the  same  way  as  a  long  appendix  can  cause  appendicular  colic. 
Removal  of  the  gall-bladder  demonstrated  the  absence  of  stones  and  cured  the 
condition.  Such  a  condition  may  be  termed  Gall-Bladder  Colic,  to  distinguish  it 
from  the  biliary  colic  produced  by  gall-stones. 

The  Cystic  duct  (Fig.  473,  CD),  is  about  2  inches  in  length,  or  rather  less,  and 
is  arranged  more  or  less  in  a  spiral  fashion  by  the  attachment  of  the  peritoneum. 
It  will  ordinarily  permit  of  the  introduction  of  a  No.  5  catheter,  but  probably  in 
a  health}^  state  the  mucous  membrane  is  in  such  folds  that  a  probe  cannot  be 
passed  along  it.  The  Hepatic  duct  (HD)  is  2  inches  in  length,  and  is  formed  by 
the  junction  of  the  right  and  left  ducts  which  issue  from  the  hver  at  either  end 
of  the  transverse  fissure  and  unite  together  at  a  very  obtuse  angle.  The  duct 
passes  down  with  the  hepatic  artery,  and  a  little  above  the  upper  border  of  the 
first  piece  of  the  duodenum  is  joined  at  a  very  acute  angle  by  the  cystic  duct. 


ABDOMINAL  SURGERY 


1071 


The  Common  Bile  duct  (CBD)  is  about  3  inches  in  length,  and  takes  a  No.  7  catheter ; 
one  inch  or  more  of  it  is  to  be  found  above  the  duodenal  border,  and  then  it 
dips  behind  that  viscus ;  and  after  lying  between  the  inner  border  of  the  gut  and 
the  head  of  the  pancreas,  it  perforates  the  bowel  obliquely  (X),  sometimes  being  dis- 
tended just  before  its  termination  to  constitute  the  ampulla  of  Vater,  and  into  this 
the  duct  or  ducts  of  the  pancreas  also  open. 

Rupture  or  Perforation  of  the  G-all-Bladder  results  from  such 
injuries  as  blows,  crushes,  kicks,  etc.,  whilst  it  may  also  be  produced 
by  penetrating  wounds  or  bullets  ;  occasionally  it  may  follow  ulcera- 
tion from  within,  as  from  a  large  impacted  gall-stone.  Blood  and 
bile  are  in   consequence   extravasated   into   the   peritoneal    cavity. 


Fig,  473. — Diagram  of  the  .Biliary  Passages  and  their  Relation  to  the 
Duodenum,  which  has  been  laid  open,  and  Pancreas. 
GB,  Gall-bladder;  CD,  cystic  duct;  HD,  hepatic  duct:  CBD,  common  bile- 
duct  ;  DS,  duct  of  Santorini ;  D IV,  duct  of  Wirsung  ;  X,  opening  of  common  bile- 
duct  and  duct  of  Wirsung  in  the  duodenum;  A,  aorta;  SA,  splenic  artery; 
SM,  superior  mesenteric  vessels. 

Pure  bile  is  sterile,  but  if  any  inflammation  of  the  biliary  passages 
has  been  present,  organisms  are  sure  to  have  found  their  way  into 
the  gall-bladder,  and  thus  complications  may  readily  ensue.  If  a 
considerable  quantity  of  bile  escapes  suddenly  into  the  peritoneal 
sac,  acute  peritonitis  is  certain  to  follow  sooner  or  later,  whether 
organisms  are  present  or  not ;  jaundice  arises  from  absorption  by  the 
peritoneum  of  bile,  which  may  also  be  found  in  the  urine.  A  more 
gradual  escape  of  the  secretion  will  probably  lead  to  the  formation 
of  a  localized  intraperitoneal  abscess  or  collection  of  fluid,  associated 
with  jaundice  and  probably  clay-coloured  stools.  In  a  penetrating 
wound  bile  and  blood  will  escape  on  the  surface,  and  septic  peritonitis 
is  almost  sure  to  follow. 

The  immediate  Symptoms  are  those  of  shock  and  severe  hypo- 
chondriac pain,  and  this  will  be  succeeded  either  by  acute  peritonitis 
or  by  the  formation  of  a  localized  intraperitoneal  swelling,  together 


I072  A  MANUAL  OF  SURGERY 

with  jaundice.  When  the  existence  of  such  a  lesion  is  suspected, 
Treatment  always  consists  in  an  exploratory  laparotomy.  The  fluid 
within  the  abdomen  is  removed  with  swabs  or  washed  away,  and 
the  gall-bladder  carefully  examined.  Should  only  a  small  injury 
be  found,  it  is  perfectly  feasible  to  close  it  by  sutures  ;  a  gauze  wick 
should,  however,  be  passed  down  to  the  lesion  for  a  few  days,  so  as  to 
provide  a  means  of  drainage,  should  leakage  occur.  A  more  serious 
rupture  will  necessitate  removal  of  the  gall-bladder.  Should  the 
common  bile-duct  be  entirely  divided,  the  ends  should  be  closed  by 
sutures  and  a  cholecystenterostomy  undertaken  ;  a  small  wound  in 
the  duct  may  be  sutured. 

Inflammation  of  the  Biliary  Passages  is  of  frequent  occurrence,  and 
generally  arises  ;  ^  a  sequela  of  a  gastro-duodenal  catarrh.  The 
affection  is  similf  in  nature  to  that  commonly  seen  in  other  tracks 
lined  with  muco  j  membrane,  and  may  be  limited  to  the  main  bile- 
ducts  and  their  e:  £;nsions  into  the  liver  (cholangitis),  or  may  also  involve 
the  gall-bladder  (cholecystitis).  The  catarrh  is  determined  by  the 
presence  of  micro-organisms,  and  streptococci,  staphylococci,  or  the 
B.  coli,  are  most  frequently  present  ;  the  condition  may  be  limited  to 
a  simple  catarrh,  or  suppuration  may  follow. 

Catarrhal  Cholangitis  is  more  of  medical  than  of  surgical  interest, 
but  its  frequency  and  its  aetiological  connection  with  the  development 
of  gall-stones  warrants  its  introduction  into  a  surgical  textbook.  In 
the  acute  form  it  is  common  in  young  people,  arising  from  over-eating 
or  injudicious  food,  or  combined  perhaps  with  exposure  to  cold  and 
wet.  The  patient  feels  ill,  perhaps  shivers,  looks  a  little  sallow,  or 
maybe  is  actually  yellow  [catarrhal  jaundice).  Abstinence  from  all 
but  fluid  food,  and  the  administration  of  mild  purgatives,  especially 
of  the  saline  type,  will  generally  free  the  patient  from  his  symptom.s 
in  a  very  short  time. 

Sometimes  the  condition  is  of  a  more  chronic  type,  occurring  then 
in  people  of  middle  life,  who  are  the  subjects  of  persistent  dyspepsia, 
often  caused  by  late  hours,  irregular  and  injudicious  meals,  constipa- 
tion, and  perhaps  mental  and  nervous  tension.  Indulgence  in 
alcohol  adds  to  the  trouble.  Such  people  are  frequently  '  livery,'  and 
look  more  or  less  sallow,  but  are  not  actually  jaundiced ;  they  lose 
weight,  and  are  irritable  to  a  degree ;  but  none  of  the  graver  symp- 
toms of  malignant  disease  are  to  be  found.  The  liver  is  probably  a 
little  enlarged  and  may  be  tender,  and  the  gall-bladder  may  be 
palpable.  It  is  in  this  type  of  patient  that  gall-stones  are  liable  to 
develop,  and  for  whom  courses  of  waters  do  so  much  good,  as  at 
Carlsbad  or  Harrogate,  where  hydro-therapeutic  measures  are  com- 
bined with  a  rigid  dietary.  The  essential  elements  of  the  treatment 
can  be  quite  well  carried  out  at  home  if  the  patients  will  submit  to 
the  restrictions  that  must  be  enforced. 

Infective  Cholangitis  is  a  much  more  serious  affection,  and  may  lead 
to  a  fatal  issue.  It  is  usually  due  to  the  presence  of  a  stone  or 
stones  in  the  common  bile-duct,  but  may  arise  from  other  causes,  e.g., 
ascarides   or   hydatid    cysts   which    have   escaped   into   the  biliary 


ABDOMINAL  SURGERY 


1073 


passages,  from  malignant  disease,  or  it  may  spread  backwards  into 
the  liver  from  a  suppurating  gall-bladder.  The  general  phenomena 
which  follow  an  attack  of  biliary  colic,  due  to  the  attempted  or 
successful  passage  of  a  gall-stone,  are  due  to  this  cause,  and  hence 
fever  with  or  without  a  shivering  fit,  a  certain  amount  of  jaundice 
(which  is  easily  comprehended  when  one  remembers  the  low  pressure 
at  which  the  bile  is  secreted),  enlargement  and  tenderness  of  the  liver 
are  to  be  looked  on  as  the  characteristic  features  of  a  mild  attack. 
Treatment  necessarily  consists  in  removal  of  the  cause,  if  possible,  or, 
failing  that,  in  draining  the  biliary  passages  by  cholecystostomy.  It 
must  not  be  forgotten  that  the  persistent  presence  of  such  a  condition 
may  lead  not  only  to  mischief  in  the  liver,  but  also  to  chronic 
pancreatitis,  and  to  adhesive  peritonitis,  which  may  complicate  future 
operative  procedures,  and  therefore  in  any  patient  with  well-marked 
symptoms  operation  should  never  be  delayed  too  long. 

In  the  more  serious  types  of  this  affection  suppuration  may  extend 
up  the  passages  and  lead  to  multiple  abscesses  in  the  liver,  a 
condition  already  noted  at  p.  1065.  Drainage  of  the  gall-bladder  and 
removal  of  the  causative  stones  is  the  only  hope  of  cure,  but  the 
prognosis  is  very  grave. 

Cholecystitis,  or  inflammation  of  the  gall-bladder,  is  most  commonly 
the  result  of  the  presence  of  stones  in  that  cavity,  but  may  also  arise 
as  a  sequela  of  typhoid  fever.  Indeed,  the  B.  typhosus  seems  to  have 
a  special  predilection  for  this  viscus,  and  may  reside  there  for  years 
after  the  primary  attack,  the  individual  or  typhoid  carrier  being  thus 
a  danger  to  the  community  from  his  ability  to  discharge  living 
organisms  at  intervals.  Streptococci  or  staphylococci  are  present  in 
the  other  cases,  with  or  without  the  B.  coli. 

There  is  nothing  specially  noticeable  about  the  pathological 
phenomena,  except  that  the  viscus  is  intraperitoneal,  and  that  there 
is  some  analogy  between  the  troubles  arising  here  and  in  the 
appendix.  There  is,  however,  less  tendency  for  the  peritoneum  to 
be  seriously  involved  owing  to  the  greater  thickness  of  the  wall,  and 
its  greater  capacity  for  stretching  ;  thus  a  distended  gall-bladder  may 
contain  a  large  quantity  of  muco-pus  without  giving  way,  and  the 
viscus  has  even  been  opened  in  the  pelvis  or  through  the  sac  of  a 
hernia.  Protective  adhesions  frequently  develop  between  the  gall- 
bladder and  the  stomach,  duodenum  or  transverse  colon,  and  not  a 
few  of  the  uncomfortable  symptoms  produced  by  gall-stones  are  due 
to  their  existence. 

The  clinical  history  varies  according  to  whether  the  condition  is 
chronic  or  acute.  In  the  chronic  variety  produced  by  gall-stones,  the 
symptoms  are  part  of  the  syndrome  characteristic  of  that  condition, 
and  are  but  little  noticeable  in  themselves.  The  gall-bladder  may  be 
enlarged  and  a  little  tender  on  pressure ;  should  the  cystic  duct  be 
blocked,  it  will  be  distended  with  mucus  or  muco-pus  according  to 
the  degree  of  irritation  present.  In  the  acute  form  it  is  evidenced  by 
marked  pain  and  tenderness  in  the  right  hypochondrium,  together  with 
vomiting,  constipation,  and  fever.     The  constipation  may  be  very 

68 


I074 


A  MANUAL  OF  SURGERY 


marked,  as  it  is  due  to  paralysis  of  neighbouring  coils  of  intestine, 
and  especially  the  transverse  colon.  The  abdominal  wall  is  held 
rigid,  and  the  right  rectus  is  very  tense  ;  but  the  enlarged  gall-bladder 
can  usually  be  detected  beneath  it.  In  one  case  it  was  as  large  as  a 
cocoa-nut,  and  on  exposure  was  of  a  brilliant  red  colour,  and  contained 
about  8  ounces  of  muco-pus ;  it  was  absolutely  free  from  adhesions 
and  contained  two  gall-stones,  one  of  them  embedded  in  the  cedematous 
wall  and  near  the  point  of  perforation.  As  a  rule,  a  sufficiency  of 
adhesions  forms  to  protect  the  general  cavity  of  the  peritoneum,  and 
then  the  abscess,  if  unrelieved  by  art,  may  burst  into  the  bowel,  or 
may  open  externally  and  discharge  itself.  In  the  most  severe  forms 
sloughing  and  gangrene  of  the  wall  follow  {phlegmonous  or  gangrenous 
cholecystitis),  and  then  general  peritoneal  infection  may  follow.  In 
the  milder  forms  the  inflammation  may  in  time  subside,  the  gall- 
bladder emptying  \tse\i  per  vias  naturaJes ;  but  adhesions  of  a  more  or 
less  severe  character  are  likely  to  be  left  and  may  cause  much 
trouble,  whilst  the  gall-bladder  itself  may  shrink  and  atrophy. 

Treatment  consists  in  dealing  with  the  cause,  if  such  be  gall-stones. 
In  the  acute  variety'  of  suppurative  inflammation,  the  gall-bladder 
must  be  opened  and  drained,  or  in  some  cases  it  may  be  possible  to 
excise  it  at  once.  The  operations  are  described"  below,  and  need  no 
special  reference. 

Cliolelithiaais  is  the  term  applied  to  the  presence  in  the  gall-bladder 
or  biliary  passages  of  G-all-stones.  These  consist  mainly  of  crystals 
of  cholesterine,  held  together  by  mucus  and  coloured  by  the  bile- 
pigment;  they  are  soluble  in  chloroform.  When  first  passed  and 
moist,  their  specific  gravity  is  a  little  higher  than  that  of  water,  and 
hence  when  immersed  in  it  they  sink ;  after  drying,  however,  they 
are  found  to  float.  The  number  present  varies  immensely;  some- 
times a  single  large  one  exists,  which  is  more  or  less  barrel-shaped 
(Plate  VT.)  ;  more  frequently  they  are  multiple,  scores  or  hundreds 
being  present,  and  are  then  usually  faceted,  and  with  a  satin-like 
yellowish  lustre.  -If  they  have  lain  long  in  the  gall-bladder,  they  are 
usually  of  a  deep  brown  or  almost  blackish  colour. 

The  Origin  of  gall-stones  is  not  yet  fully  understood,  but  there  seems 
no  doubt  that  they  are  primarily  due  to  a  chronic  catarrhal  affection 
of  the  gall-bladder  or  biliary  passages,  the  cholesterine  being  formed 
by  the  lining  epithelium.  The  original  trouble  is  probably  a  gastro- 
duodenal  catarrh,  and  the  inflammation  spreads  upwards  from  the 
bowel  to  the  gall-bladder.  Gall-stones  usually  develop  in  the  gall- 
bladder or  the  lower  biliary  passages,  but  they  can  also  form  in  the 
ducts  within  the  liver,  especially  in  cases  where  the  hepatic  derange- 
ment has  been  of  long  standing.  They  occur  most  commonly  in 
women  who  have  suffered  from  dyspepsia  and  constipation,  and  may 
be  associated  with  cancer,  either  as  cause  or  effegt.  In  one  case  the 
origin  of  the  trouble  seems  to. have  been  the  swallowing  of  a  pin 
many  years  previously,  which  worked  its  way  into  the  gall-bladder, 
set  up  an  inflammation,  which  resulted  in  the  formation  of  calculi, 
and  only  appeared  again  after  a  successful  operation,  when  sixty-six 
stones  had  been  removed. 


PLATE   VIII. 


Various  types  of   Gallstones  (natural  size). 

fi  ^\^'  u  }j  ^  ^^'^^^  barrel-shaped  stone  removed  with  the  gall-bladder,  where  it  was 
hrmly  held.  Fig.  2.— An  ordinary  gallstone  of  moderate  size.  Fisr.  3.— Black 
gallstones,  evidently  old  inhabitants  of  the  £;all-bladder,  and  deeply  stained  with  bile- 
pigment.  Fig.  4.— More  recently-formed  gallstones  with  but  little  bile-pigment,  and 
one  on  section  showing  lamination.     Fig  s.-Bright  brownish  stones  with  facets. 

\_To  face  page  1160. 


ABDOMINAL  SURGERY  1075 

The  fact  that  gall-stones  are  frequently  found  unexpectedly  on  the 
operating-table  or  in  the  post-mortem  room  suggests  that  they  may 
remain  quiescent  for  years,  and  only  cause  trouble  when  attempting 
to  escape,  or  if  associated  with  some  inflammatory  disturbance. 
Thus  the  first  evidence  of  their  presence  may  be  an  attack  of  acute 
suppurative  cholecystitis,  and  then,  unless  prompt  attention  is  given, 
diffuse  peritonitis  may  result.  Sometimes  they  cause  chronic  irrita- 
tion of  the  gall-bladder,  resulting  in  the  walls  becoming  thickened 
and  hyperaemic  at  first,  but  subsequently  white  and  opaque  ;  and  in 
time  a  process  of  sclerosis  supervenes,  which  may  lead  to  contrac- 
tion of  the  wall  upon  the  stones  which  are  thereby  encapsuled,  and 
all  attempts  to  displace  them  come  to  an  end.  Adhesions  also  form 
between  the  gall-bladder  and  surrounding  tissues,  and  thereby  the 
movements  of  the  pylorus  or  transverse  colon  may  be  hampered. 
More  frequently  the  gall-bladder  contains  enough  fluid  to  keep  its 
walls  distended,  and  then  efforts  to  expel  the  stones  follow,  giving 
rise  to  definite  painful  symptoms.  Sometimes  the  stones  slip  back ; 
at  others  they  pass  on  and  may  escape  into  the  bowel,  or  may  be 
blocked  in  the  cystic  or  the  common  bile-duct,  and  find  it  impossible 
to  progress  farther.  Such  stones  may  ulcerate  through  into  various 
viscera,  such  as  the  stomach,  duodenum,  or  colon,  and  thereby 
relief  be  given  to  the  symptoms,  or  they  may  escape  into  the  general 
peritoneal  cavity  and  cause  peritonitis. 

The  Clinical  History  of  a  case  of  cholelithiasis  is  obviously  very 
variable  according  to  the  exact  location  and  condition  present. 

1.  In  what  has  been  termed  the  Prodromal  stage  when  the  stones 
are  free  in  the  gall-bladder,  and  not  doing  much  harm,  the  symptoms 
are  referable  rather  to  the  stomach  than  to  the  hypochondrium. 
The  patient  complains  of  a  sense  of  weight  and  fulness  in  the 
epigastrium,  particularly  after  meals,  accompanied  by  flatulent 
distension,  which  is  relieved  by  belching,  or  entirely  removed  by 
vomiting.  This  may  have  lasted  for  years,  and  is  usually  accom- 
panied by  constipation.  Sometimes  the  discomfort  amounts  to  acute 
pain,  which  doubles  up  the  patient,  and  may  be  more  severe  on 
taking  a  deep  inspiration.  With  these  phenomena  there  may  be  a 
sense  of  chilliness  scarcely  amounting  to  a  rigor,  and  when  the  pain 
passes  the  patient  may  perspire.  The  patient  is  often  a  little  sallow, 
especially  on  days  when  he  feels  bilious,  and  there  is  some  tender- 
ness over  the  gall-bladder  ;  but  the  diagnosis  of  gall-stones  is  scarcely 
warranted  unless  the  pain  is  very  acute.  Unfortunately,  radiography 
does  not  help  in  this  diagnosis. 

2.  When  the  gall-stones  are  loose  in  the  bladder  and  attempting  to 
escape,  more  definite  and  distinct  phenomena  result.  Pain  is  perhaps 
the  most  marked  feature,  and  may  be  of  various  types,  [a)  There  is  the 
localized  pain,  due  to  the  irritation  of  the  gall-bladder  itself,  which 
is  rather  a  dull  ache  referred  to  the  right  hypochondrium,  shooting 
through  to  the  back  about  the  level  of  the  tenth  rib,  and  perhaps  up 
to  the  right  shoulder ;  this  form  is  usually  increased  on  movement. 
(b)  Pain  is  also  complained  of,  due  to   the  adhesions  which  form 


1076  A  MANUAL  OF  SURGERY 

about  the  gall-bladder,  and  hamper  the  movements  of  the  stomach  or 
intestine ;  this  is  often  epigastric  in  location,  and  may  be  of  a 
colicky  nature,  especially  after  meals,  {c)  The  worst  pain  is  the 
typical  biliary  colic,  due  to  the  efforts  of  Nature  to  expel  the  stones. 
This  is  often  of  an  excruciating  character,  starting  suddenly,  con- 
tinuing for  a  while,  and  often  ceasing  as  suddenly  as  it  commenced 
when  the  stone  passes  on  or  slips  back ;  the  patient  may  be  collapsed 
owing  to  its  severity.  It  radiates  from  the  right  hypochondrium, 
shooting  over  the  scapular  region  and  into  the  back  ;  the  gall-bladder 
may  be  enlarged  and  tense  during  the  attack,  and  the  liver  somewhat 
swollen.  Vomiting  occurs  during  or  after  an  attack  of  biliary  colic, 
especially  when  adhesions  to  the  stomach  or  duodenum  are  present. 
Jaundice  is  not  usual  except  after  an  attack  of  biliary  colic,  and  is 
then  due  to  the  swelling  of  the  mucous  lining  of  the  biliary  passages, 
preventing  the  escape  of  bile  ;  if  the  stone  slips  back,  it  is  not  so 
likely  to  occur.  The  presence  of  many  loose  gall-stones  usually 
determines  an  enlargement  of  the  gall-bladder,  which  can  be  felt 
from  the  outside. 

3.  Impaction  of  a  stone  in  the  cystic  duct  is  characterized  by  pain, 
which  is  more  or  less  persistent,  but  with  paroxysmal  exacerbations, 
and  the  gall-bladder  becomes  distended  with  its  own  mucoid  secre- 
tion, until  it  may  attain  a  considerable  size.  Jaundice  is  usually 
absent.  Not  uncommonly  acute  inflammatory  phenomena  follow 
(acute  suppurative  cholecystitis),  and  this  may  lead  to  ulceration  or 
perforation.  Less  frequently  chronic  suppuration  occurs,  constituting 
an  empyema  of  the  gall-bladder. 

4.  Occasionally  a  stone  becomes  lodged  at  the  junction  of  the 
cystic  and  the  hepatic  ducts,  and  then  the  manifestations  of  obstruc- 
tion are  veiy  severe,  and  the  pain  may  be  very  acute.  Icterus  is 
intense,  but  the  gall-bladder  may  be  empty  ;  the  liver  is  certain  to 
be  much  enlarged. 

5.  The  presence  of  gall-stones  in  the  common  duct  may  give  rise  to 
symptoms  of  the  most  diverse  type  ;  a  small  stone  may  originate 
very  severe  phenomena,  whilst  a  much  larger  stone  may  cause  less 
trouble.  Frequently  several  stones  are  present,  and  sometimes  they 
are  embedded  in  a  mass  of  soft  '  biliary  mud,'  consisting  of  inspis- 
sated bile  salts.  Their  location,  too,  varies  considerably  ;  a  single 
stone  is  perhaps  found  miost  frequently  in  the  lower  part  of  the  duct, 
whilst  multiple  stones  involve  its  whole  length.  The  symptoms 
caused  are  pain  of  a  paroxysmal  character  accompained  by  vomiting, 
and  jaundice,  sometimes  of  a  severe  type,  occasionally  less  marked, 
but  rarely  as  persistent  as  the  jaundice  due  to  malignant  disease. 
The  stone  is  more  or  less  moveable,  and  acts  as  a  ball-valve,  at  times 
allowing  a  certain  amount  of  bile  to  pass.  In  malignant  disease  the 
obstruction  is  absolute,  and  the  jaundice  is  thereby  maintained.  The 
liver  is  enlarged  owing  to  back  pressure  of  bile,  but  the  gall-bladder 
does  not  participate  in  this  distension,  whereas  in  malignant  disease 
or  other  causes  of  persistent  jaundice  it  is  often  dilated  to  a  consider- 
able  degree  (Courvoisier's  law).      If   the   stone    is   located  in  the 


ABDOMINAL  SURGERY  1077 

ampulla  of  Vater,  it  is  easy  to  understand  that  pancreatic  troubles 
are  likely  to  be  associated  with  the  jaundice,  but  it  may  ulcerate  into 
the  duodenum  without  much  difficulty.  Should  a  perforation  form 
posteriorly,  the  retroperitoneal  cellular  tissue  becomes  involved,  and 
a  subphrenic  abscess  may  result. 

The  Treatment  of  gall-stones  is,  in  the  first  place,  medical  in 
character,  and  consists  in  a  rigid  attention  to  the  diet  which  should  be 
simple  and  easily  digestible  ;  this  is  accompanied  by  regular  exercise 
and  the  use  of  alkaline  purgatives  of  a  saline  character  and  an 
abundance  of  pure  water.  This  is  best  carried  out  at  a  spa  such  as 
Harrogate  or  Carlsbad,  but  can  be  arranged  for  at  home,  if  the 
patient  will  submit  to  the  necessary  regulations.  Biliary  colic  is 
treated  by  fomentations,  and  if  need  be  by  an  injection  of  morphia ; 
it  is  perhaps  wise  to  administer  salol  or  some  other  intestinal 
antiseptic,  whilst  salicylate  of  soda  assists  in  increasing  the  fluidity 
of  the  bile.  It  is  quite  an  arguable  question  as  to  what  happens  in 
such  cures,  whether  the  stones  are  softened  and  passed,  or  whether 
they  become  acclimatized  in  the  gall-bladder  and  cease  to  cause 
trouble.  At  any  rate,  it  is  important  not  to  waste  too  much  time  in 
this  direction,  should  the  symptoms  persist.  It  has  been  already 
pointed  out  that  gall-stones  are  not  to  be  looked  on  as  perfectly 
innocuous ;  inflammatory  troubles  of  a  serious  character  and  even 
malignant  disease  may  be  caused  by  them,  and  therefore  the  per- 
sistence of  symptoms,  and  especially  their  aggravation,  indicate  the 
necessity  for  surgical  interference.  The  proceedings  required  vary 
somewhat  according  to  the  location  of  the  stones,  and  different 
operative  measures  have  been  devised  in  order  to  deal  effectively 
with  these  varied  conditions. 

Cholecystotomy  consists  in  opening  the  gall-bladder  for  the  removal 
of  calculi,  or  for  purposes  of  drainage.  It  is  wise  in  all  operations 
on  the  biliary  passages  to  introduce  a  firm  sandbag  horizontally 
beneath  the  patient's  back,  as  thereby  much  better  access  is  given. 
The  incision  usually  employed  is  a  vertical  one  to  the  outer  margin, 
or  through  the  substance  of  the  rectus  ;  should  it  need  to  be  enlarged, 
it  may  be  carried  up  parallel  to  the  costal  margin,  and  about  i\  inches 
from  it,  extending  as  far  as  the  middle  line  (Fig.  449,  B).  The 
peritoneum  is  opened  and  the  gall-bladder  sought  for,  any  adhesions 
present  being  carefully  divided  ;  it  will  sometimes  happen  that  these 
are  very  abundant,  and  then  the  risk  of  opening  the  bowel  by  mistake 
is  not  inconsiderable.  The  liver  is  drawn  up,  and  the  intestines  are 
pressed  downwards  and  inwards  out  of  the  field  of  operation  by 
means  of  abdominal  cloths  held  in  position  by  a  broad  retractor. 
The  general  peritoneal  cavity  is  thus  carefully  guarded  from  infec- 
tion. If  the  gall-bladder  is  much  distended,  it  is  advisable  to  tap  it 
with  a  trocar  and  cannula,  and  withdraw  the  chief  portion  of  its 
contents ;  the  opening  is  then  enlarged  sufficiently  to  allow  of  the 
introduction  of  a  scoop,  or  even  of  the  finger,  and  by  this  means 
the  calculi  are  removed.  The  bile-ducts  are  carefully  examined  both 
by  the  finger  passed  inside  as  far  as  possible,  and  outside  along  their 


to^S  A  MANUAL  OF  SURGERY 

whole  length,  and  by  means  of  a  long  probe  passed  down  the  duct. 
If  the  interior  is  tolerably  healthy,  the  cavity  not  much  dilated,  and 
the  patient's  symptoms  of  a  mild  or  almost  negative  character  (as 
when  gall-stones  are  discovered  by  accident  during  a  laparotomy  for 
some  other  condition),  it  may  be  advisable  to  suture,  up  the  wound 
in  the  bladder,  the  stitches  not  being  allowed,  however,  to  encroach 
on  the  mucous  membrane  {cholecystendysis).  A  gauze  wick  should  be 
inserted  down  to  the  incision  before  stitching  up  the  abdominal 
parietes,  so  as  to  provide  for  drainage  should  there  be  any  leakage  of 
bile.  If,  however,  the  condition  of  cholelithiasis  has  produced  definite 
symptoms  of  pain,  icterus,  etc.,  and  the  patient  has  been  '  bilious  '  in 
type  for  some  time,  temporary  drainage  of  the  biliary  passages 
{cholecystostomy)  does  good  by  relieving  the  liver.  A  medium-sized 
drainage-tube  without  any  lateral  openings  is  introduced  into  the 
gall-bladder  and  stitched  to  its  walls,  whilst  the  margins  of  the 
wound  in  the  gall-bladder  are  united  to  the  parietal  peritoneum 
and  transversalis  aponeurosis.  The  upper  and  lower  ends  of  the 
abdominal  incision  are  closed,  and  the  general  abdominal  cavity 
protected  by  packing.  The  outer  end  of  the  tube  is  passed  into  a 
bottle,  in  which  the  bile  collects.  As  a  rule,  it  suffices  to  drain  the 
biliary  passages  for  a  week  ;  the  tube  is  then  removed,  and,  if  need 
be,  a  smaller  one  introduced ;  but  as  soon  as  possible  the  tube  should 
be  omitted,  and  gauze  packing  substituted.  The  wound  usually 
closes  in  three  or  four  weeks,  but  occasionally  this  does  not  occur, 
and  then  the  discharge  of  bile  continues,  necessitating  further  treat- 
ment. If'  there  is  sufficient  evidence  of  the  existence  of  bile  in  the 
motions  to  indicate  that  the  passages  are  clear,  a  plastic  operation 
for  the  closure  of  the  fistula  may  be  undertaken ;  but  if  complete 
and  permanent  obstruction  to  the  passage  of  bile  is  suspected,  an 
artificial  communication  with  the  intestine  {cholecystenter ostomy)  should, 
if  possible,  be  established. 

Cholecystectomy,  or  removal  of  the  gall-bladder,  is  not  required  as 
a  general  rule  in  cholelithiasis.  If  the  patient  is  suitably  warned 
and  dieted,  recurrence  of  gall-stones  is  not  very  common  after  opera- 
tion. Moreover,  drainage  of  the  biliary  passages  is  often  useful  arid, 
beneficial.  If,  however,  the  gall-bladder  is  so  disorganized  by  ths 
presence  of  the  stones  as  to  make  it  henceforth  useless,  or  if  the 
cystic  duct  is  blocked  by  a  stone,  the  removal  of  which  would 
certainly  be  followed  by  stricture  of  the  duct,  then  the  gall-bladder 
had  better  be  completely  removed  with  its  contained  stones.  The 
operation  itself  is  not  very  difficult,  and  adds  but  little  to  the  danger, 
whilst  the  patient's  comfort  may  be  considerably  increased  by 
omitting  drainage.  The  liver  is  held  aside  by  a  suitable  retractor, 
and  the  stomach  and  intestines  drawn  over  to  the  left  under  cover 
of  an  abdominal  cloth.  The  serous  coat  is  divided  at  the  base  and 
on  each  side  of  the  bladder,  and  a  line  of  cleavage  is  generally  found 
without  much  difficulty  between  the  capsule  of  Glisson  and  the 
body  of  the  viscus.  It  is  then  easy  to  strip  it  off  the  liver ;  the 
cystic  vessels  are  secured  by  ligature,  and  finally  the  cystic  duct  is 


ABDOMINAL  SURGERY  1079 

tied  and  divided.  If  possible,  the  peritoneal  coat  is  drawn  together 
"over  the  gap  left  by  the  removal  of  the  gall-bladder,  but  it  is  usually 
necessary  to  pack  this  space  with  sterile  gauze  for  a  few  days. 

Choledochotomy  is  the  term  applied  to  an  operation  for  incising 
the  common  bile-duct  with  a  view  to  removing  stones  therefrom. 
There  is  but  little  difficulty  in  effecting  this  if  the  stone  is  in  the 
upper  part  above  the  duodenum ;  the  stone  is  localized  and  fixed,  and 
the  duct  incised  longitudinally  over  it.  The  peritoneum  is  guarded 
by  suitable  swabs,  and  the  stone  is  then  removed.  Careful  examina- 
tion should  be  made  both  upwards  to  the  liver  and  down  to  the 
intestine  by  a  probe  to  make  certain  that  no  further  stones  are 
present.  If  a  stone  is  lodged  behind  the  second  piece  of  the 
duodenum,  it  may  be  possible  to  manipulate  it  up,  and  make  it 
accessible  above  the  intestine ;  but  otherwise  the  duodenum  must 
be  mobilized  by  dividing  the  peritoneum  on  its  outer  edge.  It  can 
then  be  displaced  inwards  sufficiently  to  enable  the  dilated  duct  and 
stone  to  be  reached  from  the  outer  side.  In  both  of  these  operations 
an  effort  may  be  made  to  close  the  ducts  with  sutures  which  do  not 
encroach  on  the  mucous  membrane  ;  but  it  is  probably  wiser  to 
introduce  a  drainage-tube  into  and  up  the  duct  for  a  few  days  so  as 
to  relieve  the  engorgement  of  the  liver,  which  is  certain  to  be  present. 
These  wounds  usually  heal  quite  satisfactorily. 

In  a  few  cases,  when  the  stone  is  lodged  in  the  lowest  portion  of 
the  duct,  it  may  be  necessary  to  incise  the  duodenum  longitudinally 
front  and  back,  and,  after  extracting  the  stone,  to  make  a  fistula 
between  the  duct  and  the  posterior  wall  of  the  intestine  (internal 
choledochoduodenostomy).  An  impacted  stone  should  never  be  left 
in  situ,  as  although  it  may  pass  at  the  end  of  a  few  days  or  weeks, 
it  will  cause  much  pain,  and  before  becoming  dislodged  it  may 
do  much  harm,  not  only  to  the  biliary  apparatus,  but  also  to  the 
pancreas. 

Cliolecystenterostomy,  or  the  formation  of  an  artificial  communica- 
tion between  the  gall-bladder  and  the  bowel,  is  required  in  cases 
where  jaundice  persists,  owing  to  absolute  stenosis  of  the  common 
duct.  It  has  also  been  undertaken  for  the  relief  of  jaundice  due  to 
malignant  disease,  either  of  the  head  of  the  pancreas  or  of  the  intes- 
tine, causing  pressure  on  the  orifice  of  the  bile-duct ;  it  is  quite 
unjustifiable  under  these  latter  circumstances,  as  statistics  have 
shown  that  the  danger  of  such  a  proceeding  is  very  great.  The  parts 
are  exposed  as  described  above,  the  gall-bladder  and  duodenum  are 
brought  into  contact,  and  a  lateral  anastomosis  made  by  simple 
suturing  by  the  same  technique  as  for  a  lateral  anastomosis  of  the 
intestine. 

Tumours  of  tlie  Gall-bladder  and  Biliary  Passages  are  usually 
malignant,  and  of  a  columnar  carcinomatous  type ;  benign  tumours 
are  very  rare,  and  merely  of  pathological  interest.  Cancer  is  com- 
paratively common,  and  is  so  constantly  associated  with  gall-stones 
(some  authorities  state  that  90  to  95  per  cent,  of  such  cases  also  have 
gall-stones)  as  to  suggest  that  the  irritation  of  the  latter  may  induce 


loSo  A  MANUAL  OF  SURGERY 

the  neoplastic  formation.  The  disease  is  about  three  times  as 
common  in  women  as  in  men.  Cancer  of  the  gall-bladder  usually 
commences  near  the  fundus  and  spreads  upwards.  The  symptoms 
and  signs  are  those  of  a  hard,  painless  swelling  in  the  region  of  the 
gall-bladder,  with  progressive  loss  of  weight,  and  later  on  jaundice 
and  ascites.  Primary  cancer  of  the  common  bile-duct  is  rarer,  and 
causes  jaundice,  without  pain,  as  an  early  symptom,  together  with 
distension  of  the  gall-bladder.  The  jaundice  is  persistent,  and 
gradually  increases  in  severity.  Gastric  symptoms  from  pressure  of 
the  growth  on  the  pylorus  or  duodenum  may  follow,  and  extension 
in  various  directions  may  determine  different  manifestations.  In 
either  of  these  affections  lymphatic  dissemination  along  the  falci- 
form ligament  may  lead  to  the  appearance  of  a  secondary  nodule  in 
the  region  of  the  umbilicus,  which  may  be  of  diagnostic  import. 

Treatment  is  rarely  practicable,  as  the  disease  is  usually  recognised 
too  late.  Excision  of  the  gall-bladder,  and,  if  need  be,  of  the  neigh- 
bouring portion  of  the  liver,  may  be  practicable  in  a  few  cases ;  for 
tumours  of  the  common  bile-duct,  excision  is  impossible,  but  chole- 
cystenterostomy  may  relieve  the  intense  jaundice  and  add  to  the 
patient's  comfort. 

Affections  of  the  Pancreas. 

The  pancreas  is  a  glandular  organ  which  secretes  an  active 
digestive  juice,  which  escapes  into  the  intestine  through  the  duct  of 
Wirsung  (Fig.  473,  DW),  which  traverses  the  whole  length  of  the 
gland,  and  opens  with  the  common  bile-duct  into  the  ampulla  of  Vater ; 
a  small  accessory  duct  of  Santorini  (DS)  opens  into  the  bowel  about 
an  inch  higher  up.  The  pancreas  has  only  recently  received  much 
attention  from  surgeons  ;  its  depth  and  anatomical  relations  explain 
the  neglect  with  which  it  was  treated  for  so  long.  At  the  present 
time  its  affections  are  being  studied  with  a  keen  interest,  and  con- 
siderable operative  activity  is  being  directed  towards  it.  There  are 
two  chief  methods  of  approaching  it  :  (i)  The  transperitoneal,  in 
which  the  abdomen  is  opened  in  the  middle  line  above  the  umbilicus; 
the  gland  is  reached  either  above  the  stomach  by  dividing  the  small 
omentum,  or  by  traversing  the  great  omentum  just  below  the  great 
curvature  of  the  stomach,  or  by  opening  through  the  transverse 
meso-colon.  (2)  The  retroperitoneal  method  consists  in  an  incision 
below  the  last  rib  in  the  lumbar  region,  but  only  the  head  or  the  tail 
is  exposed  by  this  procedure. 

There  are  two  chief  risks  associated  with  pancreatic  lesions  or 
operations :  (i.)  The  organ  is  very  freely  supplied  with  blood,  and 
it  is  extremely  difficult  to  ensure  haemostasis.  Ligature  of  the 
pancreatic  tissue  causes  necrosis,  and  from  the  necrotic  tissue 
ferments  are  set  free  w^hich  act  injuriously  on  the  tissues  around, 
and  predispose  to  further  haemorrhage.  Deep  stitches  and  effective 
tamponade  can  alone  be  relied  on  in  this  direction,  (ii.)  The  leakage 
of  pancreatic  juice  is  a  serious  danger  to  the  patient  in  that  it  is  likely 
to  determine  necrosis  of  fat  wherever  it  spreads  ;  hence  foci  of  fat 


ABDOMINAL  SURGERY  1081 

necrosis  may  be  found  scattered  extensively  through  the  omentum  and 
mesentery  in  all  acute  pancreatic  lesions.  Moreover,  it  acts  most  pre- 
judicially on  the  peritoneum,  and  induces  either  an  aseptic  peritonitis 
and  intestinal  paralysis  which  may  prove  fatal,  or  determines  an 
infective  peritonitis  if  bacteria  are  present. 

Wounds  of  the  Pancreas  are  due  to  direct  violence  applied  to  the 
epigastrium,  and  may  result  from  penetrating  or  non-penetrating 
injuries.  They  are  usually  accompanied  by  lesions  of  other  viscera, 
such  as  the  stomach  or  duodenum,  and  surgeons  should  remember 
the  necessity  for  examining  this  viscus  in  any  traumatic  condition 
in  the  neighbourhood.  Deep  sutures  and  tamponade  must  be  used 
in  all  cases  where  solution  of  continuity  has  occurred,  the  latter 
being  needed  not  only  as  a  haemostatic  agent,  but  also  in  order  to 
drain  away  any  leakage  of  pancreatic  fluid.  Prolapse  through  an 
abdominal  wound  has  been  recorded  in  a  few  cases,  the  organ  having 
been  almost  entirely  separated  from  its  connections;  however  bruised 
or  damaged,  its  total  extirpation  must  never  be  resorted  to,  since 
diabetes  is  certain  to  follow ;  it  should  therefore  be  carefully  purified 
and  replaced. 

Acute  Pancreatitis  is  a  grave  affection,  frequently  fatal,  and  not 
uncommonly  mistaken  for  acute  obstruction  until  diagnosed  on  t,he 
operating  or  post-mortem  table.  It  may  follow  an  injury,  and  is  then 
due  to  an  interstitial  haemorrhage,  which  gradually  increases;  a  similar 
haemorrhage  sometimes  appears  spontaneously  in  alcoholic  subjects, 
and  is  termed  a  '  pancreatic  '  apoplexy ;  it  is  quite  possible  for  such 
cases  to  run  an  acute  course  and  even  prove  fatal  without  infection. 
More  usually  the  condition  is  infective,  the  bacteria  reaching  the 
gland  from  the  intestine,  or  is  determined  by  regurgitation  of 
bile  owing  to  the  impaction  of  a  biliary  calculus  in  the  ampulla  of 
Vater.  Pancreatic  calculi  also  occur,  and  may  light  up  an  attack 
of  acute  pancreatitis  ;  they  are  usually  small  and  elongated,  consist- 
ing mostly  of  carbonate  of  lime.  The  organ  becomes  enlarged, 
thickened,  and  congested  ;  purulent  foci  are  scattered  here  and  there 
through  it,  and  in  and  around  it  are  found  necrotic  spots  due  to  the 
action  of  the  pancreatic  secretion.  Sometimes  the  whole  gland  or 
a  large  portion  of  it  has  been  known  to  slough.  An  inflammatory 
effusion  develops  in  front,  which  is  usually  purulent  and  sometimes 
hsemorrhagic  ;  it  may  be  limited  to  the  lesser  sac  of  the  peritoneum, 
then  following  the  lines  of  a  subphrenic  abscess,  or  it  may  involve 
the  general  peritoneal  cavity. 

The  Symptoms  vary  much,  but  usually  start  suddenly  with  acute 
epigastric  pain,  which  soon  becomes  excruciating.  This  is  accom- 
panied by  nausea  and  sickness,  by  constipation  and  abdominal 
distension,  and  by  a  serious  collapse  which  may  quickly  prove  fatal. 
The  pain  is  due  to  the  swollen  organ  pressing  on  the  cceliac  plexus 
of  nerves.  The  swelling  of  the  abdomen  commences  in  the  epigas- 
trium, and  may  for  a  time  be  limited  to  that  region,  but  subsequently 
the  phenomena  of  acute  diffuse  peritonitis  may  supervene.  Occasion- 
ally the  trouble  quiets  down  at  the  end  of  a  few  days,  but  much  more 


lo82  A  MANUAL  OF  SURGERY 

frequently  it  is  fatal.  The  Diagnosis  usually  made  is  that  of  acute 
obstruction,  and  the  true  nature  of  the  case  is  only  recognised 
on  opening  the  abdomen.  Treatment  consists  in  laparotomy  and 
giving  an  exit  to  the  inflammatory  exudate.  If  diffuse  peritonitis 
is  present,  the  abdominal  cavity  must  be  opened  above  and  below 
and  irrigated,  and  the  local  trouble  exposed ;  dead  pancreatic 
tissue  should  be  removed,  and  effective  drainage  provided.  If  a 
localized  abscess  forms,  the  greatest  care  must  be  taken  to  guard- 
against  a  generalized  infection.  Posterior  drainage  is  advisable  in 
all  these  cases. 

Chronic  Pancreatitis  is  not  to  be  looked  on  as  a  very  uncommon 
lesion.  It  is  frequently  associated  with  gall-stones  and  inflammation 
of  the  biliary  passages,  and  may  follow  gastro-duodenal  catarrh  or 
ulceration.  The  organ  becomes  harder  than  usual,  or  is  shrunken 
and  sclerosed.  It  may  produce  a  swelling  in  the  epigastrium  which 
is  likely  to  be  mistaken  for  a  pancreatic  carcinoma,  or  the  symptoms 
may  be  mainly  of  a  dyspeptic  type.  Fixed  epigastric  pain  is  often 
present,  and  a  tender  spot  a  little  above  the  umbilicus.  Diabetes  may 
arise  in  certain  forms  of  chronic  inflammation  ;  offensive  diarrhoea 
with  undigested  fat  in  the  stools  and  rapid  wasting  are  also  suggestive 
symptoms.  Operative  treatment  may  be  of  value,  since  pancreatic 
or  biliary  calculi  may  be  found  obstructing  the  duct ;  apart  from  this, 
benefit  has  certainly  been  derived  by  cholecystostomy  and  drainage 
of  the  biliary  passages. 

Cysts  of  the  Pancreas  have  been  observed  and  treated  in  so  many 
cases  since  1887  that  their  characters  are  pretty  clearly  known. 
Simple  complete  obstruction  to  the  duct  has  been  proved  experi- 
mentally not  to  be  a  sufficient  cause  for  the  disease ;  some  patho- 
logical condition  of  the  epithelium  must  also  be  present,  preventing 
the  re-absorption  of  the  retained  secretion.  Slight  traumatism  is 
not  an  uncommon  cause,  and  a  cyst  may  develop  as  a  sequela  of  an 
attack  of  inflammation  which  has  quieted  down.  The  fluid  within  is 
usually  turbid  and  brownish  from  admixture  with  blood,  odourless, 
and  with  a  fairly  high  specific  gravity ;  it  is  of  an  alkaline  or  neutral 
reaction,  and  contains  albumen,  but  no  urea  or  bile ;  it  is  capable  of 
peptonizing  albumen,  of  emulsifying  fat,  and  of  converting  starch 
into  sugar.  The  cyst  can  be  felt  as  a  rounded,  tense,  fluctuating  or 
elastic  swelling,  placed  deeply  in  the  abdomen,  immoveable,  and 
perhaps  transmitting  the  aortic  pulsation.  The  relations  of  a  cyst  to 
the  stomach  and  transverse  colon  vary  (Figs.  474-476) ;  the  cyst 
primarily  forms  behind  the  stomach,  but  when  it  attains  any  con- 
siderable size  it  projects  anteriorly,  and  then  most  commonly 
approaches  the  abdominal  wall  below  the  stomach  and  above  the 
transverse  colon  (Fig.  475).  More  rarely  it  presents  above  the 
stomach  (Fig,  474),  or  below  the  transverse  colon  (Fig.  476). 
Pancreatic  cysts  usually  develop  in  middle  life,  occurring  most 
frequently  in  men.  Emaciation  is  sometimes  marked,  since  a  good 
proportion  of  the  fatty  food  passes  away  in  the  motions  ;  the  skin  is 
often  dirty,  earthy,  and  unhealthy-looking. 


ABDOMINAL  SURGERY 


1083 


Treatment  consists  in  laying  the  cyst  bare,  the  surgeon  usually 
finding  his  way  to  it  between  the  stomach  and  transverse  colon. 
Its  contents  are  then  drawn  off  by  trocar  and  cannula,  and  arrange- 
ments made  for  drainage.  A  large  tube  is  inserted,  either  through 
the  front,  or  from  the  back  by  the  side  of  the  vertebra;.  The 
skin  around  usually  becomes  irritated  by  the  discharge,  owing 
to  a  process  of  digestion.  The  prognosis  with  such  treatment  is 
•good,  although  healing  may  be  slow,  and  a  permanent  fistula  may 
develop.  Korte  collected  10 1  cases  operated  on,  and  of  these 
5  died,  4  from  the  direct  result  of  the  operation,  i  from  infection  of 
the  fistula. 


Fig.  474. 
Figs.  474-476.- 


FiG.  475. 


Fig.  476. 


-Diagrams  to  represent  the  Varying  Relations  of 
Pancreatic  Cysts. 


In  Fig.  474  the  cyst  (P)  projects  forwards  between  the  stomach  (S)  and  liver  into 
the  lesser  peritoneal  sac,  presenting  through  the  lesser  omentum.  In  Fig.  475 
the  cyst  is  located  below  the  stomach,  projecting  forwards  between  the 
stomach  and  the  transverse  colon  (C).  In  Fig.  476  the  cyst  lies  lower,  between 
the  transverse  colon  above  and  the  small  intestine  with  its  mesentery. 


Carcinoma  of  the  Pancreas  is  met  with  either  as  a  primary  growth 
of  a  spheroidal-celled  type,  usually  scirrhus,  or  is  secondary  to  a 
similar  disease  of  the  stomach  or  pylorus.  The  condition  is  not 
necessarily  painful  in  the  early  stages,  and  produces  an  ovoid  or 
oblong  mass  at  the  junction  of  the  epigastric  and  right  hypochondriac 
regions.  As  it  develops  it  becomes  more  painful,  and  the  patient 
quickly  wastes  and  loses  appetite  and  energy.  Jaundice  gradually 
supervenes,  and  becomes  absolute,  with  an  enlarged  gall-bladder; 
the  abdomen  is  distended  with  fluid  from  pressure  on  the  portal 
vein,  and  the  legs  may  become  cedematous  from  involvement  of  the 
inferior  vena  cava ;  whilst  the  growth  may  lead  to  distension  of  the 
stomach  from  pressure  on  and  constriction  of  the  pylorus.     In  one 


loS4  A  MANUAL  OF  SURGERY 

or  two  cases  removal  has  been  undertaken  with  success,  although  an 
exact  diagnosis  was  not  arrived  at  before  the  operation.  Sarcomata 
and  other  tumours  are  very  rare. 


AflFections  of  the  Spleen. 

Rupture  of  the  Spleen  occurs  as  a  result  of  injury,  causing  great 
shock,  pain  in  the  left  hypochondrium,  and  internal  haemorrhage, 
usually  to  such  an  extent  as  to  prove  rapidly  fatal.  In  less  severe 
cases  the  blood  collects  in  the  left  loin,  and  gravitates  towards  the 
pelvis,  the  right  loin  being  often  kept  clear  by  the  position  of  the 
mesentery.  Laparotomy  should  be  undertaken  whenever  practicable, 
and,  if  much  damaged,  the  organ  is  removed,  the  splenic  vessels 
being  secured  by  ligature ;  the  results  of  such  treatment  have  been 
most  satisfactory.  In  a  few  cases  it  has  been  possible  to  stop  the 
bleeding  by  suturing  the  spleen,  or  by  inserting  a  gauze  tampon, 
which  is  removed  in  a  few  days. 

Abscess  of  the  Spleen  may  develop  in  the  course  of  pyaemia,  or 
follow  an  injury,  especially  if  associated  with  a  lesion  of  a  neigh- 
bouring coil  of  intestine.  The  symptoms  are  merely  those  of  deep 
suppuration  in  the  left  hypochondrium,  and  the  abscess  either  finds 
its  way  externally,  or  bursts  into  the  peritoneal  cavity.  It  may  be 
opened  and  drained  with  the  same  precautions  as  for  any  other  intra- 
peritoneal collection  of  matter,  and  the  results  hitherto  obtained  have 
been  encouraging.  In  pyaemia  the  disease  is  often  fatal  before  the 
local  phenomena  are  recognised. 

Floating  Spleen  is  occasionally  congenital,  but  more  commonly 
acquired,  in  consequence  of  tight-lacing,  injuries,  or  the  presence  of 
tumours.  It  is  characterized  by  the  existence  of  a  moveable  intra- 
abdominal swelling,  whose  shape  is  that  of  the  spleen,  and  having  a 
notch  in  its  anterior  border  ;  its  size  increases  after  meals.  It  may  be  so 
displaced  as  to  lie  in  the  right  iliac  fossa,  or  even  in  the  pelvis,  and  then 
has  a  long  narrow  pedicle  which  has,  in  a  few  cases,  led  to  its  torsion 
and  strangulation.  Splenectomy  was  formerly  the  only  treatment,  if 
the  displaced  organ  caused  discomfort  or  pain  ;  it  has  been  found 
possible,  however,  to  fix  it,  and  several  successful  cases  have  now 
been  recorded.  Splenopexy;  as  the  operation  is  termed,  is  best  under- 
taken by  preparing  a  bed  for  the  organ  outside  the  peritoneum  in  the 
loose  cellular  tissue  beneath  the  floating  ribs  on  the  left  side.  The 
spleen  is  then  slipped  through  a  small  hole  specially  made  for  the 
purpose  in  the  parietal  peritoneum,  and  secured  by  stitches,  which 
pass  through  its  capsule  and  anchor  it  to  the  under  surface  of  the 
diaphragm. 

Enlargement  of  the  Spleen  is  not  uncommon,  and  is  due  to  many 
different  causes.  It  is  characterized  by  a  swelling  which  extends 
downwards  from  the  left  hypochondrium  towards  the  umbilicus,  the 
notch,  perhaps,  being  felt  in  front ,  it  hugs  the  anterior  abdominal 
wall,  so  that  intestine  is  not  found  in  front  of  it,  whilst  a  resonant 


ABDOMINAL  SURGERY  1085 

note  is  obtained  in  the  flank.    It  is  usually  moveable  with  respiration, 
and  occasionally  increases  in  size  after  meals. 

The  commonest  causes  of  this  condition  are  as  follows  :  i .  Certain 
general  diseases,  such  as  malaria,  inherited  syphilis,  rickets,  lardaceous 
disease,  lymphadenoma,  or  generalized  tuberculosis.  2.  Passive 
hyperaemia,  as  the  result  of  back-pressure  from  the  heart,  lungs,  or 
liver ;  thus  it  occurs  in  chronic  valvular  disease  of  the  heart,"  chronic 
pulmonary  disease,  and  cirrhosis  of  the  liver.  3.  It  is  also  met  with 
in  certain  blood  conditions,  such  as  spleno-medullary  leukaemia  (for 
blood-count,  see  p.  58) ;  splenic  anaemia,  in  which  the  splenic 
enlargement  is  associated  with  a  chlorotic  type  of  anaemia,  and  is 
followed  by  cirrhosis  of  the  liver,  leucocytosis  being  noticeably 
absent,  the  syndrome  constituting  what  is  known  as  Banti's  disease ; 
and  polycythaemia,  in  which  there  is  an  increase  of  the  erythrocytes 
and  an  augmented  haemoglobin  content  accompanying  the  enlarge- 
ment of  the  spleen.  4.  A  simple  splenomegaly  or  hypertrophy  of  the 
spleen  exists,  in  which  the  swelling  is  accompanied  by  no  charac- 
teristic blood  changes.  5.  Tumours  and  cysts  of  the  spleen  also  lead 
to  its  enlargement,  the  former  are  usually  secondary  and  malignant  in 
nature  ;  the  latter  may  be  due  to  hydatid  disease,  or  be  of  the  nature 
of  a  simple  serous  cyst. 

The  differential  diagnosis  of  these  conditions  cannot  be  discussed 
here,  but  it  must  suffice  to  point  out  that  the  chief  reliance  must  be 
placed  on  a  careful  and  thorough  examination  of  the  blood,  together 
with  a  complete  investigation  of  the  condition  of  the  other  organs  of 
the  body. 

Treatment  necessarily  varies  with  the  cause,  but  if  medicine  is  of 
no  avail,  the  question  of  splenectomy  will  have  to  be  considered. 
This  operation  has  been  performed  for  many  different  affections,  and 
its  value  and  position  as  a  surgical  procedure  are  now  fairly  well 
estabhshed.  For  traumatic  lesions  it  is  both  safe  and  justifiable. 
For  splenomegaly  and  for  malarial  enlargement  it  may  be  performed, 
if  serious  discomfort  is  being  caused  and  cannot  be  otherwise 
remedied.  If  drainage  fails  to  cure  a  cyst,  or  if  a  primary  growth  is 
discovered  in  a  sufficiently  early  stage,  excision  may  be  undertaken 
Splenectomy  for  leucocythasmia  is  absolutely  unjustifiable,  all  the 
cases  operated  on  having  died.  In  splenic  anaemia  excellent  results 
have  followed  removal  of  the  organ  in  the  few  cases  in  which  it  has 
been  attempted ;  the  red  cells  subsequently  increased  rapidly  in 
numbers,  as  also  their  haemoglobin  content,  whilst  the  leucocyte 
count  remained  much  the  same.  Such  a  result  indicates  that  possibly 
the  condition  is  due  to  an  increased  destruction  of  erythrocytes  in  the 
spleen,  which  is  brought  to  an  end  by  removing  the  organ. 

The  operation  itself  is  performed  through  any  suitable  incision  of 
sufficient  length ;  probably  one  in  the  linea  semilunaris  is  the  best. 
The  peritoneum  having  been  opened,  the  organ  is  carefully  examined 
to  ascertain  in  particular  whether  or  not  adhesions  are  present,  as,  if 
extensive,  any  attempt  to  break  them  down  might  result  in  fatal 
haemorrhage.     If  the  organ  is  freely  mobile,  it  is  carefully  drawn  out 


io86  A  MANUAL  OF  SURGERY 

of  the  abdomen,  and  the  anterior  layer  of  the  gastro-splenic  omentum 
divided  so  as  to  expose  the  vessels.  Care  is  taken  not  to  secure  the 
main  trunk  at  a  distance,  but  the  smaller  branches  as  they  enter  the 
hilum.  The  lieno-renal  and  lieno-phrenic  ligaments  are  divided,  and 
the  organ  thus  set  free  is  removed.  Gastric  haemorrhage  has  been' 
known  to  occur  after  this  operation,  but  is  probably  due  to  absence 
of  care  in  securing  the  vessels  close  to  the  hilum,  as  if  the  splenic 
vein  is  tied  so  as  to  include  the  veins  returning  from  the  cardiac  end 
of  the  stomach  (vasa  brevia)  congestion  of  this  part  of  the  gastric 
wall  will  result,  and  may  cause  haemorrhage. 


CHAPTER  XXXV. 
HERNIA. 

By  the  term  Hernia  is  meant  the  protrusion  of  some  viscus  from  its 
normal  situation  through  an  opening  in  the  walls  of  the.  cavity  within 
which  it  is  contained.  This  may  effect  not  only  the  abdominal  viscera, 
but  also  the  brain  and  lungs,  giving  rise  to  conditions  which  have 
been  already  described.  The  present  chapter  is  limited  to  hernia 
as  met  with  in  connection  with  the  abdomen. 

The  most  common  Situations  at  which  hernia  occurs  are  those 
spots  where  the  parietes  are  weakened  by  the  transmission  of  such 
structures  as  the  spermatic  cord  and  round  ligament  (inguinal  hernia), 
or  at  the  entrance  of  the  crural  canal,  where  the  main  vessels  of  the 
leg  pass  under  Poupart's  ligament  (femoral  hernia),  or  at  the  umbilicus 
(umbilical  hernia).  Hernial  protrusions  may,  however,  develop 
through  the  obturator  foramen,  sciatic  notch,  the  diaphragm,  and  in 
various  other  situations. 

Etiology. — A  great  many  conditions  may  be  associated,  directly  or 
indirectly,  with  the  production  of  a  hernia.  They  may,  however,  be 
described  for  practical  purposes  under  two  main  headings — the  con- 
genital and  the  acquired. 

Congenital  Causes  are  rather  predisposing  than  exciting  in  nature, 
and  must  be  looked  for  amongst  the  many  malformations  and  con- 
ditions of  imperfect  development  to  which  the  abdominal  parietes 
and  contents  are  liable.  The  following  are  the  most  important  of 
these :  {a)  The  non-obhteration  of  the  funicular  process  of  peritoneum, 
which  in  the  male  precedes  and  accompanies  the  testicle  on  its  pro- 
gress downwards  from  the  abdominal  cavity  to  the  scrotum,  and  in 
the  female  passes  along  the  round  ligament.  The  so-called  congenital 
inguinal  hernia  results  from  this,  although  it  must  be  remembered 
that  the  rupture  does  not  necessarily  show  itself  at  birth,  and,  indeed, 
may  not  appear  till  after  puberty.  It  is  probable  that  incomplete 
obliteration  of  this  process  is  the  cause  of  a  great  majority  of  the 
cases  of  oblique  inguinal  hernia,  a  small  pouch  being  left  at  the 
upper  end.  It  is  often  possible  to  demonstrate  the  existence  of  this 
in  patients  with  weak,  bulging  groins,  but  with  no  actual  hernia.  In 
females  under  the  age  of  twenty-five,  hernia  into  the  canal  of  Nuck, 
as  this  peritoneal  tube  is  called,  is  the  most  frequent  variety  met  with. 
(b)  The  late  descent  of  the  testis,  whether  it  finds  its  way  into  the 

1087 


lo88  A  MANUAL  OF  SURGERY 

scrotum  or  not,  is  usually  associated  with  the  formation  of  an 
inguinal  hernia  of  the  congenital  type,  or  of  some  form  of  interstitial 
hernia.  (c)  Inherited  weakness  of  the  abdominal  muscles  and 
parietes,  with  unusual  patency  of  the  rings,  will  certainly  predispose 
to  this  condition,  and,  moreover,  there  is  no  doubt  as  to  the  tendency 
of  hernia  to  run  in  families,  (d)  Abnormal  length  of  the  mesentery 
or  omentum  has  also  been  looked  on  as  a  causative  factor  ;  but, 
although  it  may  have  some  influence  when  other  conditions  are 
present,  it  can  per  se  have  but  little  effect,  (e)  Congenital  phimosis, 
by  inducing  forcible  acts  of  micturition,  acts  as  an  exciting  cause. 
(/)  Congenital  apertures  occur  in  the  linea  alba  or  linea  semilunaris, 
especially  opposite  one  of  the  tendinous  intersections  in  the  rectus, 
and  through  these  one  form  of  ventral  hernia  may  develop,  {g)  The 
umbilicus  is  sometimes  imperfectly  developed  at  birth,  permitting 
the  viscera  to  protrude  into  the  base  of  the  umbilical  cord  (congenital 
umbilical  hernia).  (Ji)  The  diaphragm  is  also  occasionally  defective, 
allowing  the  stomach  or  other  viscera  to  find  their  way  into  the 
thoracic  cavity. 

Acquired  Causes. — Hernia  may  result  from  any  condition  which 
tends  either  to  weaken  the  abdominal  parietes,  or  to  increase  the 
intra-abdominal  pressure.  Thus  (i)  it  may  he  post-operative,  resulting 
from  the  imperfect  development  of  a  cicatrix  after  a  laparotomy. 
(2)  It  may  be  the  outcome  of  direct  traumatism,  and  is  then  just  as 
likely  to  occur  away  from  the  hernial  regions.  If  seen  early,  the 
affected  area  will  probably  show  signs  of  injury,  such  as  tender- 
ness, swelling,  and  ecchymosis,  but  with  care  such  a  lesion  need  not. 
be  followed  by  a  hernia.  It  is  unusual  for  an  ordinary  complete 
hernia  to  develop  after  injury  or  severe  strain,  unless  a  preformed 
sac  is  present,  and  then  immediate  strangulation  is  not  an  uncommon 
sequence  ;  apart  from  this,  the  hernia,  if  seen  soon  after  the  alleged 
accident,  is  imperfectly  developed,  and  in  the  bubonocele  stage.  The 
fact  that  compensation  may  be  required  for  the  development  of  a 
hernia  should  make  practitioners  cautious  in  giving  opinions  as  to 
aetiology,  (3)  Much  more  frequently  hernia  is  due  to  chronic  strain, 
such  as  occupations  which  involve  lifting  heavy  weights,  and  the 
more  so  if  the  individual  is  forced  to  maintain  the  upright  position, 
or  wears  tight  bands  or  girths  round  the  abdomen.  Prolonged  and 
severe  bronchitis,  and  frequent  straining  to  pass  water  in  cases  of 
enlarged  prostate  or  stricture,  may  determine  the  development  of  a 
hernia ;  whilst  chronic  constipation  is  a  frequent  factor  in  its  pro- 
duction, especially  if  the  patient  makes  use  of  a  closet  with  a  high  seat, 
whereby  the  inguinal  canals  are  left  unprotected ;  a  patient  with 
weak  and  bulging  inguinal  regions  may  with  advantage  use  a  low 
commode.  (4)  Relaxation  of  the  abdominal  parietes  also  favours  hernia, 
especially  if  associated  with  or  followed  by  severe  straining.  Thus 
pregnancy  brings  about  a  stretching  of  the  wall,  especially  if  frequently 
repeated  and  followed  by  imperfect  involution  ;  and  parturition  de- 
termines the  development  of  hernia,  either  in  the  crural  region  or 
through  the  linea  alba.     Similarly  the  relaxed  and  atonic  abdominal 


HERNIA  1089 

wall,  which  bulges  down  in  the  hypogastric  region  in  old  people, 
favours  the  occurrence  of  a  direct  inguinal  hernia,  should  the  patient 
have  a  bad  cough  or  an  enlarged  prostate.  In  old  and  weakly  people 
an  additional  cause  may  be  found  in  the  slipping  downwards  of  the 
mesenteric  attachment,  causing  the  intestines  to  occupy  the  lower 
part  of  the  abdomen  rather  than  the  upper,  so  that  the  former  bulges 
out  over  the  pelvic  brim.  This  is  possibly  due  to  weakening  or 
relaxation  of  the  unstriped  muscular  tissue  which  normally  exists 
behind  the  peritoneum,  passing  from  the  posterior  abdominal  wall  to 
the  base  of  the  mesentery  ;  it  is  sometimes  called  the  muscle  of  Treitz. 
(5)  Obesity  is  also  a  predisposing  factor  to  hernia,  the  accumulated 
fat  being  deposited  in  the  omentum,  mesentery,  and  subperitoneal 
tissue,  thus  increasing  the  intra-abdominal  tension. 

Structure. — ^A  hernia  consists  of  a  sac  and  its  contents,  the  sac 
being  formed  of  peritoneum,  perhaps  thickened  by  additional  cover- 
ings, derived  from  the  abdominal  parietes,  and  the  contents  being  the 
protruded  viscera.  . 

The  sac,  or  peritoneal  investment  of  an  acquired  hernia,  is  in  the 
early  stages  funnel-shaped,  small,  and  thin,  being  derived  from  that 
portion  of  the  serous  membrane  which  normally  lies  over  the  hernial 
aperture.  As  the  rupture  increases  in  size,  the  sac  becomes  larger,  ■ 
partly  by  stretching,  and  partly  by  the  drawing  down  of  fresh  mem- 
brane from  the  neighbourhood.  Occasionally  it  stretches  irregularly 
and  becomes  sacculated,  and  sometimes  the  sac  becomes  hour-glass- 
shaped,  probably  as  the  result  of  inflammation.  The  sac  is  described 
as  consisting  of  two  portions — the  neck  and  the  fundus.  The  neck, 
sometimes  large  and  open  at  first,  gradually  becomes  narrowed, 
and  is  generally  thickened  from  the  irritation  to  which  it  has 
been  exposed,  either  from  the  wearing  of  a  truss  or  from  the  pres- 
sure of  the  contained  viscera.  The  body,  or  fundus,  varies  much 
in  size  and  shape,  and  may  undergo  considerable  alterations  in 
structure. 

[a)  The  sac  soon  becomes  adherent  to  surrounding  parts  ;  and  with 
increasing  irritation,  as  by  a  truss,  these  adhesions  become  more 
definite,  (b)  Inflammation  may  occur  as  the  result  of  injury  or 
pressure,  constituting  a  form  of  localized  peritonitis.  If  this  is  of 
a  chronic  type,  the  sac  becomes  thickened  and  opaque,  with  dilated 
vessels  coursing  over  it,  as  seen  especially  in  old  irreducible  hernias. 
Acute  or  subacute  inflammation  is  also  met  with,  resulting  in  the 
formation  of  adhesions  between  the  inner  wall  and  the  contained 
viscera,  or  between  the  opposite  sides  of  the  sac,  if  no  other  structures 
interpose.  Natural  cure  of  a  hernia  may  occasionally  be  produced 
in  this  way  by  adhesions  forming  across  the  neck  of  the  sac,  or 
by  an  adherent  plug  of  omentum,  thus  occluding  the  communication 
with  the  peritoneal  cavity.  The  lower  portion  of  the  sac  may  in 
a  similar  way  be  shut  off  from  the  upper,  either  by  a  band  of 
adhesions  or  by  a  septum  of  adherent  omentum;  this  isolated 
cavity  is  sometimes  the  seat  of  a  serous  effusion,  known  as  a 
hydrocele  of  a  hernial  sac.     (c)  Haemorrhage  into  the  sac  wall  may 

69 


logo  A  MANUAL  OF  SURGERY 

result  from  violence,  and  will  cause  it  to  become  much  thickened, 
and  even  pigmented  or  leathery  in  appearance. 

The  coverings  of  the  sac  are  indurated  in  old-standing  cases,  and 
matted  together  in  such  a  manner  as  to  make  it  difficult  to  recognise 
the  constituent  parts.  This  is  specially  noticeable  at  the  neck  of  the 
sac,  where  their  union  with  surrounding  structures  is  often  such  as 
to  constitute  an  important  predisposing  element  in  the  production 
of  strangulation.  The  opening  through  which  the  hernia  protrudes 
loses  its  characteristic  features  and  shape,  being  enlarged,  more  or 
less  circular,  and  displaced,  so  that  an  oblique  passage,  such  as  the 
inguinal  canal,  becomes  straight,  the  internal  abdominal  ring  lying 
almost  immediately  behind  the  external. 

Contents. — -Any  viscus  in  the  abdomen  may  be  found  in  the  sac  of 
a  hernia,  except,  perhaps,  the  pancreas;  as  a  rule,  however,  one  finds 
only  small  intestine  or  omentum. 

An  enterocele  is  the  name  given  to  a  hernia  containing  some  portion 
of  the  bowel.  It  is  at  first  reducible;  but  if  the  gut  becomes  adherent, 
either  to  the  sac  or  to  some  other  contained  structure,  it  is  rendered 
irreducible.  It  may  also  participate  in  an  inflammatory  condition  of 
the  sac  ;  whilst,  if  irreducible,  obstruction  may  ensue  from  impaction 
of  its  contents,  and  if  its  vessels  are  constricted  strangulation  super- 
venes. For  a  description  of  these  conditions,  see  p.  1113.  The  small 
mtestine  is  much  more  frequently  involved  than  the  large  gut.  The 
amount  of  bowel  protruded  varies  from  a  few  inches  to  several  feet. 

If  omentum  is  found  in  a  hernial  sac,  the  condition  is  known  as  an 
epiplocele.  As  long  as  it  remains  reducible,  it  is  likely  to  retain  its 
normal  texture ;  but  when  large  in  amount,  and  especially  if  irre- 
ducible, it  becomes  thickened,  brawny,  and  matted  together  to  such 
an  extent  as  almost  to  constitute  a  solid  tumour  ;  it  is  often  the  seat 
of  an  excessive  deposit  of  fat,  and  in  consequence  of  this  overgrowth 
it  may  become  irreducible,  even  when  no  adhesions  are  present. 
Serous  cysts  sometimes  develop  within  it  as  a  result  of  effusion  be- 
tween opposed  surfaces.  In  some  cases  openings  are  found  in  it  of 
sufficient  size  to  allow  the  gut  to  pass  through  and  become  strangu- 
lated. When  omentum  and  bowel  are  present  in  the  same  sac,  the 
condition  is  known  as  an  entevo -epiplocele. 

The  CcBcum  sometimes  occupies  a  hernial  sac,  either  in  aggravated 
and  large  hernias,  or  in  children  with  congenital  hernia  ;  it  has 
even  been  found  in  a  hernia  on  the  left  side.  Since  the  caecum  has 
generally  a  complete  serous  covering  and  usually  a  mesentery,  it  is 
freely  moveable,  and  may  pass  into  a  hernial  sac  in  the  same  way  as 
any  other  moveable  part  of  the  intestine.  On  the  other  hand,  a  few 
indisputable  cases  have  been  related  in  which  the  serous  envelope 
was  incomplete  in  a  so-called  'caecocele.' 

The  Vermiform  Appendix  is  occasionally  found  in  a  hernial  sac  on 
the  right  side.  It  is  rarely  free,  but  generally  fixed  by  adhesions  and 
irreducible.  The  hernia  is  more  painful  than  usual,  and  on  palpation 
the  appendix  can  sometimes  be  felt  enlarged  and  tender,  pressure 
causing  pain  referred  to  the  umbilicus.  The  patient  is  likely  to  give 
a  history  of  recurrent  attacks  of  inflammation  in  the  sac. 


HERNIA    ■  1091 

The  Bladder  may  be  associated  with  a  hernial  sac  in  two  distinct 
ways,  and  usually  in  the  inguinal  region,  (a)  The  fundus  may  be 
dragged  downwards  by  the  traction  of  the  peritoneum,  when  the 
hernia  has  attained  a  colossal  size.  There  is  then  only  a  partial 
peritoneal  investment,  the  bladder  lying  outside  the  sac,  and  being 
adherent  to  it.  Considerable  irritability  of  the  viscus  is  induced,  and, 
owing  to  stagnation  of  urine  in  the  displaced  part,  a  phosphatic  con- 
cretion may  form  therein,  and  such  has  even  been  removed  by  incision 
through  the  scrotum,  {h)  Occasionally  a  saccule  of  the  outer  wall  of 
the  bladder  becomes  adherent  to  the  peritoneum,  and  is  drawn  down 
by  it  into  the  inguinal  canal ;  its  presence  may  be  suspected  if  a  small 
hernia  is  associated  with  much  vesical  irritability.  Such  a  protrusion 
consists  merely  of  thickened  mucous  membrane  and  submucous  tissue, 
and  is  devoid  of  muscular  fibres  ;  it  is  very  liable  to  be  laid  open  when 
an  operation  for  the  radical  cure  is  undertaken.  If  such  an  accident 
happens,  the  saccule  should  be  excised,  and  the  opening  at  once 
closed  by  sutures,  which  should  not  penetrate  the  mucous  membrane. 
Failure  to  recognise  such  an  accident  is  followed  by  urinary  extra- 
vasation, possibly  intraperitoneal,  and  will  require  prompt  treatment 
if  a  fatal  issue  is  to  be  avoided.  The  wound  must  be  re-opened,  the 
gap  in  the  bladder  wall  found  and  closed,  and  effective  drainage 
provided. 

The  Ovary  and  Fallopian  Tube  are  occasionally  found  in  the  sac  of 
an  inguinal  hernia,  more  often  in  a  child  than  in  an  adult,  and  give 
rise  to  an  irreducible  swelling,  pressure  on  which  causes  a  sickening 
pain. 

Loose  foreign  bodies,  somewhat  resembling  marbles  in  size,  are  occa- 
sionally, but  very  rarely,  met  with  in  hernial  sacs.  They  are  derived 
from  the  detachment  of  one  or  more  of  the  appendices  epiploicae, 
which  subsequently  become  enlarged  from  a  deposit  of  fibrin  induced 
by  movement  in  the  peritoneal  cavity,  and  may  even  calcify. 

Signs  and  Symptoms. — The  characteristic  features  whereby  a 
hernial  protrusion  is  recognised  consist  in  the  presence  of  a  rounded 
or  pyriform  swelling,  in  one  of  the  normal  or  abnormal  situations 
already  mentioned,  which  increases  in  size  when  the  patient  stands, 
coughs,  or  strains,  having,  as  it  is  termed,  '  an  impulse  on  coughing.' 
If  intestine  is  present,  it  may  be  possible  to  obtain  a  tympanitic  note 
on  percussion,  whilst  the  tumour  is  tense  and  rounded,  and  on  pressure- 
slips  back  into  the  abdomen  with  a  distinct  gurgle.  An  enterocele 
often  gives  rise  to  dyspeptic  phenomena,  and  perhaps  to  colicky  pains. 
An  omental  hernia  feels  soft  and  doughy,  has  a  less  distinct  impulse, 
or  even  none,  on  coughing,  and  is  replaced  without  a  gurgle ;  it  is 
dull  on  percussion.  When  allowed  to  reappear,  it  does  so  slowly 
without  any  sudden  impulse,  the  omentum  insinuating  itself  gently 
down  the  inguinal  canal,  and  gradually  distending  the  sac. 

The  Treatment  of  hernia,  whether  palliative  by  means  of  trusses, 
or  radical  by  means  of  operation,  differs  so  greatly  in  the  various 
forms,  that  it  will  be  better  to  discuss  each  one  separately. 


logz 


A  MANUAL  OF  SURGERY 


Special  Forms  of  Hernia. 

Inguinal  Hernia. — The  term  inguinal  hernia  is  limited  to  those 
conditions  in  which  a  protrusion  occurs  into  the  inguinal  canal,  and 
if  allowed  to  progress,  finally  makes  its  way  through  the  external 
abdominal  ring.  If  it  extends  into  the  scrotum,  it  is  termed  complete, 
or  scrotal ;  whilst  if  it  does  not  pass  beyond  the  external  abdominal 
ring,  it  is  known  as  a  huhonocele,  or  incomplete  inguinal  hernia.  The 
neck  is  always  in  relation  with  the  deep  epigastric  artery,  and  the 
structures  of  the  cord  are  either  spread  out  over  the  sac  or  are  in 
close  proximity  to  it.  In  the  early  stages,  the  pubic  spine  can  be  felt 
to  the  outer  side  of  the  neck  of  the  sac  ;  but  as  it  increases  in  size  it 
lies  over  the  spine,  which  can  only  be  felt  after  pushing  the  hernia 
upwards  and  inwards. 


\ 


Fig.  477. — Double  Oblique 
Inguinal  Hernia. 


Fig.  478. — Diagram  of  Acquired  In- 
guinal Hernia,  showing  Serous 
Sac  with  Intestine  coming  down 
TO  the  Top  of  the  Testis. 


Two  main  varieties  of  inguinal  hernia  are  described,  viz.,  the 
oblique  and  the  direct. 

An  Oblique  Inguinal  Hernia  (Fig.  477)  is  one  which  passes  down 
the  whole  length  of  the  inguinal  canal,  entering  at  the  internal  and 
emerging  at  the  external  abdominal  ring  ;  the  deep  epigastric  artery 
is  thus  placed  to  the  inner  side  of  the  neck.  During  its  passage 
through  the  canal  every  form  of  oblique  hernia  pushes  before  it  and 
becomes  covered  by  structures  representing  the  various  layers  of  the 
abdominal  parietes.  Hence,  in  cutting  down  on  such  a  sac,  the 
surgeon  will  divide,  in  addition  to  the  skin  and  subcutaneous  tissues, 
{a)  the  intercolumnar  fascia,  derived  from  the  transverse  fibres  of 
the  external  oblique  which  pass  across  the  external  abdominal  ring  ; 
(&)  the  cremasteric  muscle  and  fascia,  representing  and  extending 
from  the  internal  oblique;  (c)  the  infundibuliform  fascia  derived  from 
the  fascia  transversalis ;  and  {d)  finally,  a  layer  of  subserous  tissue 


HERNIA 


1093 


varying  in  thickness,  and  closely  surrounding  the  peritoneal  sac. 
Probably  the  surgeon  will  only  recognise  the  muscular  fibres  of  the 
cremaster,  which  serve  as  a  useful  landmark. 

There  are  three  different  forms  of  oblique  inguinal  hernia,  viz.,  the 
acquired,  the  congenital,  and  the  infantile  or  encysted. 

I.  An  Acqtnred  Inguinal  Hernia  (Fig.  478)  is  one  in  which  the  sac 
consists  entirely  of  peritoneum  protruded  from  within  the  abdomen. 
It  gradually  increases  in  size,  and  finds  its  way  along  the  cord  to  the 
scrotum.  The  sac  usually  extends  as  far  as  the  head  of  the  epididy- 
mis, but  if  of  a  large  size  it  may  overlap  the  testicle,  which  lies 
behind  it.  The  structures  of  the  cord  are  frequently  spread  out 
over  the  sac.  In  old-standing  cases  the  internal  ring  is  dragged 
downwards  and  inwards,  and  often  lies  behind  the  outer,  and  thus  it 
may  be  difficult,  apart  from  operation,  to  determine  whether  any 
particular  hernia  is  direct  or  oblique.     Even  in  early  cases  the  sac 


Fig.  479. — Congenital  Inguinal  Hernia. 
A,  Vaginal  variety  ;  B,  funicular  type. 

is  distinctly  flask-shaped,  suggesting  that  the  condition  is  due  to  the 
non-closure  of  the  uppermost  part  of  the  funicular  process. 

2.  Congenital  Inguinal  Hernia  (Fig.  479)  is  due  to  non-closure  of  the 
funicular  process  of  peritoneum,  which  passes  down  to  the  scrotum 
with  the  testicle,  and  is  usually  obliterated  completely  except  below, 
where  it  forms  the  tunica  vaginalis.  As  already  mentioned,  the 
hernia  does  not  necessarily  appear  in  infancy,  its  occurrence  being 
often  delayed  until  puberty,  or  when  the  patient  has  to  undertake 
heavy  work.  This  form  of  hernia  is  much  more  frequently  met  with 
on  the  right  side  of  the  body,  owing  to  the  fact  that  the  right  testicle 
descends  into  the  scrotum  at  a  later  date  than  the  left.  It  is  always 
characterized  by  becoming  complete  at  once,  and  its  development 
may  be  immediately  followed  by  acute  strangulation. 

When  the  non-obliteration  is  complete  and  the  patent  funicular 
process  is  continuous  with  the  tunica  vaginalis,  the  protruded  viscera 
lie  in  contact  with  the  testis,  and  somewhat  obscure  it ;  this  is 
known  as  a  congenital  vaginal  hernia  (Fig.  479,  A).  Less  frequently 
the  funicular  process  is  patent  only  as  far  as  the  head  of  the  epididy- 


1094 


A  MANUAL  OF  SURGERY 


mis,  being  shut  off  from  the  tunica  vaginalis.  The  hernia  under 
such  circumstances  exactly  resembles  the  acquired  variety,  being 
unrecognisable  from  it  except  by  the  fact  that  it  becomes  complete 
at  once.     It  is  termed  a  congenital  fimimlav  hernia  (Fig.  479,  B). 


Fig.  480. — Infantile  Inguinal  Hernia. 
A,  Prehernial  condition  with  tunica  vaginalis  extending  upwards  to  inguinal 
canal ;  B,  hernial  sac  coining  down  behind  tunica ;  C,  sac  invaginating  the 
tunica  vaginalis. 

In  congenital  hernia  the  structures  of  the  cord  are  usually  more 
intimately  inherent  to  it  than  in  the  acquired  form.  Phimosis  is 
often  associated  with  this  condition  in  young  boys. 

3.  The  Infantile  or  Encysted  Hernia  is  one  occurring  in  individuals 

in  whom  the  funicular  process, 
although  shut  off  from  the  abdominal 
cavity  above,  remains  patent  below, 
communicating  with  the  tunica 
vaginalis,  which  cavity  extends,  in 
consequence,  as  high  as  the  in- 
guinal canal  (Fig.  480,  A).  The 
hernia  has  a  distinct  sac,  which 
passes  down  behind  the  open  pro- 
cess, or  invaginates  it  (Fig.  480, 
B  and  C).  It  cannot  be  recognised 
except  on  operation,  when  the 
surgeon  is  apt  to  open  the  tunica 
vaginalis,  which,  though  reaching 
upwards,  does  not  communicate 
with  the  general  peritoneal  cavity ; 
on  removing  or  displacing  this,  the 
true  sac  of  the  hernia  is  found 
behind  it.  This  does  not  often  occur  at  the  present  day,  when  the 
high  incision  is  made. 

A  Direct  Inguinal  Hernia  (Fig.  481)  is  one  which,  though  passing 
through  the  external  abdominal  ring,  has  only  travelled  through  a 
portion  of  the  inguinal  canal ;  it  is  never  congenital,  and  usually 


?i.— Direct  Inguinal 
Hernia. 


HERNIA 


1095 


smaller  than  the  oblique  type.  The  neck  lies  to  the  inner  side  of  the 
epigastric  artery,  which  is  often  arched  very  distinctly  over  it,  pass- 
ing also  along  its  upper  wall.  The  hernia  thus  escapes  through  the 
lowest  portion  of  the  linea  semilunaris,  and  traverses  the  space 
known  as  Hesselbach's  triangle,  which  is  bounded  internally  by  the 
outer  border  of  the  rectus  muscle,  by  the  deep  epigastric  artery 
externally,  and  by  Poupart's  ligament  below  (Fig.  482).  The 
obliterated  hypogastric  artery  passes  across  the  space  in  a  direction 
parallel  to  its  outer  border,  dividing  it  into  two  parts,  and  according 
to  whether  the  hernia  protrudes  through  the  outer  or  inner  segment, 
it  is  known  as  an  external  or  internal  direct  hernia  (Fig.  482, 
2  and  3).     The  spermatic  cord  usually  lies  to  the  outer  side  of  a 


Fig.  482. — Abdominal  Wall  from  Within,  to  show  Hernial  Apertures. 

A,  V,  External  iliac  artery  and  vein  ;  SV,  spermatic  vessels  ;  PL,  Poupart's  liga- 
ment ;  VD,  vas  deferens  ;  E,  epigastric  vessels  ;  R,  rectus  abdominis  ;  H,  ob- 
literated hypogastric  artery;  i,  internal  abdominal  ring;  2  and  5,  sites  of 
direct  hernia  in  Hesselbach's  triangle ;  4,  crural  ring  for  femoral  hernia ; 
5,  obturator  foramen  and  vessels. 

direct  hernia,  and  its  constituent  elements  are  never  spread  out  over 
the  sac  as  in  the  oblique  form.  A  direct  hernia  is  rarely  found  in 
young  people,  and  there  is  often  a  considerable  amount  of  subperi- 
toneal fatty  tissue  around  the  sac.  The  coverings  are  practically  the 
same  as  in  the  oblique  variety,  although  the  cremasteric  investment 
may  be  less  complete. 

Interstitial  Hernia  is  the  name  given  to  an  inguinal  hernia  which 
develops  in  some  abnormal  relation  to  the  abdominal  wall.  Three 
varieties  are  described :  [a)  Where  a  sac  exists  between  the  trans- 
versalis  fascia  and  the  peritoneum  {intvaparietal  form,  or  properitoneal 
hernia),  either  with  or  without  a  hernia  in  the  usual  position  ;  in  the 
former  instance  one  form  of  '  hernia  en  bissac  '  is  produced.     This 


1096  A  MANUAL  OF  SURGERY 

abnormal  pocket  of  the  sac  is  found  either  between  the  symphysis 
pubis  and  the  bladder  (hernia  inguinalis  ante-vesicalis),  or  it  extends 
outwards  towards  the  iliac  fossa  (hernia  inguinalis  intra-iliaca).  As 
no  external  swelling  is  caused  by  this  condition,  it  is  usually 
impossible  to  recognise  its  existence  prior  to  operation  ;  occasionally 
it  is  the  cause  of  a  continuation  of  the  symptoms  of  strangulation, 
when  apparently  successful  taxis  has  been  performed,  owing  to  the 
strangled  bowel  having  been  pushed  backwards  from  the  superficial 
into  the  deeper  portion  of  the  sac,  (b)  An  abnormal  expansion 
of  the  sac  is  situated  between  the  internal  and  external  oblique 
m.uscles  {interparietal  form).  A  swelling  is  thus  produced  in  the 
region  of  the  inguinal  canal,  covered  by  the  external  oblique 
aponeurosis,  and  gradually  spreading  upwards  and  outwards  parallel 
with  Poupart's  ligament.  It  may  be  associated  with  late  descent 
of  the  testis,  the  external  abdominal  ring  being  closed  so  that 
the  organ,  and  with  it  a  hernia,  has  to  travel  beneath  the  external 
oblique  aponeurosis.  Sometimes  the  condition  is  due  to  the  exist- 
ence of  a  more  or  less  complete  septum  at  the  level  of  the  external 
abdominal  ring,  formed  either  by  adhesions  or  by  a  mass  of  adherent 
omentum.  The  sac  is  then  shaped  like  an  hour-glass,  and  as  the 
usual  downward  course  of  the  hernial  contents  is  prevented,  the 
upper  part  of  the  sac  yields  laterally  above  the  site  of  the  obstruc- 
tion, and  passes  between  the  muscles,  (c)  The  hernia  escapes  as 
usual  from  the  external  abdominal  ring,  but  travels  outwards  along 
Poupart's  ligament,  somewhat  simulating  a  femoral  hernia  (extra- 
parietal  variety).  This  form  is  generally  associated  with  late  descent 
of  the  testis,  and  a  contracted  state  of  the  scrotum,  so  that  it  is  easier 
for  the  hernia,  which  is  always  of  a  congenital  type,  to  pass  into  the 
thigh,  and  be  guided  by  the  fascia  in  the  direction  indicated ;  in  a 
case  of  this  character  operated  upon  some  years  back,  the  testicle 
was  found  lying  close  to  the  anterior  superior  iliac  spine.  There  is 
no  difficulty  in  recognising  such  a  condition. 

The  Signs  of  an  inguinal  hernia  do  not  require  much  special  notice 
here,  as  we  have  already  described  the  general  clinical  features  of  a 
rupture  (p.  109 1).  In  the  early  stages,  where  merely  a  bubonocele 
exists,  a  fulness  is  noted  in  the  course  of  the  inguinal  canal,  which 
increases  when  the  patient  coughs  ;  it  is  best  detected  by  a  finger 
passed  through  the  external  ring  into  the  canal.  When  it  descends 
into  the  scrotum,  the  swelling  increases  in  size  from  above  down- 
wards, and  in  the  oblique  variety  is  continuous  with  the  fulness  in 
the  inguinal  canal.  The  structures  of  the  cord  are  masked  by  the 
presence  of  the  hernia,  but  the  testicle  is  to  be  felt  more  or  less  dis- 
tinctly at  the  lower  and  back  part  of  the  swelling.  When  of  the 
direct  variety,  the  cord  lies  to  the  outer  side,  and  although  the  hernia 
can  be  felt  projecting  from  the  external  ring,  it  passes  directly  back- 
wards, and  there  is  no  fulness  along  the  course  of  the  canal. 

Inguinal  hernia  is  usually  met  with  in  the  male  sex,  the  oblique 
variety  being  more  common  in  the  young,  and  the  direct  in  elderly 
patients.     In  the  female  sex  it  is  not  unfrequent,  however,  in  girls 


HERNIA  1097 

and  young  nulliparous  women ;  in  such  cases  it  is  almost  always 
congenital,  passing  into  the  labium  along  the  canal  of  Nuck,  but 
rarely  attains  any  considerable  size. 

The  Diagnosis  of  an  inguinal  hernia  is  a  tolerably  simple  matter  if 
it  is  uncomplicated  by  any  other  condition ;  it  may,  however,  be  diffi- 
cult, and  in  old-standing  cases  it  is  often  impossible  to  distinguish 
the  oblique  variety  from  the  direct.  The  conditions  for  which  it  may 
be  mistaken  are  best  considered  in  two  groups. 

I.  Whilst  the  hernia  is  still  incomplete  and  in  the  bubonocele  stage, 
it  has  to  be  distinguished  from  the  following  :  (a)  Encysted  hydrocele 
of  the  cord,  which  is  recognised  by  its  smooth  globular  outline  and 
tense  walls  ;  the  impulse  on  coughing  is  less  distinct,  and,  although 
freely  moveable  in  the  canal,  the  hydrocele  cannot  always  be  entirely 
reduced  into  the  abdomen,  whilst  the  characteristic  gurgle  of  a  hernia 
is  absent ;  traction  on  the  testis,  moreover,  fixes  the  tumour,  and 
renders  it  im^mobile.  The  exact  limitation  of  the  upper  end  of  the 
swelling,  if  it  can  be  reached,  is  very  characteristic  of  a  hydrocele. 
[b)  A  chronic  abscess  originating  in  the  abdominal  parietes,  or  within 
the  abdomen  or  pelvis,  will  sometimes  point  through  the  external 
abdominal  ring.  In  such  cases,  although  there  is  a  distinct  im- 
pulse on  coughing,  and  although  the  swelling  is  reducible,  it  has 
not  the  definite  outline  and  characteristic  sensation  of  a  hernia, 
being  usually  soft  and  fluctuant.  Other  evidences  pointing  to  the 
existence  of  the  original  disease  may  also  assist  in  determining  the 
nature  of  the  swelling,  (c)  Enlarged  glands  in  the  groin  which  have  be- 
come adherent  to  the  external  oblique  are  sometimes  mistaken  for  a 
hernia,  owing  to  the  fact  that  on  coughing  a  distinct  impulse  is  com- 
municated to  them ;  it  is,  however,  merely  heaving  in  nature,  and 
not  expansile,  whilst  on  digital  exploration  of  the  inguinal  canal  the 
absence  of  a  hernia  may  be  readily  ascertained,  {d)  A  testicle  retained 
in  the  inguinal  canal  is  recognised  by  that  side  of  the  scrotum  being 
empty,  and  on  pressing  the  swelling  testicular  sensation  may  be 
elicited.  The  rounded  upper  end  of  the  testis  can  often  be  detected. 
{e)  Tumours  co^isisting  of  fat  or  other  tissues  are  occasionally  seen  in  the 
inguinal  canal,  but  are  characterized  by  the  strict  limitation  of  their 
upper  border,  and  usually  by  the  absence  of  a  distinct  impulse  on 
coughing.  On  the  other  hand,  as  described  elsewhere,  a  mass  of  fat 
simulating  a  lipoma  is  sometimes  present,  resulting  from  a  protrusion 
of  the  subperitoneal  tissue,  a  hernial  sac  being  found  embedded  in 
its  interior.  (/)  HcBmatocele  of  the  cord  is  recognised  by  a  history  of 
injury,  the  presence  of  pain  and  ecchymosis,  and  the  absence  of  an 
impulse  on  coughing,  whilst  reduction  is  impracticable. 

2.  When  the  hernia  extends  into  the  scrotum,  less  difficulty  is  ex- 
perienced in  its  diagnosis.  By  examination  of  the  cord  immediately 
outside  the  external  abdominal  ring,  all  purely  scrotal  swellings, 
such  as  hydrocele  or  sarcocele,  are  readily  eliminated,  since  in  them 
the  cord  can,  in  the  early  stages,  be  felt  perfectly  free.  A  varicocele 
can  also  be  similarly  recognised  from  an  omental  hernia  by  the  con- 
dition of  the  cord  in  its  upper  region  ;  moreover,  if  the  patient  is 


1098 


A  MANUAL  OF  SURGERY 


made  to  assume  the  recumbent  posture,  the  sweUing  disappears  in 
each  instance,  but  if  a  finger  is  placed  firmly  over  the  inguinal  canal 
so  as  to  prevent  any  protrusion  of  omentum,  and  he  is  then  directed 
to  stand  up,  the  swelling  immediately  reappears  if  it  is  venous  in 
character.  To  the  practised  finger,  the  diagnosis  is  never  a  matter 
of  difficulty,  since  the  enlarged  veins  of  a  varicocele  and  omentum 
are  not  at  all  alike  to  the  touch,  the  veins  moving  freely  under  the 
finger  '  like  worms  in  a  bag.'  When  a  hernia  is  associated  with  a 
hydrocele  or  sarcocele,  a  little  more  care  is  necessary  in  order  to 
distinguish  between  the  two  swellings. 

The  Treatment  of  inguinal  hernia  is  either  palliative  by  means  of 
trusses,  or  radical. 

Palliative  Treatment. — A  truss  is  an  appliance  which  is  worn 
around  the  body  with  the  object  of  preventing  by  pressure  the 
descent  of  the  hernia.  No  one  form  is  capable  of  dealing  with  every 
case,  and  hence  the  truss  must  be  selected  with  care,  so  as  to  suit 
the  special  needs  of  the  particular  patient.  A  good  truss  consists  of 
a  pad  kept  in  position  over  the  hernial  aperture  by  a  steel  spring 

(Fig.  483),  which  fits  the 
patient  accurately,  resting 
behind  on  the  middle  piece 
of  the  sacrum,  and  passing 
laterally  midway  between  the 
crest  of  the  ilium  and  the  top 
of  the  great  trochanter.  If 
the  hernia  is  unilateral,  the 
spring  ends  on  the  sound 
side  just  behind  the  anterior 
superior  spine,  and  is  pro- 
longed anteriorly  into  a 
leather  thong  or  cross-strap, 
which  is  secured  to  a  stud  on  the  pad.  To  prevent  it  from  slipping 
up,  an  under-strap  passes  from  the  affected  side  close  behind 
the  anterior  superior  spine  along  the  fold  of  the  nates  to  the  inner 
side  of  the  thigh,  being  fixed  finally  to  a  second  stud  on  the  pad. 
The  pad  may  be  rounded  or  oval  in  shape,  and  usually  consists 
of  soft  iron  protected  by  cork,  but  polished  vulcanite,  wood,  or 
an  indiarubber  cushion  filled  with  air,  water,  or  glycerine,  may 
be  employed  instead;  it  should  be  well  covered  with  leather, 
and  the  strength  of  the  spring  must  be  so  adjusted  as  to  retain 
the  hernia  under  all  conditions  of  strain  to  which  it  may  be  sub- 
jected, but  without  the  use  of  undue  force.  In  ordering  a  truss 
from  an  instrument-maker,  the  only  measurement  required  is  that 
around  the  body,  following  the  line  taken  by  the  truss,  and  reaching 
in  front  to  the  symphysis  pubis ;  it  is  also  advisable  to  indicate  the 
size  of  the  hernia,  and  whether  the  opening  in  the  abdominal  parietes 
is  large  or  small.  In  the  earlier  cases  of  oblique  hernia,  the  pad 
should  rest  rather  over  the  inguinal  canal  than  over  the  external 
abdominal  ring,  the  object  being  to  restore  the  valve-like  action  of 


Fig.  483. 


-Inguinal  Truss. 
Brothers.) 


(Down 


HERNIA 


1099 


the  canal  by  approximating  its  sides.  In  a  direct  hernia  the  pad 
must  be  apphed  directly  over  the  opening.  If  such  an  apparatus  is 
properly  adjusted  and  continuously  worn,  a  cure  is  sometimes  estab- 
lished in  the  course  of  a  year  or  two ;  and  in  the  congenital  hernia 
of  children  a  cure  may  be  confidently  expected  if  the  mother  or 
attendants  of  the  child  conscientiously  carry  out  the  necessary  details. 
If  the  hernia  is  once  allowed  to  slip  down,  even  after  six  or  twelve 
months'  treatment,  all  the  previous  good  will  have  been  undone. 

In  infants,  an  efficient  support  is  afforded  by  a  skein  of  wool 
(specially  known  as  '  fingering '),  divided  at  one  end,  so  that  when 
placed  round  the  body  the  cut  ends  of  the  skein  can  be  passed 
through  the  loop,  forming  a  knot  over  the  inguinal  canal,  which 
acts  as  the  pad  of  a  truss.  The  cut  ends  are  now  passed  under  the 
perineum,  and  tied  to  the  transverse  portion  behind  (Fig.  484).    This 


Fig.  485. — Indiarubber  Band  Truss, 
WITH  Air-pads,  for  Infants. 

The  air-pads  fit  around  the  root  of  the 
Fig.     484.  —  Wool     Truss     for  penis,    and    are    inflated    through    the 

Treatment      of      Hernia      in  tube    tied    up    in    front.     The    under- 

Children.  straps  fit  round  the  child's  thighs. 

apparatus  is  changed  night  and  morning  when  the  child  is  bathed, 
and  also,  if  need  be,  at  shorter  intervals,  the  mother  being  previously 
instructed  as  to  how  to  support  the  hernia  whilst  the  apparatus  is 
being  removed.  In  cases  of  double  rupture  in  infants,  an  indiarubber 
band  with  two  pneumatic  air-pads  (Fig.  485),  arranged  so  as  to  fit 
over  the  inguinal  canals,  and  with  suitable  straps  and  studs,  will  often 
suffice,  and  is  certainly  more  comfortable  than  a  spring  truss.  In 
addition  to  such  pressure,  it  is  important  to  remove  all  causes  of 
intra-abdominal  tension,  as  by  circumcision,  where  phimosis  is 
present,  or  by  regulating  the  bowels. 

The  Radical  Cure  of  inguinal  hernia  is  an  operation  to  which  much 
attention  has  been  directed  of  late  years,  since  its  value  was  brought 
prominently  before  the  profession  by  the  late  Professor  John  Wood 
and  others.  It  is  very  largely  employed  at  the  present  day,  and  may 
be  expected  to  give  excellent  results  if  the  cases  are  carefully  selected. 


1 100  A  MANUAL  OF  SURGERY 

if  the  technique  is  satisfactory,  and  if  the  after-treatment  is  efficient. 
The  mortahty  is  very  small,  and  in  a  series  of  7,419  cases  collected 
by  Sultan,  it  did  not  exceed  0*48  per  cent.* 

The  selection  of  cases  for  an  operation  of  this  type,  which  is  not  an 
essential,  but  only  a  desirable  means  of  treatment  (or,  as  it  is  some- 
times termed,  an  operation  de  complaisance),  is  a  matter  requiring  con- 
siderable judgment  and  discrimination.  In  an  individual  whose 
occupation  does  not  subject  him  to  heavy  strain  or  exertion,  and  who 
possesses  a  hernia  which,  under  ordinary  circumstances,  is  easily 
commanded  by  a  suitably  applied  truss,  no  operation  is  absolutely 
necessary ;  although  one  is  perfectly  justified  in  urging  him  to  submit 
to  it,  since  he  will  be  thereby  freed  from  the  irksomeness  of  wearing 
a  truss,  and  from  the  possible  occurrence  of  strangulation.  If,  how- 
ever, the  subject  is  a  labouring  man,  exposed  to  injury  and  strain, 
and  who  may  find  it  difficult  to  provide  a  suitable  series  of  trusses, 
the  operation  should  always  be  undertaken  unless  distinctly  contra- 
indicated  (i)  by  a  general  inherited  weakness  of  the  abdominal 
muscles ;  (2)  by  a  relaxed  and  atonic  condition  of  the  abdominal 
parietes,  which  is  commonly  associated  in  elderly  people  with 
slipping  downwards  of  the  mesenteric  attachment  of  the  intestine 
(enteroptosis),  so  that  the  hypogastrium  obviously  bulges  ;  or  (3)  by 
such  constitutional  disease  as  precludes  all  unnecessary  operative 
interference.  (4)  Again,  in  cases  of  extensive  irreducible  hernia,  the 
return  of  large  masses  of  intestine  which  have  lain  for  years  in  the 
hernial  sac  so  increases  the  intra-abdominal  tension  as  frequently  to 
determine  recurrence  locally  or  elsewhere,  and  therefore  operative 
interference,  though  very  desirable  owing  to  the  great  risk  of  strangu- 
lation incurred  by  the  patient,  is  often  followed  by  very  bad  results, 
unless  the  patient  has  previously  been  put  through  a  course  of  semi- 
starvation  and  persistent  taxis  in  order  to  reduce  gradually  the  size 
of  the  protrusion. 

As  to  the  best  age  at  which  to  operate,  statistics  definitely  prove 
that  it  is  essentially  an  operation  of  adolescence,  the  results  gradually 
getting  worse  as  the  age  increases.  Young  children  should  not  be 
touched  until  careful  truss  pressure  for  a  year  has  failed,  or  unless  it 
is  impossible  to  keep  up  the  hernia  by  such  treatment.  In  any  case 
it  is  perhaps  wiser  to  delay  it  until  the  age  of  three,  or  even  later, 
owing  to  the  risk  of  infection  of  the  wound  from  the  constant  satura- 
tion of  the  dressings  with  urine. 

Very  many  different  operations  have  been  described  and  practised 
by  various  surgeons.  One  of  the  most  satisfactory  is  that  known  as 
Bassini's,  which  has  now  been  extensively  employed,  and  has  been 
followed  by  a  large  measure  of  success.  The  operation  may  be 
described  in  the  following  stages :  (i)  The  pubic  region  having  been 
previously  shaved  and  thoroughly  purified,  an  incision  is  made  in  the 
direction  of  the  inguinal  canal  and  cord,  about  2|  inches  in  length, 
its  centre  being  a  little  above  the  external  abdominal  ring.  This  is 
carried  through  the  skin  and  subcutaneous  tissues  until  the  structures 
*  Munch,  Med.  Wochens.,  February  3,  1903, 


HERNIA  I  ,oi 

of  the  cord  are  reached,  the  superficial  external  pudic  artery  beino- 
necessarily  divided  en  route  ;  the  pillars  of  the  ring  are  clearly  defined, 
and  the  external  oblique  aponeurosis  slit  up  in  the  direction  of  the 
cord.  (2)  The  sac  has  now  to  be  identified ;  if  the  hernia  is  one  of 
old  standing,  or  contains  adherent  omentum  or  intestine,  it  is  easily 
recognised;  but  if  it  is  thin,  empty,  and  of  recent  formation,  and 
especially  in  the  case  of  a  bubonocele,  its  identification  may  be  a 
matter  of  some  difficulty.  The  cremaster  and  other  coverings  of  the 
cord  are  incised  longitudinally,  and  the  sac  looked  for  and  isolated 
with  as  little  handling  and  disturbance  of  the  parts  as  possible. 
Enlarged  veins  may  be  removed,  as  also  fatty  protrusions  from  the 


Fig.  486. — Bassini's  Operation  for  Radical  Cure  of  Hernia. 
A,  A^,  Spencer  Wells  forceps,  holding  aside  the  divided  portions  of  external 
oblique  aponeurosis  ;  B,  arched  fibres  of  internal  oblique,  continuous  on  the 
inner  side  with  the  conjoined  tendon  ;  C,  hook  or  retractor  holding  aside 
the  spermatic  cord  ;  D,D,D,  D,  deep  silk  stitches  passed  behind  the  cord 
through  the  deepest  filsres  of  Poupart's  ligament  on  the  outer  side,  and 
conjoined  tendon  on  the  inner.  (The  cutaneous  incision  and  the  incision 
through  the  external  oblique  are  here  shown  much  greater  than  would 
actually  be  undertaken,  in  order  to  demonstrate  clearly  the  deeper  parts.) 

subperitoneal  tissues.  It  is  sometimes  necessary  to  lift  up  the  struc- 
tures of  the  cord  in  order  to  define  the  sac,  which  is  often  recognised 
by  the  white  convex  border  of  the  fundus.  (3)  If  the  sac  is  empty, 
it  is  freed  from  its  connection  with  the  structures  of  the  cord  without 
opening  it,  and  isolated  as  far  as  or  beyond  the  internal  abdominal 
ring,  as  indicated  by  a  collar  of  fatty  subperitoneal  tissue  surrounding 
the  neck.  If  the  hernia  is  irreducible,  the  sac  is  laid  open,  its  contents 
freed  from  adhesions,  and  the  intestine  returned  into  the  abdomen, 


II02  A  MANUAL  OF  SURGERY 

whilst  omental  tissue  is  removed,  arid  the  stump  replaced.  Adhesions 
are  carefully  divided  either  by  the  finger  or  between  ligatures ;  if  the 
gut  is  closely  adherent  to  the  sac,  it  may  be  necessary  to  leave  a  small 
portion  of  this  attached  to  the  intestine,  which  is  then  returned. 
Omentum,  whether  adherent  or  not,  should  be  removed,  as  the 
elongated  fringes  are  very  liable  to  contract  adhesions  to  the  ab- 
dominal parietes,  which  subsequently  produce  mischief.  In  removing 
omentum,  it  is  not  advisable  to  encircle  a  large  mass  with  a  single 
ligature,  as  it  is  then  more  difficult  to  replace,  the  vessels  are  less 
securely  commanded,  and  a  pocket  or  pucker  may  be  produced, 
possibly  leading  to  internal  strangulation  at  a  later  date.  Small 
portions,  including  one  or  more  of  the  larger  vessels,  should  be  taken 
up  one  after  another,  and  tied  separately  and  with  advantage  at 
different  levels,  so  as  to  assist  in  the  subsequent  return  of  the  stump. 
The  protruded  mass  is  then  cut  away  below  the  ligatures,  and  the 
stump  replaced  after  seeing  that  no  bleeding-point  remains  unsecured. 
The  sac,  being  now  emptied,  is  isolated  as  far  as  the  internal  ring. 
(4)  The  neck  is  transfixed  as  high  as  possible,  and  ligatured  with 
sterilized  silk,  and  the  sac  cut  off  below  the  ligature,  the  stump 
retracting  well  above  the  internal  ring,  and  presenting  a  flush  surface 
towards  the  intestines.  (5)  The  opening  in  the  abdominal  parietes 
is  closed  by  a  row  of  sutures  passing  through  the  arched  fibres 
of  the  internal  oblique  and  transversalis  muscles,  or  through  the 
conjoined  tendon  on  the  inner  side,  and  through  Poupart's  ligament 
on  the  outer,  the  stitches  being  all  placed  behind  the  cord.  To 
effect  this,  the  cord  is  drawn  up  out  of  the  wound  and  held  aside 
by  a  retractor  (Fig.  486,  C),  whilst  the  divided  margins  of  the  external 
oblique  aponeurosis  are  grasped  by  pressure  forceps  (A,  A^).  Gentle 
traction  on  the  lower  pair  enables  the  deepest  portion  of  Poupart's 
ligament  to  be  defined  and  seen.  The  stitches  must  secure  a  good 
hold  of  the  tissues,  but  should  not  include  the  external  oblique 
aponeurosis,  and  when  dealing  with  Poupart's  ligament  the  proximity 
of  the  iliac  vessels  must  not  be  forgotten.  Either  interrupted  or  looped 
mattress  sutures  may  be  used,  but  if  the  latter,  they  must  not  be  tied 
too  tightly,  as  they  may  strangle  the  portions  of  tissue  included  in  their 
grasp  and  cause  necrosis.  The  opening  in  the  abdominal  parietes 
is  in  this  way  commanded  as  far  do^wn  as  the  pubic  spine,  but  suffi- 
cient room  must  be  left  at  the  upper  end  for  the  passage  of  the  cord, 
undue  constriction  of  which  would  cause  atrophy  of  the  testis ;  some- 
times it  is  desirable  to  introduce  a  stitch  above  the  cord,  in  order  to 
command  a  spot  where  recurrence  is  not  uncommon.  When  the 
three  or  four  needful  stitches  have  been  introduced  and  tightened, 
the  cord  is  replaced,  and  the  divided  portions  of  the  external  oblique 
are  sutured  together  over  it.  (6)  The  wound  in  the  skin  is  closed  by 
a  continuous  suture,  and  usually  no  drainage-tube  is  needed. 

After- Treatment. — The  patient  is  placed  in  bed  with  the  head  low, 
and  the  knees  slightly  flexed  over  a  pillow.  The  wound,  as  a  rule, 
does  not  require  dressing  for  seven  or  eight  days,  w^hen,  on  removal 
of  the  stitches,  it  should  be  found  completely  healed,  if  asepsis  has 


HERNIA  1103 

been  maintained.  The  patient  should  turn  to  the  opposite  side  in 
order  to  pass  water,  and  the  greatest  care  must  be  taken  to  prevent 
the  dressing  becoming  soiled.  Occasionally  retention  of  urine  follows 
this  operation,  necessitating  the  use  of  a  catheter.  In  the  case  of 
children,  it  is  well  to  seal  the  parts  down  after  the  first  twenty-four 
hours  by  a  collodion  dressing,  and  by  preference  the  collodion  should 
be  of  the  flexile  type. 

The  recumbent  posture  should  be  maintained  for  three  weeks,  and 
nothing  but  the  slightest  work  undertaken  for  at  least  six  weeks, 
and  no  violent  effort  until  six  months  after  the  operation.  Under 
such  circumstances  the  use  of  a  truss  is  unnecessary  and,  indeed, 
undesirable,  as  its  pressure  is  liable  to  produce  atrophy  of  the  newly- 
formed  cicatricial  tissue.  When,  however,  the  abdominal  walls  are 
congenitally  weak,  or  if,  unfortunately,  the  wound  has  suppurated, 
the  deep  stitches  coming  away,  it  is  advisable  to  use  a  light  truss  for 
a  time. 

The  treatment  of  congenital  hernia  differs  in  no  particular  from  that 
already  described,  except  that  the  sac  must  be  divided  below  as  well 
as  above,  and  the  lower  opening  secured  by  suture  or  ligature,  so 
as  to  close  the  cavity  of  the  tunica  vaginalis.  The  operation  often 
proves  difficult  owing  to  the  intimate  adhesions  between  the  sac  and 
the  structures  of  the  cord,  and  it  is  sometimes  impracticable  to 
isolate  completely  the  neck  of  the  sac. 

The  other  operations  which  require  to  be  mentioned  are  as  follows : 

(a)  In  Banks''  Operation,  the  sac  is  isolated  and  removed  as  high 
as  the  internal  ring  without  any  division  of  the  external  oblique. 
Stitches  are  then  introduced  through  the  conjoined  tendon  and 
Poupart's  ligament  respectively,  including  the  external  oblique  in 
their  grasp,  and  passing  in  front  of  the  cord.  It  is  obvious  that  by 
such  a  plan  the  deep  ring  cannot  be  closed  as  accurately  as  in 
Bassini's  operation.  It  may  suffice,  however,  in  a  few  of  the  simpler 
congenital  cases. 

(b)  In  Macewen's  Method  the  aponeurosis  of  the  external  oblique  is 
most  carefully  maintained  intact,  and  the  inguinal  canal  is  explored 
through  the  external  abdominal  ring.  The  sac  is  freed  from  its 
surroundings,  and  this  liberation  goes  on  for  about  an  inch  all  round 
the  internal  abdominal  ring.  A  silk  suture  is  then  tied  to  the  fundus 
of  the  sac,  and  is  carried  by  a  curved  needle  through  the  centre  of 
the  sac  from  above  downwards,  and  again  through  the  neck  of  the 
sac  from  below  upwards.  The  needle  is  then  introduced  through  the 
inguinal  canal  under  the  loosened  abdominal  parietes,  and  is  made 
to  emerge  through  the  abdominal  muscles  a  little  above  the  inguinal 
canal ;  the  silk  thread  is  carried  through  this,  and  by  a  little  traction 
the  sac  is  carried  in,  doubled  up,  and  implanted  as  a  pad  across  the 
internal  ring.  This  thread  is  held  by  an  assistant  during  the  next 
step  of  the  operation.  This  consists  in  closing  the  canal  by  one  or 
more  looped  sutures,  passed  in  such  a  way  as  to  draw  up  Poupart's 
ligament  over  the  arched  fibres  of  the  internal  oblique  in  front  of  the 
cord.     Finally,  the  thread  used  for  the  fixation  of  the  sac  is  drawn 


1I04 


A  MANUAL  OF  SURGERY 


tight,  and  its  free  end  employed  to  close  the  external  abdominal  ring 
to  a  sufficient  extent.  The  results  of  this  proceeding  are  very  good, 
but  it  is  a  more  difficult  operation  than  Bassini's,  and  one  loses 
the  advantage  of  opening  the  canal,  and  thereby  exploring  the 
structures  of  the  cord.  Subperitoneal  lipomata  are  frequently 
found  in  the  canal,  and  these  would  inevitably  be  left,  and  would 
possibly  lead  to  a  recurrence  of  the  hernia,  if  the  canal  had  not  been 
opened  up. 

(c)  In  Halstead's*  operation  the  inguinal  canal  is  opened  up  as  in 
Bassini's  method,  and  the  cremaster  divided  longitudinally  along  the 


Fig.  487. —Operation  for  Inguinal  Hernia.     (Carless.) 

The  inguinal  canal  is  opened  up,  and  the  sac  removed  as  high  as  possible.  The 
cord  and  cremaster  (not  represented  here)  are  pressed  back  and  covered  over 
by  approximating  the  internal  oblique  and  transversalis  to  the  under  surface 
of  Poupart's  ligament  by  mattress  sutures,  which  are  introduced  as  indicated 
above,  and  tied  on  the  outer  aspect  of  the  ligament.  The  divided  segments 
of  the  external  oblique  are  then  overlapped  and  sutured. 

upper  border  of  the  cord,  and  dissected  back,  so  as  to  enable  the  sac 
and  any  enlarged  veins,  etc.,  to  be  removed.  The  lower  border 
of  the  internal  oblique  is  defined,  and  the  upper  edge  of  the 
cremaster  is  sutured  to  the  under  surface  by  a  series  of  mattress 
stitches.  The  lower  edge  of  the  internal  oblique  and  conjoined 
tendon  is  then  sutured  in  front  of  the  cord  to  the  under  surface  of 
Poupart's  ligament,  and  finally  the  divided  portions  of  the  external 
oblique  closed  by  overlapping.  If  there  is  much  tension  in  the 
deeper  stitches,  a  longitudinal  incision  through  the  sheath  of  the 
rectus  muscle  will  give  suitable  relaxation.  Excellent  results  have 
followed  this  procedure. 

*  Johns  Hopkins  Bulletin,  August,  1903. 


HERNIA  1105 

[d)  For  the  last  few  years  extensive  employment  of  a  somewhat 
similar  proceeding  has  given  most  satisfactory  results.  The  canal  is 
opened  in  the  same  way,  and  the  sac  excised,  the  ligature  being 
placed  as  high  as  possible.  The  fibres  of  the  internal  oblique  are 
then  exposed  by  thorough  retraction  of  the  divided  external ;  and 
mattress  sutures  are  introduced  through  the  internal  oblique  and 
transversalis,  or  edge  of  the  rectus  sheath,  carried  across  in  front  of 
the  cord  through  Poupart's  ligament,  and  tied  on  its  ou\er  surface 
(Fig.  487).  This  constitutes  a  firm  muscular  barrier  across  the 
canal ;  one  or  two  such  sutures  usually  suffice.  The  lower  or  outer 
segment  of  the  external  oblique  is  then  carried  up  and  stitched  down 
to  the  internal  oblique  well  above  the  mattress  sutures;  the  inner 
segment  of  the  divided  external  oblique  is  then  made  to  overlap  the 
outer,  and  stitched  down  to  Poupart's  ligament ;  the  deep  layer  of 
fascia  is  also  carefully  secured  by  sutures,  and  the  wound  closed. 
Healing  almost  invariably  occurs  without  suppuration ;  and  even 
should  this  happen,  the  stitches  are  easily  removed,  as  the  knots  are 
on  the  outer  side  of  Poupart's  ligament,  and  not  on  the  inner,  as  in 
Bassini's  and  Halstead's  methods.  In  all  these  three  methods 
epididymitis  and  hydrocele  occasionally  develop  as  sequelae. 

Recurrence  after  Operation  is  much  less  common  than  formerly, 
and  statistics  go  to  prove  that  in  experienced  hands  less  than  10  per 
cent,  of  the  cases  recur,  and  that  rarely  after  the  first  twelve  months. 
As  already  stated,  it  may  be  due  partly  to  an  injudicious  selection  of 
cases,  partly  to  errors  of  technique,  and  in  part  to  a  faulty  after-treat- 
ment, the  patient  being  given  too  much  liberty  at  too  early  a  date. 
In  connection  with  this  we  would  especially  emphasize  the  necessity 
for  isolating  the  sac  as  far  as  possible,  since  otherwise  the  infundibuli- 
form  opening  at  the  top  of  the  closed  peritoneal  canal  is  certain  to 
persist.  Another,  and  that  perhaps  the  most  common,  cause  of  re- 
currence is  septic  contamination  of  the  wound  ;  if  the  deep  stitches  are 
not  involved,  no  great  harm  is  done,  but  whenever  they  have  been  re- 
moved or  come  away  it  is  wise  to  use  a  light  truss  for  a  time  as  a  pre- 
cautionary measure.  Again,  the  mere  restoration  of  a  mass  of  in- 
testine or  omentum  into  the  abdominal  cavity  may  suffice  to  raise  the 
intra-abdominal  pressure,  and  thus  predispose  to  a  recurrence  ;  hence 
the  importance  of  removing  as  much  omental  tissue  as  possible  in  all 
bad  cases.  Relapses  may  also  be  due  to  splitting  or  tearing  of  the 
tendinous  structures  around,  either  by  the  mere  passage  of  the  needle, 
or  by  the  traction  induced  by  tightening  the  sutures  ;  indeed,  it  is  often 
the  case  that  a  hernia  originally  oblique  may  after  operation  be 
followed  by  one  that  is  direct,  and  probably  from  this  cause. 

Whenever  it  appears  likely  that  recunence  may  occur,  a  truss 
should  be  ordered.  If,  however,  a  hernia  has  developed,  a  second 
operation  should  be  performed,  if  the  condition  of  the  abdominal 
parietes  warrants  it. 

Femoral  Hernia. — A  femoral  hernia  is  one  which,  travelling  down 
the  crural  canal,  presents  at  the  inner  and  upper  part  of  the  thigh 
through  the  saphenous  opening.     It  occurs  most  commonly  in  women 

70 


iio6    ^  A  MANUAL  OF  SURGERY 

on  account  of  the  greater  expansion  of  the  iliac  crests  allowing  in- 
creased space  beneath  Poupart's  ligament,  and  especially  in  those 
who  have  borne  children.  During  parturition  the  inguinal  regions 
are  in  a  measure  protected,  and  hence  inguinal  hernia  is  rarely  caused 
in  this  way.  In  young  people,  however,  it  is  more  common  in  the 
male  sex. 

The  crural  canal  constitutes  the  inner  compartment  of  the  femoral 
sheath,  a  space  usually  occupied  by  fatty  cellular  tissue,  lymphatic 
vessels,  and  perhaps  a  lymphatic  gland.  It  is  about  |  inch  in  length 
anteriorly,  and  i^  inches  along  its  posterior  wall ;  it  is  closed  above 
by  a  thickened  portion  of  the  subserous  cellular  tissue  known  as  the 
septum  crurale,,and  its  lower  end  is  formed  by  the  saphenous  open- 
ing, and  closed  by  the  cribriform  fascia.  Hence  a  femoral  hernia, 
as  it  passes  downwards,  receives  the  following  coverings  :  (a)  peri- 
toneum ;  (b)  subserous  cellular  tissue,  including  the  septum  crurale, 
a  layer  sometimes  known  as  the  fascia  propria,  and  occasionally 
represented  by  a  thick  fatty  envelope ;  (c)  the  anterior  layer  of  the 
femoral  sheath,  derived  from  the  fascia  tranversalis  ;  [d)  cribriform 
fascia  ;  (e)  subcutaneous  tissue  ;  and  (/)  skin.  In  its  passage  through 
the  canal  it  is  situated  immediately  internal  to  the  femoral  vein,  and 
pressure  upon  this  may  produce  oedema  of  the  leg,  whilst  Gimbernat's 
ligament  lies  to  the  inner  side.  The  spermatic  cord  or  round  ligament 
is  placed  just  above  and  internal  to  it,  but  on  a  superficial  plane, 
whilst  the  epigastric  artery  is  not  very  far  from  the  outer  side  of 
the  neck.  Occasionally  the  obturator  artery  arises  from  this  latter 
vessel  (once  in  three  and  a  half  subjects) ;  it  may  pass  to  the  inner 
side  of  the  neck  of  the  sac  along  the  border  of  Gimbernat's  ligament 
(once  in  seventy-five  times),  but  more  commonly  runs  between  the 
neck  and  the  femoral  vein.  When  once  it  has  emerged  from  the 
saphenous  opening,  a  femoral  hernia  usually  travels  upwards  and  out- 
wards along  Poupart's  ligament  towards  the  anterior  superior  iliac 
spine,  being  guided  by  the  attachment  of  the  deep  layer  of  the  super- 
ficial fascia ;  when  of  large  size,  it  may  extend  considerably  above 
the  level  of  Poupart's  ligament.  Femoral  herniae  are  less  likely  to 
contain  omentum  than  the  inguinal  variety  :  a  portion  of  the  ileum 
is  most  often  present,  but  occasionally  the  ovary  or  Fallopian  tube 
may  be  found  in  the  sac. 

The  Signs  of  a  femoral  hernia  are  very  characteristic.  A  rounded 
swelling  with  an  impulse  on  coughing,  and  more  or  less  reducible, 
forms  on  the  inner  side  of  the  thigh,  its  neck  or  aperture  of  com- 
munication with  the  abdomen  lying  to  the  inner  side  of  the  femoral 
vessels,  and  to  the  outer  side  of  the  pubic  spine,  which  can  always 
be  easily  felt  (Fig.  488).  There  is  usually  but  little  difficulty  in 
making  a  diagnosis,  although  occasionally  some  care  is  needed,  (a)  An 
inguinal  hernia  is  recognised  by  the  fact  that  its  neck  occupies 
the  inguinal  canal,  the  saphenous  opening  being  free ;  whilst  it  is 
also  above  and  internal  to  the  pubic  spine,  and  above  Poupart's 
ligament  at  its  point  of  exit ;  it  tends  to  pass  downwards  into  the 
scrotum,  or  in  females  into  the  labium^     Femoral  hernia,  on  the 


HERNIA 


1 107 


other  hand,  usually  (but  not  invariably)  occurs  in  women  over 
twenty-five  years  of  age  ;  the  inguinal  canal  is  free,  whilst  the  neck 
is  in  the  situation  of  the  crural  canal,  below  and  external  to  the 
pubic  spine,  and  below  Poupart's  ligament ;  moreover,  it  travels 
upwards  and  outwards,  the  labium  being  unaffected,  (b)  An  enlarged 
lymphatic  gland  over  the  saphenous  opening  may  simulate  this  con- 
dition very  closely ;  but  the  absence  of  impulse  on  coughing  and  of 
the  usual  hernial  signs  is  generally  sufficient  to  distingish  it ;  when, 
however,  the  hernia  is  purely 
omental  and  irreducible,  the  impulse 
is  so  slightly  marked  that  correct 
diagnosis  in  a  stout  woman  is  often 
difficult  without  an  exploratory  in- 
cision, (c)  A  small  lipoma  in  the 
canal  somewhat  resembles  a  hernia, 
but  the  limitation  of  the  tumour,  its 
greater  mobility,  and  the  absence  of 
an  impulse  on  coughing,  should 
suffice  to  prevent  a  mistake,  {d)  A 
psoas  abscess  pointing  at  the  saphenous 
opening  resembles  a  hernia  in  the  ex- 
istence of  a  reducible  swelling  with 
an  expansile  impulse  on  coughing. 
It  is  distinguished  from  it  by  the  facts 
that  there  is  no  gurgle  on  reduction  ; 
that  the  abscess,  as  it  passes  under  Poupart's  ligament,  lies  to  the 
outer  side  of  and  behind  the  vessels ;  and  that  distinct  fluctuation 
occurs  between  the  swelling  in  the  saphenous  opening  and  the  tumour, 
which  can  always  be  felt  in  the  iliac  fossa  ;  the  characteristic  signs 
of  spinal  caries  are  also  usually  present,  {e)  In  varix  of  the  saphena, 
if  a  pouch  or  ampulla  forms  close  to  its  entrance  into  the  femoral 
vein,  it  may  be  mistaken  for  a  femoral  hernia  on  account  of  the 
marked  impulse  on  coughing,  and  because  the  swelling  disappears  on 
assuming  the  recumbent  position.  It  is,  however,  usually  associated 
with  the  signs  of  varix  below,  and  by  the  fact  that,  although 
pressure  is  maintained  over  the  upper  part  of  the  crural  canal  after 
the  vein  has  been  emptied,  the  swelling  regains  its  ordinary  size 
when  the  patient  stands  up.  The  impulse  is  of  a  different  character 
to  that  of  a  hernia ;  the  blood  can  be  felt  to  be  driven  past  the  ex- 
amining finger  with  a  thrill,  instead  of  there  merely  being  an  expansile 
bulge. 

Treatment. — When  reducible  and  of  small  size,  a  femoral  hernia 
may  be  treated  by  the  use  of  a  truss,  similar  in  nature  to  that  used  for 
an  inguinal  hernia,  except  that  the  pad  extends  somewhat  lower,  so 
as  to  maintain  pressure  along  the  course  of  the  canal.  A  badly- fitting 
truss  may  compress  the  femoral  vein,  and  lead  to  oedema  of  the  leg. 

Operative  Treatment  is  undertaken  either  for  the  relief  of  strangu- 
lation, or,  if  a  radical  cure  is  desired,  as  an  operation  de  complaisance. 
The  remarks  already  made  as  regards  the  cure  of  inguinal  hernia, 


Fig.  488. — Femoral  Hernia. 


no8 


A  MANUAL  OF  SURGERY 


and  the  general  principles  there  enunciated,  apply  also  to  this  variety. 
The  apposition  of  the  anterior  and  posterior  walls  of  the  crural  canal 
is  the  essential  element  in  the  operation,  and  this  practically  resolves 
itself  into  the  fixation  of  the  inner  end  of  Poupart's  ligament  to  the 
horizontal  ramus  of  the  pubis  or  the  structures  overlying  it.  The  sac 
is  exposed  by  a  vertical  incision  along  the  course  of  the  crural  canal 
(Fig.  449,  G),  cleared  of  its  fatty  covering,  which  is  often  thick  and 
abundant,  emptied  of  its  contents  by  reduction,  and  then  cut  away  after 
transfixing  and  tying  the  neck.  Some  surgeons,  however,  retain  the  sac, 
pushing  it  back  into  the  abdomen,  and  using  it  as  a  pad  across  the 
upper  opening  of  the  canal.  The  fatty  covering  of  the  sac  must  be  dealt 
with  in  a  similar  way.  The  deep  ring  is  then  commanded  by  one  of  the 
following  methods  :    (i)  In  the  great  majority  of  cases  it  will  suffice  to 


Fig.  489. — Diagram  of  the  Radical  Cure  for  Femoral  Hernia. 

The  position  of  the  femoral  vein  and  artery  is  indicated,  and  the  internal  saphena 
vein  passes  up  through  the  saphenous  ring  to  join  the  former.  The  spermatic 
cord  is  seen  above,  and  the  situation  of  the  suture  to  close  the  crural  canal. 


introduce  stitches  through  the  inner  end  of  Poupart's  ligament 
(Fig.  489),  and  deeply  through  the  horizontal  fibres  of  Cooper's 
ligament,  which  lie  in  close  apposition  to  the  horizontal  ramus  of  the 
pubis.  There  are  but  few  cases  where  this  manoeuvre,  if  effectively 
carried  out,  is  not  sufficient  to  determine  closure  of  the  canal ;  but  for 
this  purpose  the  hernia  needle  must  be  carried  down  to  the  bone,  and 
not  merely  through  the  fascia  over  the  pectineus.  (2)  In  a  few  cases, 
perhaps,  where  the  opening  is  larger,  it  may  be  desirable  to  approxi- 
mate Poupart's  ligament  to  the  horizontal  ramus  by  some  other 
method,  and  for  this  purpose  Roux  has  advised  the  use  of  a  f) -shaped 
metal  staple,  which  traverses  the  ligament,  and  the  free  ends  of 
which  are  driven  into  the  bone.  This  plan  appears  to  us  undesir- 
able, since  the  staple  occasionally  works  loose,  and  then  the  proximity 
of  the  femoral  vein  makes  it  an  unwelcome  neighbour.     (3)  A  good 


HERNIA  1 1 09 

substitute  for  this  plan  has  been  practised  by  Nicoll*  of  Glasgow, 
who  drills  the  horizontal  ramus  from  below  upwards  in  two  spots,  and 
then  by  passing  a  mattress  suture  through  Poupart's  ligament  and  the 
free  ends  through  these  drill-holes,  tying  them  below,  the  ligament 
is  safely  approximated  to  the  inner  and  upper  aspect  of  the  pubis. 

Umbilical  Hernia. — Three  different  forms  of  umbilical  hernia  are 
described. 

1.  Congenital  Umbilical  Hernia,  or  Exomphalos,  is  an  exceedingly 
rare  condition,  due  to  imperfect  closure  of  the  abdominal  walls,  as 
a  result  of  which  part  of  the  intestine  is  found  at  birth  in  a  cavity  at 
the  base  of  the  umbilical  cord,  which  is  bulbous  and  enlarged.  If 
the  condition  is  overlooked,  it  may  be  included  in  the  ligature  with 
which  the  cord  is  tied,  and  fatal  strangulation,  or  at  the  best  a  faecal 
fistula,  will  result.  If  left  untreated  until  the  cord  has  separated,  the 
peritoneal  cavity  will  be  laid  open,  and  septic  peritonitis  ensue.  The 
only  treatment  is  immediate  laparotomy,  reduction  of  the  gut,  and 
closure  of  the  umbilical  opening  by  sutures,  if  such  be  possible. 

2.  The  Umbilical  Hernia  of  Infants  and  Yoimg  People,  or,  as  it  is 
commonly  called,  '  starting  of  the  navel,'  is  due  to  weakness  of  the 
umbilical  cicatrix,  which  yields  before  the  intra-abdominal  pressure. 
Its  occurrence  is  often  determined  by  chronic  constipation  or 
phimosis,  necessitating  continual  straining  in  order  to  evacuate  the 
bowels  or  bladder.  The  condition  rarely  persists  till  adult  life,  as  it  is 
easily  cured.  Treatment  consists  in  regulating  the  bowels  and  in  the 
performance  of  circumcision,  if  necessary,  whilst  the  local  condition  is 
dealt  with  by  strapping  the  abdominal  wall  in  such  a  way  as  to  tuck  the 
umbilical  cicatrix  inwards  ;  no  pad  is  required.  In  persistent  cases 
it  may  be  necessary  to  lay  the  sac  open  and  remove  it,  suturing 
the  parts  together,  as  described  in  detail  below.  In  these  cases  the 
opening  is  often  a  transverse  chink  rather  than  a  round  hole,  and  it 
is  sometimes  advisable  to  introduce  the  sutures  in  a  vertical  direction, 
thereby  securing  transverse  apposition. 

3.  The  so-called  Umbilical  Hernia  of  Adults  is  usually  due  to  a  pro- 
trusion of  omentum  or  intestine  through  an  opening  in  the  linea  alba, 
either  immediately  above  or  below  the  umbilicus,  the  former  being 
the  more  common.  It  occurs  most  frequently  in  women  who  have 
borne  children,  being  sometimes  due  to  actual  rupture  of  the  linea 
alba  and  separation  of  the  recti  muscles.  A  peritoneal  sac  is 
present,  but  in  old-standing  cases  it  is  extremely  attenuated,  and 
so  adherent  to  surrounding  parts  as  to  be  unrecognisable,  whilst 
the  contents  may  be  matted  together  in  an  almost  inextricable 
confusion.  Under  such  circumstances  obstruction  is  very  liable 
to  ensue,  and  if  combined,  as  is  not  uncommon,  with  a  sub- 
acute form  of  inflammation,  it  may  even  run  on  to  strangulation. 
Moreover,  the  skin  over  the  tumour  becomes  stretched,  atrophic,  and 
not  unfrequently  ulcerated,  so  that  perforation  may  threaten.  The 
hernia  is  often  lobulated  in  character,  and  a  considerable  deposit  of 
fat  may  sometimes  surround  it. 

•  Scottish  Med.  and  Surg.  Joitrn. ,  December,  1903. 


iiio  A  MANUAL  OF  SURGERY 

Treatment. — When  of  large  size,  and  occurring  in  stout  individuals, 
it  should  be  supported  by  a  bag  truss,  whilst  the  patient  is  placed  on 
such  dietetic  and  hygienic  measures  as  shall  assist  in  the  reduction  of 
excessive  corpulency.  In  favourable  cases  operative  treatment  can 
be  undertaken.  A  vertical  incision  is  made  over  the  site  of  the 
tumour,  and  to  effect  this  without  wounding  the  subjacent  gut,  it 
may  be  advisable  to  pinch  up  the  skin  on  either  side,  and  divide  it  by 
transfixion.  The  sac  is  then  opened,  the  incision  being  enlarged,  if 
necessary,  so  as  to  allow  the  contents  to  be  drawn  aside  and  the 
opening  in  the  abdominal  wall  exposed.  When  the  intestine  has 
been  reduced  and  omentum  removed,  the  sac  is  dissected  up  to  the 
margins  of  the  opening  into  the  abdomen,  which  is  usually  small  in 
size  and  circular  in  shape,  whilst  the  edges  are  firm  and  thickened. 
The  sac  may  now  be  cut  away  close  to  the  opening,  and  all  bleeding- 
points  secured.  The  aperture  is  then  closed  in  the  following  way : 
Several  deep  transverse  sutures  are  passed  through  the  whole  thick- 
ness of  the  abdominal  wall  on  each  side,  and  tightened  after  a  row  of 
interrupted  sutures  has  drawn  the  peritoneal  surfaces  into  contact. 
By  this  means  the  circular  aperture  is  obliterated  and  the  margins 
united  in  the  median  line.  The  external  wound  may  now  be  closed, 
any  redundant  skin  being  cut  away  ;  it  is  usually  safer  to  insert  a 
drainage-tube  in  the  more  extensive  cases. 

Most  surgeons  have  discovered  by  experience  that  such  a  pro- 
cedure is  insufficient  in  any  but  the  slighter  cases,  and  that  a  much 
more  radical  operation  is  required  when  the  hernia  is  large  and  irre- 
ducible, and  the  patient  at  all  inclined  to  corpulence,  (i)  The  early, 
steps  of  the  operation  are  identical,  but  it  will  be  found  advantageous 
to  place  the  cutaneous  incision  to  one  side  of  the  tumour  rather  than 
over  its  centre.  The  freeing  of  the  omentum  may  be  a  matter  of 
great  difficulty,  as  it  is  often  adherent  to  the  margins  of  the  opening. 
(2)  It  will  then  be  found  that  the  anterior  layer  of  the  sheath  of  the 
rectus  is  prolonged  over,  and  soon  lost  on  the  sac.  An  incision  is 
made  all  round  the  neck  of  the  sac  through  this  aponeurotic  covering 
to  reach  down  to  the  subperitoneal  tissue  ;  stitches  are  now  intro- 
duced across  the  opening  through  the  peritoneum  and  this  detached 
ring  of  aponeurotic  tissue  in  order  to  effect  its  closure  (Fig.  490)  ;  all 
redundant  sac  is  clipped  away  with  scissors,  bleeding-points  being 
secured.  (3)  The  recti  muscles  are  now  laid  bare  on  either  side,  and 
their  posterior  surfaces  and  edges  loosened  so  that  they,  together  with 
the  anterior  layer  of  their  sheaths,  can  be  brought  into  apposition 
over  the  closed  neck  of  the  sac,  which  is  thereby  buried.  To  do  this 
effectively  the  incisions  may  have  to  be  prolonged  up  and  down  the 
abdominal  wall  for  some  distance,  since  the  recti  are  usually  displaced 
outwards  some  way  above  and  below  the  opening.  Silkworm  gut  may 
be  advisably  used  to  bring  the  margins  together.  Redundant  skin  is 
now  cut  away  with  a  free  hand,  so  that  the  abdominal  integument  may 
not  be  unduly  lax,  but  shall  just  cover  the  muscles  comfortably.  In 
stout  patients  this  may  involve  the  removal  of  considerable  masses  of  fat. 

An  operation  of  this  type  is  a  severe  one,  and  not  to  be  lightly 


HERNIA  nil 

entered  upon ;  but  if  it  is  carefully  conducted,  the  results  in  many 
cases  are  most  successful.  Of  course  it  is  very  desirable  that  the 
patient  should  not  put  any  strain  on  the  abdominal  wall  for  some 
time ;  she  should  rest  in  bed  for  six  weeks  after  the  operation. 

A  Ventral  Hernia  is  the  term  used  in  describing  any  protrusion 
occurring  at  some  spot  in  the  anterior  abdominal  wall  other  than 
those  already  mentioned.     Several  forms  may  be  met  with : 

I.  It  consists  not  uncommonly  of  a  protrusion  of  subserous  fatty 
tissue  through  a  congenital  or  acquired  opening  in  the  linea  alba,  lineae 
semilunares,  or  lineae  transversae,  especially  at  the  junctions  of  the 


Fig.  490. — Diagrammatic  Representation  of  the  Radical  Cure  of  an  Um- 
bilical Hernia  where  the  Recti  Muscles  are  considerably  displaced. 

The  short  cross-lines  represent  the  sutures  which  close  the  opening  in  the  peri- 
toneum ;  the  long  ones,  the  sutures  needed  for  apposing  the  edges  of  the  recti 
muscles  and  the  anterior  walls  of  their  sheaths. 


last  with  the  former.  They  are  more  common  above  than  below  the 
umbilicus,  and  if,  as  not  unfrequently  happens,  the  fatty  tissue  pro- 
liferates, a  localized  tumour  resembling  a  lipoma  is  produced,  which 
goes  by  the  name  of  a  '  fatty  hernia  of  the  linea  alba.'  A  portion  of 
peritoneum  is  drawn  through  the  opening  into  the  centre  of  these 
masses  when  they  have  persisted  for  some  little  time,  and  a  true 
hernia  is  thus  induced.  A  similar  condition  is  met  with  in  the  inguinal 
and  crural  regions,  and  probably  most  of  the  cases  described  as 
Hpomata  in  these  parts  are  of  this  nature.     Considerable  pain  and 


III2  A  MANUAL  OF  SURGERY 

abdominal  disturbance  (vomiting,  colic,  etc.)  accompany  almost  every 
movement  of  the  body,  being  caused  partly  by  the  traction  of  the 
peritoneum,  partly  by  the  constriction  of  the  neck  of  the  sac  against 
the  sharp  edges  of  the  small  opening.  Treatment  consists  in  the 
removal  of  the  projecting  mass,  care  being  taken  not  to  include  auy 
viscera  in  the  suture  with  which  the  base  is  surrounded.  The  stump  is 
pushed  back  into  the  abdomen,  and  the  opening  closed  by  deep  sutures. 

2.  After  operations  involving  the  division  of  the  abdominal  parietes, 
ventral  hernia  may  be  caused  by  the  yielding  of  the  cicatrix,  especially 
if  the  wound  suppurates,  and  the  deep  stitches  come  away  or  are 
removed,  or  if  the  opening  is  left  patent  for  the  purpose  of  draining 
an  intra-abdominal  abscess.  Treatment  of  such  cases  consists  in 
dividing  the  skin  and  subjacent  fibrous  tissues,  defining  and  refreshing 
the  edges  of  the  parietal  wound,  and  drawing  them  together  with 
buried  sutures.  The  peritoneum  need  not  always  be  opened  in  such 
a  procedure,  but  it  is  sometimes  wiser  to  do  so.  Especially  is  this 
the  case  when  a  ventral  hernia  forms  after  an  operation  for  suppura- 
tive appendicitis;  the  appendix  is  sometimes  left  at  the  primary 
operation,  and  the  surgeon  may  rightly  take  the  opportunity  of 
removing  it  during  the  operation  required  for  the  cure  of  the  hernia. 

It  is  astonishing  to  note  what  extensive  gaps  in  the  abdominal  wall 
can  be  effectively  cured  by  simple  suturing,  if  sufficient  care  is  taken 
to  loosen  the  parts  from  adhesions.  Sometimes,  however,  the  defect 
is  too  extensive  for  treatment  in  this  manner,  and  then  the  surgeon 
may  advisably  utilize  a  silver  filigree,  which  is  implanted  across  the 
opening  on  a  level  with  the  subperitoneal  tissue.  Of  course  it  is 
effectively  sterilized  before  use,  and  forms  a  permanent  barrier  against 
further  hernial  protrusions.* 

3.  In  women  who  have  borne  children  the  hnea  alba  often  stretches 
and  yields,  allowing  considerable  separation  of  the  recti  muscles  for 
almost  their  whole  length.  If  placed  in  the  recumbent  posture,  and 
told  to  raise  their  head  and  shoulders  from  the  bed  without  using 
their  elbows  for  support,  the  linea  protrudes  as  a  longitudinal  ridge  of 
considerable  breadth.  Much  discomfort  and  dyspepsia  arises  from 
this  cause,  owing  to  the  inefficient  support  given  to  the  intestines.  A 
firm  abdominal  belt  may  be  used  as  a  palliative  measure,  but  opera- 
tion is  very  desirable.  The  thinned  linea  alba  is  split  down  the 
middle  from  top  to  bottom  if  need  be  ;  on  one  side — say,  the  right — 
it,  together  with  the  neighbouring  rectus  muscle,  is  separated  from 
the  subcutaneous  tissues  and  tucked  under  the  rectus  on  the  left  side, 
its  free  end  being  secured  by  a  row  of  mattress  sutures  passing 
through  its  edge  and  the  left  linea  semilunaris,  and  being  tied  super- 
ficiaily  The  left  free  edge  is  subsequently  secured  to  the  right  linea 
semilunaris  by  a  row  of  stitches.  Redundant  fat  and  skin  is 
removed,  and  the  wound  closed  by  sutures.  In  this  way  the 
abdominal  wall  is  drawn  together  like  a  double-breasted  coat,  and 
excellent  results  follow. 

A  Lumbar  Hernia  is  a  condition  of  considerable  rarity,  in  which  the 
*  ISIacGavin,  Practitioner,  August,  1906. 


HERNIA  1 1 13 

abdominal  viscera  protrude  by  the  side  of  the  erector  spinae,  coming 
to  the  surface  between  the  latissimus  dorsi  and  the  external  oblique, 
in  the  space  known  as  Petit's  triangle.  It  is  perhaps  seen  most 
frequently  after  operations  upon  the  kidney  where  suppuration  has 
occurred,  and  the  deep  stitches  have  had  to  be  removed.  The  ordinary 
signs  of  a  hernia  are  present,  and  with  a  little  care  the  condition  is 
readily  distinguished  from  a  lumbar  abscess.  Tyeatment  may  be  con- 
ducted along  the  same  lines  as  for  a  ventral  hernia. 

A  Diaphragmatic  Hernia  is  rarely  recognised  ante-mortem.  A  few 
cases  of  strangulation  have,  however,  been  diagnosed.  It  is  usually 
congenital  in  origin,  arising  from  imperfect  development  of  one  or 
both  halves  of  the  diaphragm,  and  is  most  common  on  the  left  side. 
It  may,  however,  result  from  traumatic  lesions,  such  as  stabs, 
involving  the  diaphragm.  The  transverse  colon  or  stomach  generally 
protrudes  into  the  thorax,  and  there  is  usually  no  peritoneal  sac. 
Treatment  is  impracticable  in  the  majority  of  instances,  although  one 
or  two  cases  of  traumatic  hernia  have  been  successfully  operated  on 
through  the  chest  wall  and  pleural  cavity,  thus  permitting  the  closure 
of  the  hole  in  the  diaphragm. 

Obturator  Hernia  consists  in  a  protrusion  of  intestine  through  the 
upper  part  of  the  thyroid  foramen,  and  has  usually  been  observed  in 
elderly  females.  It  is  not  often  recognised  in  the  living,  except  when 
strangulated,  and  even  then  it  is  more  likely  to  be  discovered  from 
the  abdominal  aspect  during  a  laparotomy  for  acute  obstruction  than 
diagnosed  apart  from  operation.  In  a  few  cases,  however,  it  has 
been  noted  that,  in  addition  to  the  general  signs  of  strangulation, 
there  was  a  sense  of  deep  resistance  and  of  fulness  close  to  the  origin 
of  the  adductor  muscles  ;  whilst  pain  was  referred  down  the  obturator 
nerve  to  the  inner  side  of  the  knee.  Rectal  or  vaginal  examination 
may  throw  some  light  on  the  nature  of  the  case.  Treatment  has 
generally  been  confined  to  cases  of  strangulation,  and  in  these  an 
incision  is  made  over  the  inner  aspect  of  Scarpa's  triangle,  and  the 
pectineus  divided  or  displaced.  The  sac  when  found  should  be 
opened,  and  strangulation  relieved  by  cutting  upwards,  the  obturator 
vessels  being  usually  situated  below  the  neck  of  the  sac.  If  found 
during  a  laparotomy  for  obstruction,  the  same  precautions  must  be 
taken  as  for  a  Richter  hernia  in  the  femoral  region  when  discovered 
in  the  same  way  (p.  1126). 

Other  forms  of  hernia — e.g.,  pudic,  pudendal,  vaginal,  sciatic,  etc. — 
have  been  described,  but  are  so  uncommon  that  they  need  no  special 
mention. 

Abnormal  Conditions  of  Herniae. 

Irreducibility  of  a  Hernia  is  generally  due  to  the  presence  01 
adhesions,  either  between  the  contents  and  the  sac,  or  between  the 
contents  themselves,  which  are  thus  united  into  a  mass  too  large  to 
pass  through  the  aperture  of  communication  with  the  abdomen.  This 
is  often  associated  with  contraction  of  the  neck  of  the  sac,  which 
arises  either  from  the  pressure  of  an  ill-fitting  truss  or  the  constant 


III4  A  MANUAL  OF  SURGERY 

drag  of  the  contents.  Overgrowth  or  an  excessive  deposit  of  fat  in 
the  omentum  may  result  in  irreducibility,  whilst  cysts  may  occa- 
sionally form,  as  already  described. 

The  local  signs  of  this  condition  are  very  evident,  whilst  dyspepsia, 
colicky  pains,  and  a  sense  of  dragging  are  among  the  most  prominent 
systems. 

Treatment. — i.  It  may  sometimes  be  remedied  by  forcible  taxis 
applied  at  intervals,  between  which  the  patient  is  kept  in  bed,  and  an 
icebag  applied  so  as  to  contract  the  parts  ;  moreover,  the  patient  if 
fat,  should  be  carefully  dieted.  It  is  most  important  not  to  operate 
on  large  hernias  of  this  nature  until  some  such  preliminary  treatment 
has  been  undertaken  ;  the  sudden  reduction  of  a  large  amount  of 
intestine  into  the  abdominal  cavity  has  been  responsible  for  several 
deaths  from  interference  with  the  heart's  action.  2.  Another  plan 
consists  in  the  use  of  what  is  known  as  the  hinged-cup  truss  ;  the 
hernia  is  supported  in  a  suitable  leather  bag  hinged  to  the  lower  part 
of  a  truss,  upward  pressure  being  maintained  by  means  of  an  elastic 
spring.  By  the  use  of  one  or  other  of  these  plans  reduction  may 
after  a  time  be  accomplished  ;  but  we  are  not  in  favour  of  any  such 
proceedings,  except  in  very  large  herniae.  3.  In  healthy  individuals, 
and  if  the  rupture  is  not  too  large,  operation  is  preferable  and  much 
more  satisfactory,  omentum  being  removed  and  adhesions  divided,  as 
already  described.  4.  In  a  few  very  aggravated  cases,  it  is  only 
possible  to  support  the  hernia  by  an  elastic  bag. 

Inflamed  Hernia  is  one  characterized  by  the  existence  of  a  localized 
peritonitis  involving  the  sac,  and  perhaps  also  the  contents.  It 
usually  arises  from  injury,  such  as  ill-directed  taxis,  or  from  injudicious 
truss  pressure.  The  symptoms  are  those  of  a  local  inflammation, 
the  part  becoming  hot,  painful,  tender,  and  swollen,  and  perhaps  the 
skin  over  it  congested ;  this  is  associated  with  general  fever,  malaise, 
nausea,  and  vomiting,  whilst  constipation  is  generally  present.  A  con- 
dition is  thus  induced  somewhat  resembling  strangulation  ;  but  it  is 
distinguished  from  the  latter  by  the  presence  of  fever  instead  of 
shock,  the  absence  of  tension  in  the  sac,  and  the  character  of  the 
vomiting,  which  is  not  faecal.  The  hernia  is  irreducible,  at  any  rate 
for  a  time,  probably  more  on  account  of  the  pain,  which  prevents 
taxis,  than  from  any  mechanical  reason,  except  in  old-standing  cases 
where  previously  formed  adhesions  exist.  Lymph  is  deposited  on 
the  serous  surfaces,  and  this  usually  leads  to  the  formation  of  adhe- 
sions. Occasionally,  where  omentum  is  alone  present,  an  attack  of 
this  type  may  result  in  a  natural  cure,  especially  in  the  umbilical 
variety. 

The  Treatment  consists  in  putting  the  patient  to  bed  and  restricting 
his  diet  to  fluids,  whilst  fomentations  are  applied  to  the  part.  A 
little  opium  may  also  be  administered  to  allay  the  pain,  and  possibly 
the  lower  bowel  emptied  by  an  enema.  Should  the  condition  persist 
in  spite  of  treatment,  it  will  be  wise  to  operate,  as  otherwise  strangu- 
lation might  follow. 

Obstructed  Hernia  is  a  condition  in  which  the  onward  passage  of 


HERNIA  1 1  IS 

faeces  through  the  gut  contained  in  a  hernial  sac  is  prevented.  It  is 
moat  frequently  seen  in  the  umbilical  variety,  and,  of  course,  only  in- 
volves the  large  gut.  It  is  due  to  an  accumulation  of  undigested  food 
or  faeces,  the  condition  being  aggravated  by  the  presence  of  flatus 
derived  from  the  decomposition  of  the  contents  of  the  bowel.  Nausea 
and  vomiting  are  induced,  the  latter,  however,  rarely  becoming  faecu- 
lent,  whilst  constipation  is  usually  present,  although  the  lower  bowel 
may  empty  itself  and  flatus  may  pass.  Locally,  the  tumour  becomes 
irreducible  and  distended,  but  not  tense  as  in  strangulation,  and  a 
doughy  mass,  which  can  be  moulded  and  indented  by  the  fingers, 
is  felt  within  the  sac.  There  is  no  tenderness,  but  the  patient  com- 
plains of  a  good  deal  of  intermittent  colicky  pain.  If  unrelieved,  a 
subacute  form  of  inflammation  may  supervene,  and  this  may  pass  on 
to  strangulation,  and  even  death. 

Treatment  consists  in  the  use  of  copious  enemata,  and  the  applica- 
tion of  an  icebag  to  the  hernia,  followed  by  carefully-applied  taxis, 
so  as  to  assist  the  onward  passage  of  the  impacted  contents.  As 
soon  as  the  obstruction  is  overcome,  a  brisk  purge  should  be 
administered. 

Strangulated  Hernia. 

A  hernia  is  said  to  be  strangulated  when  the  contents  are  con- 
stricted in  such  a  way  as  to  obstruct  and  ultimately  to  arrest  the 
flow  of  blood  in  the  vessels  contained  therein.  Interference  with 
the  passage  of  faeces  is  not  an  essential  in  this  condition,  since  omen- 
tum alone  may  be  involved,  or  the  intestine,  if  present,  may  only  have 
a  portion  of  its  lumen  constricted,  as  in  the  form  known  as  Richter's 
hernia  (Fig.  491),  whilst  in  Littrd's  hernia  a  diverticulum  is  similarly 
affected. 

Two  chief  varieties  of  strangulation  are  described :  those  occur- 
ring within  the  abdomen,  which  are  dealt  with  more  fully  in 
Chapter  XXXVI.,  and  those  which  are  extra-abdominal ;  it  is  only 
the  latter  to  which  we  shall  now  direct  attention. 

External  Strangulated  Hernia  arises  in  one  of  two  ways :  (a)  The 
hernia  becomes  strangled  immediately  after  its  formation ;  this 
is  most  frequently  seen  in  children  or  adolescents,  the  hernia  being 
then  of  the  congenital  type,  and  having  a  long  narrow  sac.  (b)  In 
adults  it  more  frequently  results  from  extrusion  of  an  additional 
amount  of  the  abdominal  contents  into  the  sac,  as  the  outcome  of  some 
sudden  violent  effort.  This  condition  usually  obtains  in  old-standing 
herniae,  the  neck  of  the  sac  having  previously  become  thickened  and 
contracted,  either  by  the  pressure  of  a  truss  or  the  irritation  of  the 
protruded  viscera.  The  former  of  these  two  conditions  is  generally 
acute  in  character,  the  latter  more  often  subacute. 

The  site  of  the  constriction  is  either  at  the  neck  of  the  sac,  or  in 
the  dense  tissues  external  to  it  (Plate  VII.),  but  occasionally  it  exists 
elsewhere.  Most  frequently  the  active  agent  in  the  strangulation  is 
the  thickened  sac  wall  itself ;  but  in  femoral  and  umbilical  herniae 
structures  outside  the  sac,  such  as  Gimbernat's  ligament  or  the  linea 
alba,  may  be  the  actual  cause  of  the  constriction,  whilst  it  may  also 


Iii6  A  MANUAL  OF  SURGERY 

be  produced  by  the  passage  of  a  coil  of  intestine  under  a  tight  adhe- 
sion or  through  a  sht  or  aperture  in  the  omentum  contained  in  the 
sac.  In  those  herniae  which  become  strangulated  immediately  after 
their  protrusion,  the  constricting  cause  is  invariably  the  resistance  of 
the  tissues  surrounding  the  opening  in  the  abdominal  parietes. 

Pathological  Phenomena. — The  effects  of  strangulation  vary  some- 
what with  the  tightness  of  the  constriction.  The  circulation  is  seldom 
arrested  entirely  at  the  onset  of  the  symptoms;  but  the  pressure 
affects  first,  and,  more  especially,  the  veins,  and  later,  by  the  con- 
gestion and  exudation  thus  produced,  the  flow  in  the  arteries  is 
brought  to  a  standstill.  Hence  the  constricted  tissues  are  congested 
to  begin  with,  and  then,  partly  as  a  result  of  the  deficient  supply  of 
arterial  blood,  mainly  in  consequence  of  bacterial  invasion,  gangrene 
ensues,  with  or  without  an  intervening  period  of  inflammation. 

When  a  portion  of  intestine  is  strangulated,  it  first  becomes  of  a 
dusky  red,  chocolate,  or  claret  colour,  owing  to  vascular  congestion ; 
it  is  thickened  and  stiff  from  exudation  into  its  walls,  and  distended 
by  the  formation  of  gas  within  its  lumen,  owing  to  the  arrest  of 
peristalsis  and  the  putrefaction  of  its  contents.  The  surface  for  a 
time  remains  smooth  and  shiny,  but  as  the  exudation  into  the  sac 
increases,  the  endothelium  is  shed.  Occasionally  some  of  the  super- 
ficial capillaries  rupture,  giving  rise  to  ecchymoses,  whilst  in  rarer 
instances,  and  possibly  as  the  result  of  injudicious  taxis,  the  con- 
gested vessels  completely  empty  themselves  into  the  sac,  which  is 
thus  filled  with  clotted  blood,  the  intestine  in  consequence  becoming 
lax  and  yellowish-gray  in  colour.  When  the  strangulation  is  relieved 
in  this  early  stage,  the  bowel  soon  regains  its  former  healthy  appear- 
ance. If  inflammation  occurs,  the  surface  becomes  rough  from  the 
deposit  of  lymph,  and  entirely  loses  its  shiny  and  polished  aspect. 
Gangrene  results  partly  from  the  prolonged  stagnation  of  blood,  and 
partly  from  the  invasion  of  the  intestinal  wall  by  the  B.  coli  and  other 
anaerobic  inhabitants  of  the  gut,  which,  as  soon  as  the  vitality  of  the 
intestinal  wall  is  sufficiently  impaired,  migrate  through  it,  and  by 
their  development  produce  toxic  bodies  which  still  further  assist  the 
gangrenous  process.  As  soon  as  it  is  established,  the  intestine  turns 
an  ashy  gray  or  black  colour,  usually  at  one  or  more  spots  which 
gradually  spread,  lose  all  lustre  and  polish,  and  after  a  time  become 
soft,  lacerable,  and  offensive.  Gangrene*  is  much  more  common  in 
the  femoral  and  umbilical  forms  of  hernia  than  in  the  inguinal ;  it  is 
generally  developed  in  two  or  three  days,  but  occasionally  may  super- 
vene in  less  than  twenty-four  hours  from  the  onset  of  the  strangulation. 
It  is  more  often  seen  in  small  herniae  of  recent  origin  than  in  large 
old-standing  ones.  At  the  point  of  strangulation  the  gut  is  completely 
anaemic  and  liable  to  ulceration  or  gangtene,  which  may  subsequently 
result  in  perforation ;  adhesions  may,  however,  form  between  it  and 
the  neck  of  the  sac,  thus  preventing  contamination  of  the  general 
peritoneal  cavity.'    The  intestine  above  the  site  of  strangulation  becomes 

*  For  a  valuable  paper  on  '  Gangrene  in  Strangulated  Hernia,'  see  Corner, 
St,  Thomas's  Hospital  Reports,  vol,  xxix. 


PLATE    IX. 


/. 


^ 


if' 


y- 


strangulated  Hernia. 


\To  face  page  1170. 


HERNIA  1117 

paralyzed,  and  peristalsis  is  entirely  arrested,  even  in  a  Richter's 
hernia.  Faecal  material,  accumulating  and  undergoing  decomposi- 
tion, gives  rise  to  a  catarrhal  enteritis,  and  even  occasionally  to  ster- 
coral ulcers,  which  may  perforate  and  cause  general  peritonitis  ;  this, 
however,  is  not  very  common  in  external  strangulation,  since  the 
small  intestine  is  usually  involved,  and  solid  faeces  are  absent.  In 
more  chronic  cases  gangrene  of  the  gut  may  be  induced  by  the  pres- 
sure of  the  accumulated  contents  and  the  action  of  the  B.  coli.  The 
portion  of  the  bowel  below  the  constriction  may  be  affected  in  a  similar 
manner,  owing  to  the  arrest  of  the  peristalsis,  but  to  a  slighter  degree. 

Omentum,  when  strangled,  is  at  first  congested  and  of  a  dark  red  or 
purplish  colour,  and  later  on  infiltrated  and  matted  together.  If, 
however,  it  has  contracted  adhesions  to  the  sac,  and  no  gut  is  present, 
the  trouble  may  subside,  since  its  vitality  may  be  maintained  through 
the  adhesions,  and  a  natural  cure  of  the  hernia  may  result.  Where 
such  a  condition  is  not  present,  gangrene  supervenes,  and  the  omentum 
then  becomes  ashy  gray  or  brown  in  colour,  and  is  pultaceous  and 
friable.  It  does  not  become  offensive  unless  associated  Avith  intes- 
tine, since  it  does  not  contain  any  intrinsic  source  of  putrefaction. 

The  sac  is  usually  distended  with  fluid,  which  at  the  commence- 
ment is  serous  in  character,  and  perhaps  blood-stained,  whilst  subse- 
quently it  becomes  turbid  and  mixed  with  lymph  ;  finally,  it  is  dark 
brown  or  yellowish-green,  with  a  marked  and  most  objectionable 
odour.  Sometimes  there  is  but  little  or  no  effusion  of  fluid,  a  con- 
dition generally  due  to  complete  strangulation  of  arteries  and  veins 
simultaneously,  and  often  the  precursor  of  early  gangrene.  The 
serous  lining  of  the  sac  is  but  slightly  affected  in  the  early  stages ;  as, 
however,  the  case  progresses  to  inflammation  or  death  of  the  contents, 
it  also  becomes  inflamed,  and  ultimately  gangrenous  from  the  activity 
of  bacteria,  which  by  this  time  have  penetrated  to  the  turbid  serum 
contained  within  it.  The  skin  and  surrounding  tissues  become 
cedematous,  congested,  and  crepitant,  and,  finally,  a  natural  cure  may 
be  determined  by  sloughing  and  the  establishment  of  an  artificial  anus. 

After  the  relief  of  strangulation,  even  if  no  gangrene  has  occurred, 
the  patient  is  not  free  from  risk,  owing  to  changes  which  may  possibly 
follow  the  temporary  arrest  of  the  circulation,  since  the  prolonged 
blood-stasis  in  the  bowel  may  be  followed  by  inflammation,  owing  to 
the  damage  done  to  the  vessel  walls,  or  by  gangrene,  owing  to  the 
diminished  vitality  of  the  bowel  w^all  rendering  it  more  vulnerable  to 
the  attacks  of  the  intestinal  bacteria.    . 

The  Clinical  History  of  a  case  of  strangulation  is  usually  so  char- 
acteristic that  there  can  be  but  little  uncertainty  as  to  the  diagnosis. 
The  general  symptoms  are  similar  to  those  described  at  p.  1130,  as 
occurring  in  all  cases  of  acute  intestinal  obstruction.  The  patient 
during  some  sudden  effort  notices  a  severe  pain,  localized  at  first  to 
one  of  the  hernial  regions,  or  referred  to  the  umbilicus  ;  this  is  accom- 
panied by  the  usual  evidences  of  shock — i.e.,  he  feels  faint,  the  pulse 
becomes  slow  and  weak,  the  temperature  falls,  and  the  surface  is 
covered  by  a  cold,  clammy  sweat.     This  shock  is  often  not  very  pro- 


Iii8  A  MANUAL  OF  SURGERY 

longed,  and  is  associated  with  or  quickly  followed  by  vomiting,  at 
first  gastric,  then  bilious,  and  finally  stercoraceous  or  faecal.  As  this 
continues,  the  pain  increases  in  severity,  and  radiates  over  the  whole 
of  the  abdomen,  which  becomes  tense,  tender,  and  tympanitic. 
Symptoms  of  exhaustion  supervene,  caused  partly  by  the  pain  and 
vomiting,  and  partly  by  the  inability  to  take  food  ;  probably  the 
absorption  of  toxic  material  from  the  intestines  also  assists  in  its  pro- 
duction. Complete  constipation  is  usually  present,  but  the  patient 
may  pass  flatus  or  faeces  from  the  lower  part  of  the  intestine.  The 
onset  of  gangrene  is  generally  accompanied  by  a  sudden  fall  of  tem- 
perature and  a  cessation  of  pain,  whilst  the  pulse  becomes  weak, 
rapid,  and  intermittent,  the  surface  is  covered  by  a  cold  sweat,  the 
countenance  becomes  shrunken  and  drawn  (the  so-called  fades 
Hippocraiica),  hiccough  follows,  and  finally  the  patient  dies,  usually 
as  a  result  of  toxaemia  due  to  the  absorption  of  products  developed 
either  in  the  bowel  wall  or  sac,  or  in  consequence  of  acute  generalized 
peritonitis. 

Locally,  a  tumour  is  found  in  one  of  the  usual  sites  of  a  hernia,  or 
if  already  the  subject  of  this  condition,  the  patient  may  notice  that 
his  rupture  has  suddenly  become  larger.  The  swelling  is  irreducible, 
tense,  extremely  tender  and  painful,  and  without  impulse  on  cough- 
ing. It  is  hard  and  rounded  if  bowel  is  involved,  softer  and  more 
doughy  to  the  touch,  if  omentum.  When  gangrene  ensues,  the 
tension  within  the  sac  is  reduced,  pain  and  tenderness  cease,  whilst 
the  skin  over  the  tumour  becomes  dusky,  inflamed,  and  oedematous ; 
finally,  evidences  of  gangrene  show  themselves  externally,  the  parts 
becoming  dark  in  appearance,  and  soft  and  emphysematous  to  the 
touch.  If  the  patient  survive,  the  necrotic  tissues  separate,  and  an 
artificial  anus  is  produced  either  naturally  or  through  the  intervention 
of  the  surgeon.     Suppuration  within  the  sac  is  uncommon. 

Occasionally,  however,  cases  are  met  with  in  which  the  above- 
described  signs  are  considerably  modified,  and  gangrene  of  the  gut 
may  occur  without  the  exaggerated  phenomena  of  a  serious  toxaemic 
type  indicated  above.  In  one  case  the  patient  complained  of  no  incoi- 
venience  beyond  slight  pain,  although  incipient  gangrene  was  present; 
he  walked  into  hospital  saying  that  he  never  felt  better  in  his  life. 

The  early  symptoms  arising  from  strangulation  of  a  portion  of  the 
lumen  of  the  intestine  (Richters  hernia,  Fig.  491)  are  sometimes  less 
marked  than  when  a  complete  loop  is  constricted,  but  the  later 
phenomena  are  always  very  severe.  It  is  usually  of  the  femoral 
variety,  and  the  ileum  is  most  frequently  involved.  If  less  than  half 
the  circumference  of  the  bowel  is  constricted,  the  obstruction  is  not 
always  complete  at  first,  flatus  and  faeces  being  sometimes  passed ; 
but  where  more  than  half  the  circumference  of  the  bowel  is  engaged, 
complete  obstruction  from  kinking  or  paralysis  of  the  gut  ensues. 
The  vomiting  is  less  marked  than  in  other  cases,  and  is- not  so 
commonly  f  aeculent.  The  tumour  produced  is  small  in  size,  but  tense 
and  tender.  It  is  quite  possible,  however,  for  it  to  be  overlooked, 
even  when  the  groin  is  examined,  and  the  diagnosis  is  then  likely  to 


HERNIA 


iiig 


be  made  either  on  the  operating  or  post-mortem  table.  The  prog- 
nosis in  these  cases  is  always  grave,  partly  from  the  difficulty  ex- 
perienced in  diagnosis,  partly  from  the  tightness  of  the  constriction ; 
death  usually  results  from  perforative  peritonitis,  which  is  occasionally 
due  to  wounding  of  the  gut  by  the  hernia  knife.  The  mortality  in 
these  cases  is  calculated  at  62  per  cent.,  which  is  in  marked  contrast 
with  that  of  about  35  per  cent.,  which  is  usually  said  to  be  charac- 
teristic of  strangulated  hernia.  The  mortality  for  all  cases  of 
strangulated  hernia  admitted  to  King's  College  Hospital  during  the 
years  1892  to  1897  only  amounted  to  i6-6  per  cent. 

The  occurrence  of  strangulation  in.  a  pure  epiplocele  is  very  rare ;  the 
symptoms  are  vague  in  character,  and  the  diagnosis  is  often  difficult. 
The  presence  of  a  soft,  doughy,  tender  swelling  in  any  of  the  hernial 
regions,  combined  with  pain,  bilious  vomiting,  and  possibly  constipa- 
tion, is  always  a  significant  feature.  So 
long  as  no  kinking  of  the  bowel  is  caused 
thereby,  the  symptoms  may  remain  in- 
definite, the  vomiting  never  becoming 
faecal ;  but  as  time  goes  on,  arrest  of 
peristalsis  may  lead  to  true  obstruction, 
or  even  general  peritonitis.  As  already 
mentioned,  strangulated  omentum  does 
not  per  se  become  offensive  ;  but  occa- 
sionally a  neighbouring  coil  of  intestine 
may  be  dragged  upon,  and  its  circulation 
disturbed  sufficiently  to  enable  the  B.  coli 
to  escape,  and  then  it  may  find  its  way 
into  the  sac,  and  an  infective  inflamma- 
tion may  result. 

The  Treatment  of  a  strangulated 
hernia  consists  in  reducing  the  contents 
by  taxis,  or  by  operation. 

Taxis  is  the  term  employed  for  the 
manipulation  by  means  of  which  a 
hernia  is  reduced.  In  cases  of  strangulation,  it  must  be  used  with 
gentleness  and  great  care,  since  the  involved  portion  of  intestine  is 
congested  and  easily  torn.  The  patient  is  laid  on  a  couch  with  the 
head  supported  and  the  thighs  slightly  flexed,  so  as  to  relax  the 
abdominal  muscles.  The  fundus  of  the  tumour  is  then  grasped  with 
one  hand,  and  steady  pressure  employed,  having  for  its  object  the 
emptying  of  the  congested  bloodvessels,  and  consequently  a  diminu- 
tion in  the  size  of  the  hernia;  the  fingers  of  the  other  hand  manipulate 
the  neck  of  the  sac,  in  order  that  the  part  which  has  most  recently 
been  protruded  may  be  first  returned.  The  direction  in  which  taxis 
is  made  varies  in  different  cases.  In  inguinal  hernia,  it  should  be 
directed  upwards,  outwards,  and  backwards.  In  a  femoral  hernia 
which  has  extended  beyond  the  saphenous  opening,  taxis  is  first 
employed  downwards  and  inwards  in  order  to  make  the  gut  re-enter 
the  crural  canal,  and  then  finally  backwards  and  upwards,  the  margins 


Fig.  491. — Richter's  Hernia. 
(Diagrammatic.) 


itad  A  MANUAL  OF  SURGERY 

of  the  saphenous  opening  being  relaxed  by  flexing  and  slightly  in- 
verting the  thigh.  In  umbilical  hernia,  the  pressure  is  mainly  directed 
backwards. 

It  must  be  admitted  that  in  the  past  taxis  has  often  been  used 
injudiciously  and  in  cases  where  it  could  not  be  expected  to  do  any 
good  ;  the  bowel  has  sometimes  been  ruptured  or  its  wall  bruised, 
the  mesentery  torn,  and  other  serious  results  have  followed.  At  the 
present  day  operative  treatment  for  hernia  is  eminently  successful, 
and  open  exploration  of  the  sac  enables  one  to  judge  of  the  condition 
of  the  gut  and  prevents  the  likelihood  of  returning  to  the  abdomen 
an  infected  and  even  gangrenous  focus.  Hence  it  may  be  stated  that 
taxis  is  permissible  when  the  hernia  is  of  large  size,  particularly  if 
inguinal,  when  the  symptoms  have  a  mild  onset  and  do  not  become 
severe,  and  especially  if  taxis  has  been  successful  on  former  occasions. 
It  may  also  be  employed  in  old  people  with  diabetes  or  albuminuria, 
or  in  insanitary  surroundings.  Taxis  is  objectionable,  and  if  employed 
at  all  should  be  used  very  cautiously,  when  the  hernia  is  small  and 
tense,  and  particularly  if  femoral ;  when  the  onset  is  acute  and 
sudden  ;  when  the  symptoms  are  well  marked,  and  especially  if  they 
become  so  in  the  early  stages  of  the  case  ;  if  strangulation  follows 
on  the  first  development  of  the  hernia ;  and  of  course  if  the  case 
has  lasted  for  some  time  and  faecal  vomiting  is  present.  A  final 
attempt  may  always  be  made  before  operation  when  the  patient  is 
anaesthetized. 

In  some  of  the  slighter  and  earlier  conditions  of  strangulation,  and 
especially  if  the  patient  has  had  similar  attacks  before  which  have 
been  relieved  without  operation,  reposition  may  be  assisted  by 
applying  fomentations  for  half  an  hour,  followed  by  the  use  of  an 
icebag,  reduction  sometimes  taking  place  spontaneously  or  being 
brought  about  by  taxis.  The  heat  relaxes  the  tissues  around  the 
neck  of  the  sac,  and  the  effect  of  the  cold  is  not  only  to  constrict 
these  tissues,  but  also  to  induce  contraction  of  the  intestinal  blood- 
vessels and  muscles. 

Persistence  of  Symptoms  after  Apparently  Successful  Taxis. — It 
happens  occasionally  that  although  the  surgeon  may  have  apparently 
reduced  the  hernia  satisfactorily,  the  symptoms  of  strangulation— 
viz.,  pain,  vomiting,  and  constipation — persist.  Such  may  be  due  to 
a  variety  of  conditions,  and  considerable  judgment  is  needed  in  coming 
to  a  correct  decision  in  any  particular  case,  (i.)  Infective  gangrene 
may  involve  the  released  coil  of  gut  and  spread  to  the  portion  above 
it,  causing  death  from  peritonitis  and  toxaemia,  (ii.)  Ulceration  and 
perforation  may  occur  along  the  'constriction  groove.'  (iii.)  The 
rupture  reduced  may  not  be  the  one  which  has  given  rise  to  the 
symptoms,  an  internal  hernia,  or  one  in  some  other  region,  co-exist- 
ing, (iv.)  The  strangulation  may  have  been  caused,  not  by  the  neck 
of  the  sac,  but  by  a  slit  in  the  omentum  contained  in  the  sac.  Reduc- 
tion in  such  a  case  would  not  relieve  the  symptoms,  the  whole  mass 
being  returned  into  the  abdomen,  (v.)  A  volvulus  may  have  been 
present,    either  wholly  or   partly  in  the  sac,  and  may  have    been 


HERNIA  1 121 

reduced  untwisted.  Occasionally  a  volvulus  is  produced  by  the 
manipulations  of  reduction,  especially  when  the  mesentery  has  been 
lengthened  in  long-standing  hernia  and  the  bowel  paralyzed  by  the 
strangulation,  (vi.)  The  hernial  sac  may  have  a  diverticulum  or 
pocket  communicating  with  it  at  its  upper  end  (intraparietal  inter- 
stitial hernia),  or  it  may  be  shaped  like  an  hour-glass.  It  is  possible 
to  reduce  the  intestine  from  the  lower  portion  of  this  so-called 
hernia  en  bissac  into  the  upper  pocket,  and  then  of  course  the  symp- 
toms persist,  (vii.)  Reduction  en  bloc  or  en  masse  ought  never  to 
be  seen,  as  it  can  only  occur  when  considerable,  and  therefore  an 
unjustifiable  amount  of  force  has  been  employed.  The  sac  and  its 
contents  are  together  reduced  from  their  superficial  position  to  the 
deep  aspect  of  the  abdominal  parietes,  the  hernia  then  lying  between 
the  muscular  planes  or  in  the  subserous  areolar  tissue,  and  the  con- 
striction remaining.  The  hernia  gradually  disappears,  but  without 
the  characteristic  gurgle.  In  such  a  case  the  sac  sometimes  gives 
way,  the  intestine  and  the  portion  of  the  neck  which  compresses,  it 
being  pushed  upwards.  When  occurring  in  the  inguinal  region  it  is 
recognised  by  the  persistence  of  symptoms,  and  by  the  fact  that  a 
finger  inserted  into  the  canal,  which  is  unduly  patent,  detects  a  tense 
rounded  swelling  at  its  upper  end.  It  also  happens,  but  less  commonly, 
in  the  femoral  region,  and  in  either  variety  the  hernia  may  slip  down 
again  a  short  time  after  its  apparent  reduction. 

In  any  case  where,  after  an  apparently  successful  taxis,  the 
symptoms  of  strangulation  are  still  present,  a  most  careful  investiga- 
tion is  needed  in  order  to  ascertain,  if  possible,  the  cause.  Thus,  the 
character  and  frequency  of  the  vomiting  must  be  considered,  since 
it  may  be  due  to  the  anaesthetic,  but  then  loses  its  faecal  character,  and 
is  less  severe.  If  the  vomiting  is  associated  with  a  certain  amount  of 
local  pain,  and  possibly  with  some  blood-stained  diarrhoea  or  the 
passage  of  mucus,  the  probability  is  that  the  coil  of  gut  has  been  in 
reality  reduced,  but  has  subsequently  become  inflamed.  Apart  from 
such  indications  the  affected  region  must  be  thoroughly  explored  with 
the  finger,  so  as  to  ascertain  whether  any  tumour  can  be  felt  at  the 
upper  or  deeper  end,  as  occurs  in  reduction  en  masse.  Should  this 
throw  no  light  upon  the  case,  the  other  hernial  apertures  must  each 
in  turn  be  examined,  and  finally  an  incision  is  made  over  the  sup- 
posed site  of  strangulation,  and  an  exhaustive  search  made  for  the 
sac.  If  no  help  is  thus  obtained,  the  abdomen  must  be  opened,  and 
some  internal  complication  sought  for.  In  the  inguinal  region,  all  that 
is  needed  is  to  prolong  the  first  incision  upwards  and  outwards ;  in 
a  femoral  hernia,  it  is  perhaps  wiser  to  make  a  separate  laparotomy 
wound  in  the  middle  line,  so  as  to  avoid  the  division  of  Poupart  s 
ligament ;  whilst  in  the  umbilical  variety,  the  requirements  of  the 
case  are  met  by  simply  increasing  the  size  of  the  communication 
between  the  sac  and  the  abdominal  cavity. 

The  Operative  Treatment  of  strangulated  hernia  should  always  be 
undertaken  at  as  early  a  date  as  possible,  when  once  it  is  certain  that 
the  bowel  is  constricted.     Nothing  can  be  gained  by  v/aiting,  whilst 

71 


1122  A  MANUAL  OF  SURGERY 

even  the  delay  of  an  hour  may  make  it  doubtful  whether  the  result 
will  be  successful  or  not.  There  is  always  sufficient  time  to  permit 
of  efficient  purification  of  the  parts,  and  it  may  be  desirable  to 
empty  the  lower  bowel  by  an  enema,  or  if  there  is  much  vomiting 
to  wash  out  the  stomach.  The  administration  of  an  anaesthetic  needs 
care,  and  in  the  worst  cases  local  anaesthesia  or  spinal  analgesia 
must  be  depended  on.  A  suitable  incision  is  then  made  down 
to  the  sac,  which  should  be  recognised  by  its  tense  and  rounded  out- 
line. It  is  isolated  as  far  as  possible  from  surrounding  structures,  and 
then  carefully  opened.  The  amount  of  fluid  varies  much,  and  is 
sometimes  very  small,  so  that  the  possibility  of  injuring  the  bowel 
must  be  kept  in  mind.  Having  given  exit  to  the  fluid  from  the  sac 
and  noted  its  characte-rs,  the  surgeon  carefully  examines  the  bowel  or 
omentum.  The  cause  of  strangulation  is  then  looked  for  and  divided 
by  a  special  hernia  knife,  which  practically  consists  of  a  curved 
blunt-ended  bistoury,  the  cutting  blade  being  limited  to  an  extent  of 
about  f  inch  from  the  blunt  end.  If  such  is  not  to  hand,  an  ordinary 
blunt-ended  curved  bistoury  will  suffice.  The  index-finger  is  em- 
ployed to  repress  and  guard  the  intestine,  and  acts  better  than  a 
director,  since  intestine  is  likely  to  curl  up  on  either  side  of  the  instru- 
ment, and  may  thus  be  injured.  The  knife  is  then  slipped  on  the  flat 
under  the  constriction,  and  turned  so  as  to  divide  it ;  it  is  better  to 
nick  it  slightly  in  two  or  three  places  than  to  incise  it  by  one  deep  cut. 

The  gut  is  carefully  drawn  down  into  the  wound,  and  its  condition 
at  the  site  of  strangulation  examined ;  it  is  sometimes  a  matter  of 
difficulty  to  decide  whether  it  should  be  returned  or  not.  Of  course 
when  gangrene  is  obviously  present  further  treatment  is  necessary ; 
but  in  many  cases  the  condition  of  the  bowel  is  doubtful.  It  is  then 
well  to  delay  action  for  a  few  minutes,  and  perhaps  douche  the  parts 
with  warm  salt  solution.  A  gradual  change  of  colour  from  a  deep 
claret  to  a  more  definite  red  indicates  that  the  circulation  is  still 
active  ;  occasionally,  however,  it  will  be  found  that  no  change  occurs 
in  spite  of  division  of  the  constriction,  or  that  the  admittance  of  the 
circulation  brings  into  evidence  here  and  there  patches  that  remain 
unaltered  ;  these  are  probably  gangrenous,  and  it  is  wise  to  deal  with 
them  as  such.  Omentum,  if  small  in  amount  and  recently  pro- 
lapsed, may  be  reduced,  but  it  is  better  practice  to  remove  any  con- 
gested portion,  or  that  which  has  evidently  been  in  the  sac  for  some 
time.   The  method  of  its  removal  has  been  already  described  (p.  1 102). 

According  to  the  condition  of  the  intestine,  the  further  steps  of  the 
operation  are  modified  as  follows  : 

I.  If  the  gut,  though  congested,  shows  no  sign  of  gangrene  or  per- 
foration, it  may  be  safely  reduced.  This  is  not  always  a  matter  of 
ease,  owing  to  the  fact  that  the  effusion  into  its  walls  has  made  it 
stiff  and  firm.  Prolonged  and  steady  pressure  with  the  fingers  will, 
however,  sufficiently  remove  the  exudation  to  permit  of  its  reposition 
into  the  abdomen.  All  manipulation  directed  to  the  intestine  must, 
of  course,  be  of  the  gentlest  nature,  since  its  congested  state  makes 
it  more  friable  than  usual. 


HERNIA  1 123 

2.  If  the  gut  has  been  tightly  strangled  and  gangrene  is  threatening, 
it  is  advisable  to  resect  it  at  once,  the  incisions  being  made  well  above 
and  below  the  sites  of  constriction ;  the  divided  ends  are  united  by 
one  of  the  plans  detailed  at  p.  1040.  If,  however,  the  bowel  is  in  a 
doubtful  condition,  but  recovery  thought  possible,  it  is  gently  replaced 
just  inside  the  abdomen,  after  freely  dividing  the  constriction,  and  a 
large  drainage-tube  is  inserted  down  to  it.  There  is  no  need  to  fix 
the  bowel ;  it  is  already  inflamed  and  paralyzed,  and  hence  will  not 
change  its  position,  especially  if  a  small  dose  of  opium  is  subse- 
quently administered.  In  this  way,  even  if  gangrene  or  perforation 
occurs,  a  track  is  left  for  the  escape  of  the  contents,  while  a  localized 
plastic  inflammation  will  shut  off  the  general  peritoneal  cavity.  A 
faecal  fistula  may  thus  be  formed,  but  it  often  closes  spontaneously  at 
a  later  date. 

3.  If  the  gut  at  the  time  of  operation  is  evidently  gangrenous,  the 
ideal  treatment  consists  in  {a)  total  removal  of  the  affected  coil,  and  of 
som^e  inches  below  and  above  it,  especially  the  latter,  so  as  to  be  well 
clear  of  the  infected  focus.  The  ends  are  united  together  in  the 
usual  way,  and  a  considerable  degree  of  success  may  be  expected  in 
patients  who  have  not  been  left  too  long.  The  intestinal  canal  is  at 
once  restored  to  functional  utility,  so  that  the  fluid  and  offensive  faecal 
material  can  pass  onwards,  whilst  the  absorption  of  toxins  from  the 
stinking  gangrenous  gut  wall  is  stopped,  (h)  In  only  too  many  of 
these  cases,  however,  the  general  condition  is  almost  hopelessly  bad 
through  delay,  and  primary  enterectomy,  even  in  expert  hands,  takes 
some  time.  It  is  then  necessary  to  open  the  bowel  and  make  an 
artificial  anus.  It  is  essential  that  a  free  passage  should  be  made 
under  the  constriction  into  the  gut  above,  but  if  possible  without 
detaching  or  loosening  adhesions  at  the  neck  of  the  sac,  whereby  peri- 
toneal infection  is  prevented.  The  introduction  of  the  finger  up  the 
bowel  may  be  followed  by  a  free  flow  of  faeces ;  but  if  not,  then  the 
constriction  may  be  dilated  from  inside  the  bowel  by  dressing-forceps 
and  a  large  drainage-tube  introduced  ;  or  the  constriction  at  the  neck 
may  be  carefully  divided  from  outside,  and  either  a  Paul's  tube  or  a 
large  drainage-tube  inserted.  Of  course  one  should  cut  away  as  much 
of  the  stinking  gut  as  practicable.  An  artificial  anus  is  thus  formed, 
through  which  for  a  time  the  patient  can  discharge  the  intestinal 
contents,  and  unless  this  desideratum  is  at  once  attained,  failure  is  very 
likely  to  follow  the  operation.  The  wound  is  left  open  and  a  suitable 
dressing  applied,  into  which  the  faeces  can  be  received  ;  possibly  the 
best  application  is  a  layer  of  protective  with  a  sufficient  hole  in  the 
centre  to  allow  the  faeces  to  pass,  and  then  over  it  a  thick  layer  of  tenax. 

The  relative  value  of  the  two  methods  cannot  be  fairly  measured 
by  statistics,  since  so  many  of  the  cases  treated  by  the  formation 
of  an  artificial  anus  are  hopeless  from  the  beginning.  There  can  be 
no  question  that,  with  our  present  methods  of  intestinal  suture,  a 
large  measure  of  success  may  be  expected  from  the  adoption  of  primary 
resection  in  the  majority  of  cases. 

Having  thus  dealt  with  the  hernial  contents,  it  is  always  advisable 


1124  A  MANUAL  OF  SURGERY    - 

to  perform  a  radical  cure  in  uncomplicated  cases,  so  as  to  prevent  any 
recurrence  of  the  condition.  This  is  undertaken  according  to  the 
methods  already  described,  and*  the  external  wound  subsequently 
closed  and  drained. 

The  After- Treatment  in  cases  of  strangulated  hernia  is  of  the 
greatest  importance.  The  patient  is  placed  in  bed,  and  absolute 
quiet  is  maintained,  no  food  being  allowed  for  twenty-four  hours, 
although  a  little  ice  may  be  sucked  or  hot  water  sipped  in  order  to 
relieve  thirst.  If  there  is  no  pain,  opium  need  not  be  administered, 
as  it  helps  to  maintain  the  paralyzed  condition  of  the  bowel ;  severe 
pain  may,  however,  call  for  the  hypodermic  injection  of  a  small  dose 
of  morphia.  Liquid  food  can  usually  be  taken  at  the  end  of  twenty- 
four  hours,  and,  if  the  patient's  condition  remains  satisfactory,  it  is 
unnecessary  to  administer  any  purgative,  the  bowels  often  acting 
naturally ;  if  they  remain  unrelieved  for  five  or  six  days,  a  dose  of 
castor  oil  should  be  given. 

Various  Complications  may  arise  after  the  operation,  needing 
special  notice,  (i)  Vomiting  may  persist  for  a  time  as  a  result  of 
the  anaesthetic.  It  loses,  however,  its  fseculent  character,  and  may 
generally  be  stopped  by  washing  out  the  stomach  or  by  the  hypoder- 
mic injection  of  morphia.  (2)  The  Paralytic  condition  of  the  gut 
may  remain  for  some  considerable  time,  causing  prolonged  constipa- 
tion. If  there  is  no  evidence  of  inflammatory  mischief,  it  is  best 
treated  by  the  administration  of  a  purgative  or  by  a  turpentine 
enema.  (3)  Acute  Enteritis  may  arise  either  in  the  portion  of  strangu- 
lated gut  or  just  above.  This  is  usually  indicated  by  localized  pain, 
and  perhaps  the  passage  of  mucus,  which  may  be  so  abundant  as  to 
amount  to  diarrhoea;  the  vomiting,  moreover,  persists,  but  is  no 
longer  stercoraceous.  It  is  best  treated  by  the  administration  of 
bismuth  combined  with  morphia,  whilst  all  solid  food  is  interdicted, 
(4)  It  is  possible  that  although  the  gut  looked  healthy  at  the  time 
of  operation,  its  walls  were  in  reality  already  infected,  and  in 
spite  of  the  relief  of  the  constriction,  infective  gangrene  may  follow, 
causing  death  from  peritonitis.  (5)  Occasionally  acute  septic  peri- 
tonitis results  from  a  localized  perforation,  either  of  a  small  gan- 
grenous patch  or  from  ulceration  along  the  '  constriction  groove.' 
Treatment. — -The  condition  is  obviously  one  of  the  gravest  import, 
and  must  be  dealt  with  actively  if  the  patient  is  to  be  saved.  The 
abdomen  must  be  opened,  the  affected  coil  identified,  and  if  need  be 
resected,  or  fixed  in  the  wound  and  opened  for  drainage  purposes.  The 
peritoneal  cavity  itself  is  dealt  with  according  to  the  rules  already 
given.  (6)  Localized  Peritonitis  may  be  looked  on  as  a  conservative 
measure,  whereby  Nature  isolates  some  focus  of  danger  from  the 
general  peritoneal  cavity.  Occasionally  localized  suppuration  follows 
as  the  result  of  a  limited  ulceration  or  perforation  of  the  gut ;  the  pus 
must  then  be  let  out  at  the  earliest  possible  moment,  but  a  faecal 
fistula  is  very  likely  to  follow. 

It  is  impossible  to  describe  in  detail  every  form  of  strangulated 
hernia.      A   few   facts,  however,  must    be   stated   about   the   more 


HERNIA  1125 

important  varieties.  In  Strangulated  Inguinal  Hernia  the  constric- 
tion most  commonly  occurs  at  the  neck  of  the  sac,  usually  close  to 
the  external  abdominal  ring,  as  a  result  of  the  condensation  of  the 
surrounding  tissues.  The  signs  are  generally  very  characteristic,  and 
the  condition  can  rarely  be  mistaken.  Some  difficulty  may  be  ex- 
perienced in  distinguishing  it  from  inflammation  of  an  undescended  testis  ; 
in  this,  however,  there  is  no  persistent  vomiting  or  constipation, 
whilst  the  absence  of  the  testis  below,  and  the  existence  of  the  peculiar 
testicular  sensation,  when  the  swelling  in  the  canal  is  compressed, 
should  clear  up  the  case.  Occasionally  the  two  conditions  co-exist, 
and  then  a  correct  diagnosis,  apart  from  an  open  exploration,  may  be 
almost  impossible.  Torsion  of  the  testis,  and  subsequent  strangulation 
of  the  organ,  give  rise  to  a  swelling  not  at  all  unlike  a  strangulated 
hernia,  but  the  absence  of  constipation  and  fsecal  vomiting  should 
prevent  mistakes. 

Division  of  the  stricture  in  the  course  of  the  operation  is  performed 
in  a  vertical  direction,  the  surgeon  cutting  directly  upwards,  the 
reason  being  that  it  is  impossible  in  old-standing  cases  to  be  certain 
whether  the  hernia  is  oblique  or  direct,  and  thus  the  liability  to  injury 
of  the  epigastric  artery  is  diminished.  If,  however,  the  modern 
method  of  operation  is  followed,  and  the  external  oblique  aponeurosis 
exposed  and  freely  divided,  it  will  often  be  found  that  the  constriction 
is  relieved  by  this  means  alone,  and  reduction  becomes  possible. 
The  sac,  however,  should  always  be  opened,  and  the  condition  of  the 
bowel  examined. 

In  Strangulated  Femoral  Hernia  it  is  more  common  to  find  bowel 
than  omentum,  and  it  is  in  this  situation  that  partial  herniae 
(Richter's)  are  most  frequently  met  with.  A  tense  painful  swelling 
is  felt,  situated  in  the  neighbourhood  of  the  saphenous  opening, 
and  the  diagnosis  from  inflamed  lymphatic  glands  and  phlebitis  of 
a  varicose  saphena  vein  may  not  be  altogether  easy,  particularly  if 
omentum  alone  is  present.  The  history  of  the  case,  and  a  careful 
consideration  of  the  physical  signs  and  symptoms,  should  generally 
be  sufficient  to  clear  up  the  diagnosis.  The  constriction  is  usually 
met  with  opposite  Gimbcrnat's  ligament,  and  to  divide  it  the  surgeon 
must  cut  directly  inwards,  so  as  to  incise  that  structure.  The  plan 
already  mentioned  of  nicking  it  in  two  or  three  places,  rather  than 
freely  dividing  it,  is  especially  useful  in  this  situation,  on  account  of 
the  occasional  abnormal  course  of  the  obturator  artery,  which  is 
stated  to  be  wounded  once  in  every  150  cases.  The  accident  would 
be  recognised  by  the  occurrence  of  free  haemorrhage  after  the  use 
of  the  hernia  knife.  In  such  a  case,  the  rupture  is  first  reduced,  the 
wound  enlarged  upwards,  and  both  ends  of  the  divided  vessel  secured, 
if  possible  ;  failing  this,  carefully  adjusted  pressure  may  be  employed. 
Where  the  constriction  is  very  tight,  so  that  it  is  almost  impossible 
to  pass  a  director  between  Gimbernat's  ligament  and  the  intestine, 
the  plan  already  mentioned  of  dividing  the  constriction  from  without 
may  be  utilized  with  advantage. 

Gangrene  is  more  than  twice  as  common  in  femoral  hernia  as  in 


1 126  A  MANUAL  OF  SURGERY 

inguinal  (19*5  per  cent,  in  femoral  against  6-i  per  cent,  in  inguinal). 
Where  enterectomy  is  feasible,  it  will  often  be  necessary  to  open 
the  abdomen  by  an  additional  incision  above  the  pelvic  brim,  and 
then,  having  divided  the  constriction  at  the  neck  of  the  sac,  the 
affected  coil  must  be  slipped  back  and  pulled  out  of  the  upper  wound, 
the  greatest  care  being  taken  not  to  contaminate  other  coils  of 
intestine.  The  shortness  of  the  mesentery  renders  it  impossible  to 
perform  the  necessary  manipulations  through  the  wound  in  the  groin. 
It  is  quite  possible  to  overlook  the  existence  of  a  small  Richter's 
hernia,  and  only  to  ascertain  its  presence  during  a  laparotomy  for  an 
acute  attack  of  obstruction.  Under  these  circumstances  the  greatest 
gentleness  must  be  exercised  in  any  attempts  to  withdraw  the  bowel 
from  the  sac  for  fear  of  tearing  the  gut  and  flooding  the  peritoneal 
cavity  with  fluid  fseces.  It  is  usually  well  to  cut  down  on  the  hernia 
from  outside,  open  the  sac,  and  divide  the  constriction  ;  and  then 
partly  from  without,  partly  from  within,  to  reduce  the  strangled 
portion  of  bowel,  which  is  brought  to  the  surface  and  carefully 
examined.  In  many  such  cases  drainage  of  the  gut  by  a  Paul's  tube 
will  be  required,  and  a  subsequent  enterectomy. 

Sequelae  of  Strangulabed  Hernia.— (i)  Artificial  Anus  may  arise  from  the  slough- 
ing of  the  intestine  and  overlying  skin  apart  from  operation  ;  or  from  the 
surgeon's  interference,  either  by  his  opening  the  gut  in  mistake  for  the  sac,  or 
by  his  incising  it  when  gangrenous  ;  or  it  may  slough  subsequently,  if  left  in  situ 
when  gangrene  is  threatening.  After  a  time  the  surrounding  parts  settle  down 
and  heal  over,  the  diversion  of  the  faeces  from  their  natural  course  becoming 
more  and  more  complete,  owing  to  the  formation  of  a  spur  of  mucous  membrane, 
which  lies  across  and  blocks  the  entrance  to  the  lower  portion  of  the  bowel. 
This  spur  arises  partly  as  a  result  of  the  kinking  of  the  gut,  partly  from  the 
intra-abdominal  pressure,  which  pushes  the  exposed  inner  wall  of  the  intestine 
forwards.  The  effects  produced  by  an  artificial  anus  on  the  individual  vary  with 
the  portion  of  the  bowel  involved.  If  the  jejunum  or  upper  part  of  the  ileum  is 
thus  opened,  the  patient  soon  loses  ground  and  becomes  emaciated,  owing  to  the 
escape  of  the  intestinal  contents  before  the  nutritive  elements  of  the  food  have 
been  absorbed.  Eczema  of  the  skin  in  the  neighbourhood  is  usually  produced, 
resulting  from  the  irritation  of  the  faeces.     For  treatment,  see  p.  1038. 

(2)  Faecal  Fistula  occasionally  results  from  a  strangulated  hernia,  owing  to  a 
perforative  inflammation  of  the  gut  after  the  relief  o?  strangulation,  whether  at 
the  site  of  constriction,  or  above  or  below  it,  in  the  latter  case  arising  from  a 
stercoral  ulcer.  Though  the  lesion  may  be  intraperitoneal,  it  by  no  means 
follows  that  general  peritonitis  need  result,  since  sufficient  plastic  material  may 
be  formed  around  it  to  shut  off  the  general  peritoneal  cavity,  and  to  allow  the 
extravasated  contents  of  the  bowel  to  find  their  way  outwards  through  a  sinuous 
track  to  the  external  wound.  It  may  be  some  days  before  any  evidence  of  the 
existence  of  this  condition  appears.  Not  uncommonly  the  opening  will  close 
naturally  as  a  result  of  cicatricial  contraction,  and  hence  no  steps  need  be  taken 
to  deal  with  it  until  all  hopes  of  such  a  result  have  faded.  Where,  however,  it 
persists,  attempts  may  be  made  to  effect  this  purpose  by  injecting  stimulating 
lotions,  or  by  applying  the  actual  cautery  to  the  interior  of  the  fistula ;  but  more 
frequently  an  operation  to  expose,  if  practicable,  the  wound  in  the  gut,  and  to 
close  it  by  suture,  or  to  remove  the  afiected  segment,  will  be  necessary. 

(3)  Stenosis  of  the  gut  at  the  site  of  strangulation  may  ensue,  giving  rise  to  the 
symptoms  already  indicated  (p.  1027),  which  may  appear  weeks  or  months  later. 


CHAPTER  XXXVI. 

INTESTINAL   OBSTRUCTION. 

By  Intestinal  Obstruction,*  or  Ileus,  is  meant  a  condition  in  which 
the  onward  passage  of  faeces  is  prevented.  It  is  often  associated 
with  vascular  phenomena,  due  to  strangulation  or  kinking  of  the  gut, 
which  result  in  a  deficient  supply  of  arterial  blood  reaching  the  part, 
thereby  predisposing  to  gangrene. 

Various  elements  enter  into  the  picture  provided  by  a  classical 
case  of  obstruction,  and  of  these  the  most  marked  are : 

I.  Coprostasis,  or  retention  of  faeces.  The  fact  that  simple  con- 
stipation may  last  for  a  week  or  more  at  a  time,  and  do  no  harm  to 
the  patient  beyond  a  certain  slight  degree  of  toxic  poisoning,  demon- 
strates that  this  is  not  the  only  element  in  cases  of  obstruction,  and 
indeed  is  often  an  almost  insignificant  factor  in  acute  cases.  Yet  it 
colours  the  whole  picture,  and  has  very  marked  results  in  the  clinical 
manifestations.  Retention  of  the  intestinal  contents  is  certain  to  be 
followed  by  their  decomposition  and  liquefaction,  and  this  causes  the 
intestinal  canal  to  be  filled  with  a  quantity  of  offensive  fluid  material, 
partly  due  to  bacterial  activity,  partly  to  the  pouring  out  of  a  con- 
siderable quantity  of  secretion  from  the  congested  gut  wall.  If  the 
obstruction  is  only  partial,  this  liquefaction  of  the  bowel  contents 
may  enable  them  to  pass  on,  and  the  patient's  attack  of  partial 
obstruction  is  followed  by  one  of  diarrhoea,  whereby  relief  is  obtained. 
If  the  obstruction,  however,  is  complete,  the  intestine  above  the  block 
is  gradually  filled  with  this  decomposing  material,  from  which  toxins 
may  be  absorbed,  the  patient  being  thereby  poisoned. 

A  second  result  of  this  decomposition  of  the  retained  faeces  is  the 
development  of  gas,  which  may  be  so  marked  as  to  lead  to  great 
abdominal  distension  or  meteorism.  Whilst  present  in  almost  every 
case  to  a  certain  degree,  it  is  most  marked  when  there  is  considerable 
involvement  of  the  mesentery,  and  experiments  on  animals  indicate 
that  constriction  of  the  nerves  contained  therein  is  the  chief  factor 
in  its  production. 

*  For  much  of  the  material  incorporated  in  this  chapter  we  beg  to  acknowledge 
our  indebtedness  to  Sir  Frederick  Treves'  classical  text-book  on  the  subject 
(published  by  Cassell  and  Co.),  than  whicli  nothing  better  has  appeared,  and 
which  we  have  freely  utilized. 

1 1 27 


ij28  A  MANUAL  OF  SURGERV 

2.  Increased  peristalsis,  with  the  object  of  forcing  the  intestinal 
contents  past  the  block,  is  often  an  important  feature  in  the  case, 
leading  to  severe  pain  of  a  colicky  character.  So  violent  may  these 
efforts  become  that  the  bowel,  weakened  by  distension  and  inflam- 
mation, is  finally  torn,  and  perforative  peritonitis  rapidly  ends  the  case. 

3.  Regurgitant  vomiting  is  always  a  prominent  element.  At  first 
the  gastric  contents  alone  are  ejected,  but  later  the  vomit  becomes 
bilious,  and  even  stercoraceous  or  faecal.  The  origin  of  this  pheno- 
menon is  still  a  little  dubious.  Some  have  considered  it  due  to  anti- 
peristalsis  ;  others  maintain  that  the  ordinary  onward  movements  of 
the  bowel  are  quite  sufficient  to  explain  it.  The  intestinal  contents 
are  urged  forwards  against  the  face  of  the  obstruction,  and,  being 
unable  to  pass,  an  axial  regurgitant  stream  is  produced.  It  is  a  little 
difficult  to  see  how  this  could  occur  when  the  lower  end  of  the  colon 
is  the  part  affected.  Whatever  the  mechanical  explanation,  there  is 
no  question  as  to  the  influence  of  the  nervous  system  in  its  production, 
or  as  to  its  being  chiefly  reflex  in  character,  which  is  evident  from 
the  fact  that  it  occurs  whether  omentum  or  bowel  is  strangled. 
Hence,  it  is  easy  to  understand  that  it  commences  early  in  children 
and  sensitive  women,  on  account  of  the  greater  irritability  of  their 
nervous  centres,  whilst  it  is  also  more  marked  when  the  small 
intestine  is  involved.  Anything  that  increases  peristalsis  naturally 
intensifies  its  occurrence. 

4.  Nervous  phenomena  also  add  their  peculiar  features  to  the 
picture.  The  affected  coil  of  bowel  is  directly  paralyzed  by  the 
lesion,  but,  in  addition,  various  reflex  manifestations  occur.  Thus, 
in  acute  cases  the  patient  suff"ers  almost  at  once  from  shock,  which 
passes  off  after  a  time,  and  from  collapse  due  to  toxaemia  at  a  later 
date ;  vomiting  and  perhaps  hiccough  develop  reflexly,  and  the  latter 
sign  is  always  to  be  looked  on  with  grave  suspicion  and  as  an  omen 
of  bad  import.  In  the  latest  stages  intestinal  paralysis  from  the 
onset  of  peritonitis  may  dominate  the  scene. 

5.  Infective  phenomena  are  likely  to  follow  sooner  or  later,  the 
bowel  walls  being  attacked  by  the  virulent  organisms  contained 
within  them.  Complete  paralysis  and  want  of  blood-supply  pre- 
dispose them  to  bacterial  invasion,  and  hence  the  more  acute  forms 
of  infective  gangrene  are  chiefly  seen  in  conditions  of  the  strangula- 
tion type  ;  when  mere  obstruction  is  present  without  vascular  changes, 
microbic  invasion  rarely  produces  more  than  a  patchy  necrosis,  or, 
more  commonly,  perforative  ulceration.  Of  course,  when  infective 
gangrene  is  present,  virulent  toxins  develop  in  the  walls  of  the  gut, 
and  a  rapid  depreciation  of  the  patient's  general  condition  follows 
from  their  absorption. 

6.  Finally,  death,  is  almost  certain  to  ensue  apart  from  surgical 
assistance,  although  a  few  cases  may  recover  spontaneously.  The 
final  event  is  due  either  to  perforative  peritonitis,  or  to  simple 
exhaustion,  the  result  of  toxic  absorption  from  the  retained  faeces  or 
from  the  necrotic  intestinal  wall,  of  constant  pain  and  vomiting, 
want  of  nutrition,  and  general  dehydration  of  the  tissues. 


INTESTINAL  OBSTRUCTION  nag 

Causes. — Much  elaborate  work  has  been  undertaken  to  produce  a 
satisfactory  classification  of  the  many  diverse  causes  of  intestinal 
obstruction ;  and  when  one  mentions  the  fact  that  a  recent  attempt 
included  eighty  distinct  causative  lesions,  it  is  obvious  that  there  is  an 
abundant  field  for  this  type  of  ingenuity.  It  must  suffice  here  to  state 
that  there  are  two  great  divisions — the  dynamic  and  the  mechanical. 

(i)  Dynamic  ileus  is  due  to  some  paralytic  or  spasmodic  condition 
of  the  intestinal  wall,  which  results  in  interference  with  its  power  of 
transmitting  onwards  its  contents.  Paralysis  of  the  bowel  results 
from:  (a)  Diffuse  or  localized  acute  infective  inflammation,  as  in 
septic  peritonitis  or  acute  appendicitis ;  (b)  torsion  of  intra-abdominal 
viscera,  such  as  the  spleen  or  omentum,  or  of  tumours — e.g.,  ovarian 
cysts,  leading  to  the  so-called  '  aseptic '  peritonitis ;  (c)  embolus  or 
thrombosis  of  the  mesenteric  vessels,  leading  to  necrosis ;  (d)  nervous 
lesions,  which  may  involve  the  spinal  cord  itself,  or  more  frequently 
the  peripheral  nerves — e.g.,  a  tumour  at  the  root  of  the  mesentery. 
Spasm  of  the  gut,  as  by  chronic  lead-poisoning,  may  also  determine 
obstructive  phenomena. 

(2)  Mechanical  ileus  is  the  variety  most  commonly  seen,  [a)  The 
gut  may  be  strangled  by  bands  or  through  apertures,  causing  internal 
strangulation,  (b)  It  may  be  kinked  over  bands,  thereby  determining 
not  only  occlusion  of  the  lumen,  but  also  a  marked  interference  with 
the  vascular  supply,  (c)  The  intestine  may  be  twisted  on  its  own  axis, 
giving  rise  to  a  condition  known  as  volvulus,  (d)  One  portion  of  the 
bowel  may  be  invaginated  into  a  neighbouring  portion,  constituting  an 
intussusception,  {e)  The  lumen  of  the  bowel  may  be  blocked  by 
foreign  bodies  or  accumulations  of  faeces  (obturation).  (/)  The 
onward  passage  of  the  faeces  may  be  rendered  difficult  or  impossible 
by  the  gut  becoming  narrowed,  as  from  cicatricial  or  cancerous  stenosis, 
or  the  pressure  of  external  tumours. 

The  most  useful  division  is,  however,  the  clinical,  grouping  together 
those  cases  which  present  a  similarity  of  symptoms;  and  this 
method  will  be  employed  here,  the  subject  being  discussed  under 
the  three  headings — Acute  Obstruction,  Chronic  Obstruction,  and 
Intussusception. 

Acute  Intestinal  Obstruction. 

The  following  are  the  chief  Causes  which  give  rise  to  this  condition  : 

1.  Strangulation  by  bands  or  adhesions,  or  through  apertures,  etc. 

2.  Volvulus. 

3.  The  impaction  of  foreign  bodies. 

4.  Strangulation  over  a  band  or  acute  kinking  of  the  gut,  both  -very 
rare  conditions. 

5.  Acute  intussusception. 

6.  It  may  be  the  termination  of  a  chronic  obstruction. 

7.  Acute  localized  paralysis  of  the  gut  due  to  an  infective  inflam- 
mation— e.g.,  acute  suppurative  appendicitis. 

8.  Acute  enterospasm. 

It  will  be  noted  that  in  the  first  five  of  these  causes,  where  the 
ileus  is  primary,  there  is  a  definite  vascular  lesion  in  addition  to  the 


I130 


A  MANUAL  OF  SURGERY 


obstruction,  which  threatens  the  patient  at  an  early  date  with  per- 
forative ulceration  or  gangrene,  and  it  is  mainly  on  the  presence  ot 
this  element  that  the  acuteness  of  the  case  depends. 

The  General  Symptoms  of  acute  obstruction  are  practically  identical 
with  those  of  a  strangulated  hernia.  The  patient  is  suddenly  seized 
with  severe  abdominal  pain  somewhat  of  the  nature  of  colic,  and 
perhaps  referred  to  the  umbilicus,  coming  on  sometimes  during  some 
special  effort — e.g.,  lifting  a  heavy  weight,  or  sometimes  when  lying 
quietly  in  bed.  At  the  same  time  he  suffers  from  shock,  as  evidenced 
by  a  weak  pulse,  pale  face,  and  cold,  clammy  sweat,  the  temperature 


Fig.  492. — Strangulation  of  a  Ccul  of  the  Lower  End  of  the  Ileum  by 
A  Band  developed  in  the  Neighbourhood  of  the  Vermiform  Appendix. 
(King's  College  Hospital  Museum.) 

of  the  body  falling  below  the  normal.  The  shock  is  usually  more  or 
less  recovered  from,  but  the  pain  persists,  and  is  liable  to  exacerba- 
tion and  intermissions,  soon  becoming  continuous.  Vomiting  ensues, 
being  at  first  limited  to  the  contents  of  the  stomach,  but  quickly 
changes  to  a  bilious,  stercoraceous,  or  even  faecal  character.  Dis- 
tension of  the  abdomen  is  generally  present,  but  its  amount  and 
characters  vary  with  the  site  of  the  lesion.  Signs  of  constitutional 
depression  and  exhaustion  follow  in  a  short  time,  the  pulse  becoming 
weak,  rapid,  and  thready,  the  temperature  remaining  subnormal 
(except  occasionally  after  the  supervention  of  peritonitis,  when  it 
may  rise  a  few  degrees),  the  face  looking  drawn  (fades  Hippo- 
cratica),  and  the  abdomen  being  distended  and  painful.  Finally,  if 
unrelieved  by  treatment,  the  patient  dies,  and  usually  within  seven 
to  ten  days  from  the  onset,  owing  to  exhaustion  or  perforative  peri- 
tonitis.    Constipation  may  be  absolute  from  the  first,  not  even  flatus 


INTESTINAL  OBSTRUCTION 


Fig.  493  — Strangula- 
tion BY  Band. 


being  passed,  but  at  any  time  the  lower  bowel  may  empty  itself,  and 
raise  false  hopes  as  to  the  prognosis. 

The  Special  Forms  of  Acute  Obstruction  must  now  be  considered 
senatitm. 

I.  Strangulation  by  Bands  or  Adhesions,  through  Apertures,  etc. — 
Causes. — (a)  Isolated  peritoneal  bands  and  adhesions  axe  usually  the  result 
of  old  plastic  peritonitis  of  a  localized  and  chronic  character.  The 
greatest  variety  is  met  with  in  the  appearance  and  situation  of  these 
adhesions  ;  most  frequently  they  are  single  and 
cord-like  ;  sometimes  they  are  broad  and  mem- 
branous, constituting  a  false  ligament ;  or,  again, 
they  may  be  multiple.  A  common  situation  is 
between  different  parts  of  the  mesentery,  or 
between  the  mesentery  and  some  other  viscus, 
the  cause  being  either  disease  of  that  viscus 
(usually  a  pelvic  organ,  the  caecum,  or  the 
appendix),  or  inflammation  of  a  mesenteric 
gland  with  localized  peritonitis.  Whatever  the 
exact  cause,  the  mischief  is  most  frequently 
found  either  in  the  right  iliac  fossa  or  in  the 
pelvis.  Two  methods  of  producing  strangula- 
tion exist ;  either  the  bowel  passes  under  the 
arch  or  loop  formed  by  a  short  constricting 
band,  and  cannot  return  (Fig.  492)  ;  or,  if  the 
band  is  long,  it  may  form  a  loop  or  noose 
through  which  the  bowel  passes,  and  so  becomes  strangled  (Fig.  493). 
{b)  Cords  formed  by  the  omentum  result  from  union  between  its  fimbriated 
extremities  and  some  part  of  the  viscera  or  parietes,  forming  at  first 
a  broad  band-like  adhesion,  which  is  gradually  moulded  into  a  rounded 
cord  by  the  constant  dragging  and  pulling  to  which  it  is  subjected. 
They  are  usually  coarser  and  thicker  than  those  due  to  peritonitis. 
The  mechanism  of  strangulation  is  identical,  the  noose  form  being 
perhaps  the  more  common,  since  the  adhesions  are  likely  to  be  longer. 
{c)  Meckel's  diverticulum  (p.  1020)  is  liable  to  cause  strangulation  when 
its  free  end  becomes  adherent  either  to  the  parietes  or  to  the  viscera ; 
it  is  attached  most  frequently  to  the  mesentery  of  the  ileum,  and 
after  that  to  the  neighbourhood  of  the  umbilicus.  Occasionally  the 
diverticulum  ends  in  a  fibrous  cord,  which  may  remain  fixed  to  the 
umbilicus,  or  floats  free  in  the  abdominal  cavity,  and  subsequently 
becomes  adherent  to  some  other  structure,  thus  producing  a  fibrous 
cord.  Strangulation  may  be  effected  by  bowel  passing  under  the 
loop  formed  by  the  adherent  diverticulum.  {d)  The  vermiform 
appendix,  appendices  epiploic^,  or  Fallopian  tubes  may  contract  abnormal 
attachments,  and  thus  form  arches  or  loops  under  which  bowel  may 
pass  and  become  strangled,  [e)  Slits,  pouches,  and  apertures  in  the 
peritoneal  investment,  whether  normal  or  abnormal,  may  lead  to 
strangulation.  All  external  herniae  may  be  grouped  under  this 
heading,  as  also  those  conditions  known  as  internal  hernia,  in  which 
the  abdominal  contents  find  their  way  into  pouches  in  the  posterior 


1132  A  MANUAL  OF  SURGERY 

wall  of  the  peritoneum — e.g.,  into  the  lesser  sac  of  the  omentum,  the 
fossa  duodeno-jejunalis,  or  into  some  of  the  retro-caecal  fossae.  Slitf 
may  also  be  found  in  the  omentum  or  mesentery,  either  congenital, 
traumatic,  or  the  result  of  operations. 

Phenomena. — This  form  of  obstruction  usually  occurs  in  young 
people,  and  is  rare  after  forty ;  it  constitutes  more  than  a  fourth  of  all 
the  forms  of  internal  obstruction,  and  the  lower  2  feet  of  the  ileum 
are  most  frequently  involved.  There  may  be  a  previous  history  of 
peritonitis,  but  that  may  have  been  overlooked  or  forgotten ;  the 
onset  is  usually  sudden,  and  the  symptoms  of  strangulation,  as 
detailed  above,  are  of  a  typical  character.  The  abdomen  is  flaccid 
at  first,  and  not  tender  until  peritonitis  ensues,  on  about  the  third  or 
fourth  day.  There  is  generally  no  obvious  tumour,  and  no  peristalsis 
or  dilated  coils  of  intestine  are  to  be  seen.  Occasionally  an  area  of 
localized  fulness  or  of  fixed  and  limited  tenderness  may  indicate  the 
site  of  the  lesion.  The  average  duration  is  about  five  to  seven  days, 
the  patients  dying  of  exhaustion  or  toxaemia  following  peritonitis. 

2.  Volvulus  is  the  most  common  cause  of  acute  primary  obstruc- 
tion of  the  large  intestine.  By  it  is  meant  a  rotation  of  the  gut 
upon  its  own  mesenteric  axis  in  such  a  way  as  to  interfere  not 
only  with  the  passage  of  the  intestinal  contents,  but  also  sooner  or 
later  with  the  circulation,  determining  a  condition  of  strangulation. 
Occasionally  a  similar  result  is  brought  about  by  the  intertwining 
of  one  coil,  usually  of  small  intestine,  with  another.  The  sigmoid 
flexure  is  the  part  generally  affected,  although  it  occurs  in  the 
caecum  when  there  is  a  definite  meso-caecum,  or  in  the  small 
intestine.  In  the  former  situation  it  is  predisposed  to  by  a  long 
narrow  sigmoid  meso-colon,  so  that  the  two  ends  of  the  loop  are 
brought  closely  together ;  this  condition  may  be  of  congenital  origin, 
but  is  usually  due  to  the  traction  induced  by  prolonged  chronic  con- 
stipation ;  a  distended  sigmoid  hanging  into  the  pelvic  cavity  drags 
upon  and  elongates  the  meso-colon,  tending  to  approximate  the  two 
ends  of  the  loop,  and  necessarily  causing  a  slight  obstruction  at  these 
spots.  Some  irregular  movement  of  the  gut  or  of  the  abdominal 
walls  suffices  to  cause  rotation  of  the  pedicle,  and  thus  brings  about 
the  volvulus.  When  once  present,  plastic  peritonitis  soon  fixes  the 
coil,  whilst  the  pressure  on  the  vessels  causes  venous  congestion 
and  such  obstruction  to  the  arterial  supply  of  the  gut  as  almost 
certainly  to  end  in  its  death.  Distension  of  the  coil  with  gas  from 
decomposition  of  the  retained  fasces  also  aggravates  the  condition. 

Symptoms. — Volvulus  is  rare  before  the  age  of  forty,  and  appar- 
ently occurs  more  often  in  the  male  sex.  A  history  of  chronic  con- 
stipation precedes  it,  but  the  acute  symptoms  start  abruptly.  Pain 
is  always  present,  at  first  intermittent,  but  finally  constant,  and  there 
is  usually  early  tenderness  over  the  sigmoid  flexure.  The  pain, 
vomiting,  and  collapse  are  not  so  severe  or  marked  as  in  other  forms 
of  strangulation,  but  abdominal  distension  from  excessive  flatus,  and 
resulting  dyspnoea  and  thoracic  embarrassment,  are  very  distressing. 
Tenesmus  is  occasionally  present.     A  localized  peritonitis  is  usually 


INTESTINAL  OBSTRUCTION  1133 

developed,  but  sometimes  it  becomes  dififuse.  Natural  cure  is  un- 
known, the  patient  dying  either  in  five  or  six  days  from  collapse 
and  interference  with  respiration,  or  at  a  somewhat  later  date  from 
peritonitis. 

3.  Impacted  Foreign  Bodies,  which  may  cause  intestinal  obstruc- 
tion, are  of  three  types  :  gall-stones,  foreign  bodies  that  have  been 
swallowed,  or  intestinal  concretions  (enteroliths).  The  general  facts 
connected  with  their  presence  in  the  intestine  have  been  already 
noted  (p.  1024). 

Gall-stones  only  cause  obstruction  when  of  large  size,  and  then 
usually  gain  entrance  to  the  intestine  by  ulceration  from  the  gall- 
bladder into  the  duodenum.  The  usual  site  of  impaction  is  in  the 
lower  ileum.  Women  over  fifty  are  most  often  the  subjects  of  this 
condition,  and  there  may  be  merely  a  history  of  some  inflammatory 
lesion  in  the  region  of  the  gall-bladder,  and  none  of  biliary  colic. 
Such  patients  frequently  suffer  from  intermittent  subacute  attacks  of 
incomplete  obstruction,  which,  though  severe  for  a  time,  are  relieved 
by  purgatives.  If  the  gall-stone  is  not  passed,  a  final  acute  attack 
supervenes,  which  begins  suddenly  with  pain  and  slight  collapse, 
followed  by  vomiting,  which  is  constant  and  copious,  and  in  twenty- 
four  to  thirty-six  hours  becomes  fsecal.  The  obstruction  is  often 
incomplete,  flatus  and  even  faeces  being  occasionally  passed.  The 
abdomen  is  soft  and  flaccid,  and  the  affected  coil  and  the  gall-stone 
are  rarely  to  be  felt.  Necessarily  the  symptoms  vary  with  the  site 
of  impaction,  usually  becoming  more  urgent  as  the  duodenum  is 
approached.     Death  results  from  peritonitis  or  exhaustion. 

Similarly,  enteroliths  are  usually  impacted  near  the  caecum,  and  if 
causing  acute  obstruction  the  symptoms  are  similar  to  those  produced 
by  a  large  gall-stone,  being  preceded  by  chronic  attacks  and  severe 
colicky  pain.  In  thin  persons  their  presence  may  be  detected  by 
palpation  of  the  abdomen. 

4.  Acute  obstruction  ensues  when  a  coil  of  intestine  lodges  across 
a  tightly-dravm  adhesion,  the  lumen  at  each  end  being  thereby  entirely 
occluded,  and  the  circulation  arrested.  The  usual  acute  symptoms 
follow,  which  may,  however,  be  relieved  spontaneously.  Sudden 
kinking  of  the  gut  may  lead  to  the  same  result,  being  due  to  the 
contraction  of  fibrous  adhesions  or  the  dragging  of  diverticula. 

5.  For  Acute  Intussusception,  see  1139. 

6.  When  acute  symptoms  are  developed  at  the  termination  of  a 
case  of  chronic  obstruction,  the  pain  which  had  been  intermittent 
becomes  constant,  the  vomiting  more  violent  and  fsecal  in  character, 
and  the  fatal  termination  is  due  to  acute  peritonitis,  or  to  exhaustion 
and  toxaemia.  Absolute  constipation  is  always  present,  and  the  ab- 
domen much  distended. 

7.  True  obstruction  is  sometimes  associated  with  acute  localized 
enteritis  or  peritonitis,  such  as  is  seen  in  appendicitis,  when  the 
intestinal  walls  are  paralyzed.  This  symptom  is  sometimes  very 
marked,  and  even  faecal  vomiting  may  occur,  but  by  careful  atten- 
tion to  the  history  and  general  condition  of  the  patient   a   correct 


'134 


A  MANUAL  OF  SURGERY 


diagnosis  should  be  reached.  We  append  a  table  illustrating  the 
chief  diagnostic  points  between  acute  strangulation  and  acute  ap- 
pendicitis associated  with  peritonitis,  one  of  the  commonest  causes  of 
dynamic  ileus : 


Acute  Internal  Strangulation. 

Acute  Appendicitis  with 
Peritonitis. 

Onset   - 

Abrupt. 

May  be  preceded  by  local  pain. 

Rigor    - 

Absent. 

Often  present. 

Temperature 

Subnormal  at  first,  rising  at 

High  at  first,  falling  later  from 

onset  of  peritonitis. 

exhaustion  or  toxaemia. 

Pain      - 

Severe;  referred  to  the  um- 

Severe ;  usually  referred  to  the 

bilicus. 

right  iliac  fossa. 

Tenderness  - 

Absent  till  peritonitis  comes 

Present   over  caecum   even    in 

on. 

early   stages,  and   gradually 
spreading. 

Vomiting 

Early,     marked,     and     soon 

Less  urgent,  and  seldom  faecal, 

faecal. 

except  as  a  late  symptom. 

Abdominal 

Flaccid     till     peritonitis     is 

Tense  and  rigid  from  the  first. 

parietes     - 

present. 

In  most  forms  of  dynamic  ileus  the  obstructive  phenomena  are 
usually  secondary  to  some  peritonitic  trouble,  or  to  some  intra- 
abdominal lesion  which  produces  its  own  symptoms  first,  and  then 
obstructive  phenomena  only  as  a  secondary  result  of  inflammatory 
paralysis.  Thus  in  torsion  of  the  pedicle  of  an  ovarian  cyst,  the 
patient  first  complains  of  pain,  and  the  tumour  becomes  large  and 
tender.  Should  it  be  neglected,  aseptic  peritonitis  ensues  ;  after  a 
variable  period  intestinal  paralysis  follows,  and  obstructive  symp- 
toms of  a  distressing  type  are  produced,  which  will  probably  prove 
fatal,  even  if  the  cause  is  removed. 

8.  Enterospasm  is  the  name  applied  to  a  functional  disorder  occur- 
ring in  patients  of  a  neurotic  type,  in  which  one  or  more  sections  of 
the  intestinal  canal  undergo  purposeless  tetanic  contraction.  The 
colon  is  more  commonly  affected  than  the  small  bowel,  and  especially 
the  caecal  and  sigmoid  sections.  In  the  acute  form  the  symptoms  of 
urgent  obstruction  may  be  produced,  and  even  peritonitis  sinmlated ; 
but  more  frequently  the  attacks  are  chronic,  and  persistent  constipa- 
tion results.  Sometimes  the  appendix  is  tender,  and  has  been 
removed  for  this  affection  without  benefit.  Antispasmodics  of  the 
belladonna  type  are  required,  and  purgatives  do  but  little  good. 

For  diagnosis  and  method  of  examination  of  cases  of  acute  obstruc- 
tion, see  p.  1 142. 

The  Treatment  of  acute  obstruction  is  practically  included  in  one 
word — Laparotomy.  The  condition  of  the  gut  is  in  most  cases 
identical  with  that  found  in  a  strangulated  hernia,  and  although  a 
few  patients  may  recover  by  palliative  measures — e.g.,  enemata, 
opium,  ice,  etc. — yet  the  majority  would  be  gravely  injured  by  the 
delay  caused   by   their   employment.      The   danger   of   laparotomy 


INTESTINAL  OBSTRUCTION  1135 

increases  directly  with  delay ;  hence,  the  sooner  it  is  undertaken, 
the  better  for  the  patient.  Whilst  preparations  for  the  operation  are 
being  made,  an  enema  may  be  administered  to  clear  the  lower  bowel, 
ice  being  given  to  suck,  and  a  small  dose  of  opium  to  relieve  urgent 
pain.  Two  main  objects  must  always  be  striven  after  in  the  opera- 
tive treatment  of  such  cases — viz.,  (a)  to  empty  the  distended  bowel, 
and  (b)  to  remove  the  cause  of  the  obstruction.  The  second  of  these 
requisites  is  always  most  desirable,  but  unless  at  the  same  time  the 
putrid  contents  of  the  upper  portion  of  the  intestine  are  removed, 
little  real  good  has  been  accomplished,  since  the  patient  is  being 
slowly  poisoned  by  septic  absorption.  The  late  Mr.  Greig  Smith 
declared  most  emphatically  that  '  no  operation  for  intestinal  ob- 
struction is  complete  if  the  patient  leaves  the  operating-table  with 
a  greatly  distended  abdomen.'  Hence,  in  many  cases  it  is  desirable 
to  deal  with  the  engorged  bowel  first  by  establishing  an  artificial 
anus,  and  to  leave  the  search  for  the  obstructing  body  till  a  later  date. 
A  very  high  death-rate  must  always  be  expected  in  these  cases,  but 
statistics  prove  that,  in  cases  where  the  cause  of  the  obstruction  is  not 
at  once  obvious,  primary  enterostomy,  if  followed  by  a  satisfactory 
discharge  of  the  intestinal  contents,  gives  results  in  many  instances 
equal  to,  or  even  better  than,  treatment  directed  towards  the  cause  of 
the  trouble- 
In  the  most  urgent  cases,  where  the  patient's  abdomen  is  acutely  dis- 
tended, and  faecal  vomiting  has  been  present  for  some  time,  it  is  not 
advisable  to  administer  a  general  anaesthetic  :  if  such  is  attempted, 
the  patient's  life  is  often  lost  from  stoppage  of  the  respiration,  pre- 
cipitated possibly  by  a  severe  attack  of  faecal  vomiting.  Local 
anaesthesia  by  Schleich's  method  of  infiltration  must  be  relied  on, 
or  spinal  analgesia,  and  a  small  incision  made  through  the  linea 
alba  below  the  umbilicus  ;  the  first  presenting  coil  of  intestine  is 
withdrawn,  and  after  protecting  the  peritoneal  cavity  with  gauze  or 
swabs,  is  tapped  with  a  large  trocar  and  cannula  so  as  to  allow  the 
first  gush  of  flatus  and  faeces  to  be  carried  away  from  the  wound.  The 
opening  is  then  enlarged  sufficiently  to  allow  a  Paul's  tube  to  be 
introduced  and  tied  in,  and  whilst  the  bowel  is  emptying  itself,  it  is 
fixed  by  stitches  to  the  abdominal  wall.  The  stomach  should  always 
be  thoroughly  washed  out  with  warm  water  before  or  during  the 
operation. 

In  less  severe  cases,  the  stomach  should  be  washed  out  as  a  prelimi- 
nary measure  before  administering  the  anaesthetic.  The  head  must 
not  be  placed  on  a  lower  level  than  the  stomach,  for  fear  of  fluid 
regurgitating  along  the  cesophagus  and  choking  the  patient ;  several 
deaths  from  this  cause  have  been  reported.  The  abdomen  is  then 
opened  in  the  middle  line  below  the  umbilicus,  and  a  definite  search 
made  for  the  cause  of  the  obstruction  if  it  is  not  at  once  obvious.  The 
hand  is  first  passed  to  the  hernial  regions,  and  then  to  the  right  iliac 
fossa,  so  that  the  caecum  may  be  examined.  If  this  is  distended,  the 
cause  necessarily  lies  below  it ;  if  collapsed,  above  it.  In  the  former 
case,  the  condition  of  the  sigmoid  flexure  should  next  be  investigated, 


II36  A  MANUAL  OF  SURGERY 

and  finally,  if  this  viscus  is  collapsed,  the  hand  should  be  run  along 
the  colon,  special  attention  being  directed  to  the  splenic  flexure,  ll 
the  caecum-  is  collapsed,  perhaps  the  best  method  to  adopt  is  gently  to 
withdraw  from  the  abdomen  successive  portions  of  gut,  about  a  foot 
at  a  time.  These  are  carefully  examined,  and  replaced  by  the 
assistant  whilst  the  next  portion  is  being  withdrawn.  The  remainder 
of  the  intestines  during  this  process  are  protected  and  kept  back  by 
the  application  of  hot  sterilized  abdominal  cloths.  The  cause  of  the 
obstruction  is  in  this  way  sooner  or  later  discovered,  and  may  be 
dealt  with  according  to  circumstances.  If  the  intestines  are  too 
distended  to  allow  of  such  manipulation,  it  may  be  advisable  to  open 
or  tap  one  or  more  of  the  dilated  coils,  and  thus  reduce  the  distension 
before  proceeding  with  any  methodical  search  for  the  obstruction. 
For  this  purpose  a  small  trocar  and  cannula  is  inserted  through  the 
anti -mesenteric  border  ;  the  flatus  and  fasces  are  allowed  to  escape  ; 
and  the  puncture  is  subsequently  buried  by  a  purse-string  suture. 
It  is  sometimes  necessary  to  perform  this  in  two  or  three  different 
situations. 

Omental  bands  or  peritoneal  adhesions  should  be  divided  between 
ligatures.  The  vermiform  appendix  may  be  removed,  or  a  Meckel's 
diverticulum  excised.  A  volvulus  should  be  untwisted,  if  possible ; 
but  this  is  usually  impracticable,  owing  to  peritoneal  adhesions, 
and  in  such  cases  it  is  advisable  to  withdraw  the  coil  from  the 
abdomen,  and  if  the  large  intestine  is  involved,  an  artificial  anus 
should  be  made.  Foreign  bodies  are,  if  possible,  displaced  for- 
wards or  backwards  to  a  more  healthy  portion  of  the  bowel,  and 
then  removed  by  a  longitudinal  incision  along  the  anti-mesenteric 
border,  the  wound  being  subsequently  closed  by  a  row  of  Lembert's 
sutures.  Of  coiirse  volvulus  of  the  small  intestine  or  gangrene  of 
the  gut,  if  present,  may  necessitate  an  enterectomy,  but  it  must 
always  be  kept  in  view  that  the  essential  feature  of  the  opera- 
tion is  drainage  of  the  intestine,  and  therefore  the  establishment 
of  an  artificial  anus  as  a  temporary  measure  is  often  desirable ; 
re-union  can  be  effected  when  the  gut  has  emptied  itself. 

Chronic  Intestinal  Obstruction. 

The  Causes  of  chronic  obstruction  are  very  numerous,  and,  looked 
at  from  an  anatomical  standpoint,  may  be  divided  into  the  following 
groups : 

1.  Intra-intestinal  conditions — e.g.,  impaction  of  faeces,  foreign 
bodies,  etc. 

2.  Affections  of  the  intestinal  wall,  such  as  stricture,  new  growths, 
especially  those  of  a  cancerous  type,  adhesions  or  matting  together  of 
coils  of  intestine,  contraction  or  kinking  of  the  gut  from  mesenteric 
gland  disease,  etc. 

3.  Compression  of  the  bowel  by  tumours,  cicatricial  bands,  etc., 
developing  outside  the  intestine. 

Faecal  impaction  and  the  development  of  a  cancerous  growth  are 
far  and  away  the  commonest  causes  of  chronic  obstruction, 


INTESTINAL  OBSTRUCTION  1137 

The  General  Symptoms  of  chronic  obstruction  are  more  or  less  as 
follows :  The  patient  suffers  from  gradually  increasing  constipation, 
alternating  occasionally  with  watery  diarrhoea,  spurious  in  nature, 
and  set  up  partly  by  a  catarrhal  enteritis  due  to  the  irritation  of 
retained  faeces,  partly  by  decomposition  of  the  fsecal  material.  At 
irregular  intervals  more  severe  symptoms  arise,  consisting  of  pain, 
colic,  vomiting,  and  absolute  constipation,  owing  to  some  temporary 
complete  obstruction,  as  by  the  impaction  of  a  mass  of  undigested 
food  or  faeces,  assisted  perhaps  by  a  valve-like  fold  of  mucous 
membrane  across  the  passage.  The  abdomen  becomes  distended, 
and  coils  of  gut  may  be  seen  in  a  condition  of  active  peristalsis. 
These  attacks  usually  pass  off  after  a  time,  a  copious  evacuation  of 
the  bowels  taking  place,  either  naturally  or  after  the  administration 
of  a  purgative.  Finally,  one  of  these  seizures  persists  and  destroys 
the  patient,  either  by  exhaustion  or  by  perforation  followed  by  peri- 
tonitis, unless  suitable  treatment  is  promptly  adopted.  The  vomiting 
is  never  such  a  marked  feature  as  in 
acute  obstruction,  until  the  final  stage, 
when  it  becomes  fsecal.  The  abdomen 
is  always  more  or  less  distended  and 
tympanitic,  and  its  contour  varies  with 

the  site  of  the  obstruction;  if  this  is  .^^^  .,.. 

situated  above  the  ileo-caecal  valve,  the        /         ^^f  '      tp^^ 
swelling  is  mainly  central,  whilst  if  in       /  \^    ■■       ''^W 

the  rectum  or  lower  portion  of  the 
colon,  it  is  most  marked  in  the  flanks. 
Distended  coils  of  intestine  can  be 
plainly  seen  through  the  abdominal 
walls  in  thin  subjects,  as  also  evident 
peristalsis.  When  arising  from  simple  Fig.  494.  — Diagram  to  in- 
stricture,  no  tumour  is  to  be  felt ;  but  dicate  the  Usual  Sites  of 
■c  J       .  V  .1-  J   -r   ,1  F^CAL  Impaction — viz. .the 

if  due  to  malignant  disease,  and  if  the  ^^^^^^^  Transverse  Colon. 

abdomen   is   not    very    distended,    the         ^.nd  Sigmoid. 
growth  may  possibly  be  detected. 

Fsecal  Impaction  occurs  in  adult  females  who  have  previously 
suffered  from  chronic  constipation.  The  caecum  and  sigmoid  flexure 
are  the  most  common  seats  of  obstruction,  but  the  transverse  colon 
is  not  unfrequently  affected  (Fig.  494). _  A  doughy  tumour  may  often 
be  felt  at  one  of  these  spots,  which  can  in  some  cases  be  indented 
with  the  fingers,  whilst  in  others  it  may  be  of  stony  hardness.  The 
surface  of  the  mass  is  usually  more  or  less  nodulated,  and  the 
intestine  tender  from  the  accompanying  inflammation.  The  tem- 
perature is  often  raised,  from  toxic  absorption  through  the  intestinal 
wall,  and  there  may  even  be  a  rigor.  The  acute  symptoms  are 
always  preceded  by  a  prolonged  period  of  malaise  and  ill-health,  the 
appetite  being  defective,  the  breath  oftensive,  and  the  tongue  foul. 
On  rectal  examination  the  presence  of  scybala  may  often  be  detected. 

The  special  symptoms  arising  from  the  other  conditions  which 
give  rise  to  chronic  obstruction,  such  as  stenosis  of  the  bow^el,  have 
^een  already  referred  to. 

72 


1 138  A  MANUAL  OF  SURGERY 

The  Diagnosis  of  chronic  obstruction  is  obvious,  but  it  is  often  by 
no  means  easy  to  ascertain  the  exact  cause  of  the  trouble.  A 
thorough  investigation  of  the  case,  according  to  the  plan  given  here- 
after, must  hb  undertaken,  and  by  this  means  ■  some  conclusion  may 
be  arrived  at  as  to  the  nature  and  seat  of  the  obstruction. 

The  Treatment  of  chronic  obstruction  is  always  a  matter  of  diffi- 
culty and  anxiet}^  owing  to  the  uncertainty  often  felt  as  to  the  diag- 
nosis. It  ought  to  be  possible,  however,  to  decide  whether  the  block 
is  located  in  the  large  or  small  intestine,  since  the  character  of  the 
abdominal  distension  and  the  symptoms  are  tolerably  distinctive  in 
the  two  forms. 

If  the  case  is  not  of  the  most  urgent  t}-pe,  the  patient  is  put  to  bed, 
the  diet  restricted  to  fluids,  and  belladonna,  combined  \^-ith  small 
doses  of  calomel,  administered.  At  the  same  time  copious  enemata 
should  be  given  two  or  three  times  daily,  and  preferably  in  the  genu- 
pectoral  position,  or  lying  on  the  right  side  with  the  pelvis  well 
raised.  Purgatives  are  studiously  avoided,  as  also  opium ;  probably 
the  patient  has  taken  plenty  of  the  former  before  coming  under 
observation,  whilst  the  latter,  although  it  may  check  vomiting  and 
relieve  pain,  is  certain  to  mask  symptoms,  and  thus  prevent  the  true 
course  of  the  disease  from  being  watched.  Should  the  s}Tnptoms  be 
urgent  from  the  commencement,  or  the  treatment  suggested  fail,  the 
question  of  operation  has  to  be  faced.  If  the  obstruction  is  located 
in  the  small  intestine,  a  laparotomy  must  be  imdertaken,  using  the 
same  precautions  as  in  acute  cases.  If  the  cause  of  the  trouble  is 
easily  found,  a  coil  situated  just  above  is  withdrawn  from  the  abdo- 
men, opened,  and  a  Paul's  tube  tied  in  so  as  to  allow  retained  faecal 
material  to  escape.  It  is  wiser  not  to  deal  ^\ith  the  local  trouble 
(unless  strangulation  is  present)  until  the  urgent  s}Tnptoms  have 
disappeared.  If,  however,  the  patient's  condition  is  serious,  and  the 
site  of  obstruction  cannot  be  readily  found,  any  distended  coil  may  be 
withdra\^Ti  and  opened.  The  practice  of  allowing  numerous  coils  of 
intestine  to  escape  in  order  to  facilitate  the  exploration  of  the  abdo- 
men is  not  to  be  recommended. 

^^'hen  the  cause  of  the  obstruction  is  located  in  the  large  intestine, 
colotomy  is  usually  required.  The  lumbar  operation  may  possibly 
be  undertaken  ;  but  the  majorit}'  of  surgeons  at  the  present  time 
prefer  the  iliac  proceeding.  If  the  rectiun  or  sigmoid  flexure  is 
clearly  the  seat  of  the  trouble,  the  usual  incision  on  the  left  side  can 
be  made ;  but  if  there  is  no  indication  as  to  the  part  of  the  colon 
involved,  a  median  laparotomy  is  perhaps  preferable,  a  distended 
portion  of  the  gut  being  withdra-s^m  and  tapped,  and  a  Paul's  tube 
tied  in. 

In  chronic  peritonitis,  where  the  intestines  are  hopelessly  matted 
together,  but  little  can  be  done  beyond  the  administration  of  enemata, 
and  possibly  abdominal  massage.  The  histor}^  of  the  case  will 
generally  suffice  to  suggest  its  nature,  and  operative  treatment  should 
then  be  avoided. 

Faecal  impaction  requires  the  regular  and  repeated  administration 


INTESTINAL  OBSTRUCTION 


"39 


of  large  enemata,  given  through  a  long  tube,  whilst  belladonna  and 
calomel  may  be  also  administered.  Should  hard  scybala  be  lodged 
in  the  rectum,  it  may  be  necessary  to  break  them  up  in  situ,  and 
remove  them  piecemeal. 

*  Intussusception. 

By  Intussusception  is  meant  the  protrusion  or  invagination  of  one 
part  of  the  intestine  into  another,  giving  rise  to  the  condition  illus- 
trated in  Fig.  495.  The  constituent  parts  are  seen  more  diagram- 
matically  in  Fig.  496.  The  upper  portion  is  always  prolapsed  into 
the  lower,  except  occasionally  during  the  irregular  peristalsis  which 
takes  place  during  the  death-throes.  The  invaginated  portion  (a)  is 
known  as  the  intussitsceptj  m,  whilst  the  lower  portion  (S)  into  which 
it  is  protruded  is  known 
as  the  intussuscipiens.  An 
intussusception,  then,  con- 
sists of  three  layers — the 
outer  or  ensheathing  layer 
(i.)  an  inner  or  entering 
layer  (iii.),  and  between  the 
two' the  returning  layer  (ii.). 
Not  only  does  the  intestine 
enter,  but  with  it  a  certain 
portion  of  the  mesentery; 
and  it  is  to  the  constriction 
of  the  vessels  contained 
therein,  and  later  on  possi- 
bly to  their  complete  ob- 
struction, that  the  more 
serious  phenomena  are  due 
— e.g.,  gangrene,  perfora- 
tion, or  rupture  of  the  gut. 
In  addition  to  this,  actual 
obstruction  to  the  passage 
of  the  intestinal  contents 
may  be  brought  about  by 
the  traction  of  the  mesen- 
tery, which  renders  the  oriiice  of  the  intussusceptum  slit-like,  by  the 
swelling  and  congestion  of  the  intestinal  wall,  or  perhaps  by  the 
impaction  of  a  portion  of  undigested  food  within  the  lumen  of  the  gut. 
Peritonitis  usually  follows,  being  possibly  due  to  the  invasion  of  a 
portion  of  the  damaged  intestinal  wall  by  the  B.  coli  or  other  intestinal 
organisms.  If  limited  in  extent,  it  may  merely  lead  to  irreducibility 
of  the  intussusception,  owing  to  adhesions  forming  between  the  serous 
coats  of  the  entering  and  returning  layers.  In  other  cases,  and  es- 
pecially when  ulceration  or  gangrene  is  present,  a  diffuse  peritonitis 
may  be  lighted  up,  and  this  may  result  in  the  death  of  the  patient.  The 
bowel  above  the  site  of  invagination  becomes  dilated,  and  possibly 
stercoral  ulcers  may  be  formed,  particularly  in  the  more  chronic  cases. 


Fig.   495. — Intussusception.     (From   Speci 
MEN  IN  College  of  Surgeoxs'  Museum.) 


II40 


A  MANUAL  OF  SURGERY 


m 


/r\ 


—  n 


The  Cause  of  intussusception  is  generally  stated  to  be  irregular  and 
violent  peristalsis,  however  induced,  whether  by  the  presence  of  irritat- 
ing ingesta,  or  by  the  existence  of  polypoid  tumours,  malignant 
growths,  or  possibly  worms ;  the  presence  of  scybalous  masses  of 
faeces  may  also  lead  to  its  occurrence.  In  a  few  cases  injury — e.g., 
blows  on  the  abdomen,  or  severe  strains  during  jumping — -have  been 
held  responsible  for  its  onset,  but  very  frequently  no  cause  can  be 
assigned. 

Intussusception  is  met  with  in  four  chief  situations:  (i)  The  ileo- 
cecal variety  is  much  the  commonest,  constituting  44  per  cent,  of  all 
cases  (Treves).  In  it  the  ileum  is  protruded  into  the  colon,  the  apex 
of  the  intussusceptum  being  formed  'by  the  ileo-caecal  valve.  Owing 
to  the  great  mobility  of  the  ileum,  a  considerable  portion  of  gut  may 

be  thus  invaginated,  and  a  good 
many  cases  have  been  observed  in 
which  it  has  actually  projected 
through  the  anus.  (2)  The  enteric 
variety  involving  the  small  intestine 
comes  next  in  order  of  frequency, 
being  met  with  in  30  per  cent,  of 
the  cases.  It  is  most  often  seen  in 
the  lower  jejunum,  and  is  rarely  of 
great  size.  (3)  The  col.'c  form  may 
occur  at  any  "part  of  the  colon  or 
rectum,  and,  owing  to  the  fixity  of 
this  portion  of  the  gut,  is  limited 
in  extent.  It  is  met  with  in  about 
18  per  cent,  of  the  cases.  (4)  The 
ileo -colic  only  occurs  in  8  per  cent. ; 
in  it  the  ileum  is  prolapsed  through 
the  ileo-caecal  valve,  which  for  a 
time  retains  its  normal  position  ; 
but  after  the  intussusception  has 
attained  a  certain  size,  the  valve 
and  caecum  are  also  invaginated  into 
the  ascending  colon.  In  each  of 
these  varieties,  except  the  last,  the 
intussusception  grows  at  the  expense  of  the  external  or  ensheathing 
layer,  the  apex  of  the  protrusion  being  always  formed  by  the  same 
portion  of  gut ;  but  in  the  ileo-colic  variety,  as  just  stated,  it  increases 
by  the  passage  of  more  and  more  of  the  ileum  through  the  valve ; 
after  a  time  this  stops,  and  is  replaced  by  the  ordinary  form  of  growth. 
Intussusception  is  occasionally  met  with  as  a  post-mortem  pheno- 
menon, resulting  from  the  irregular  intestinal  movements  which  occur 
during  the  death  crisis.  The  condition  is  recognised  as  being  of  this 
nature  by  the  absence  of  inflammatory  signs,  by  the  fact  that  it  is 
sometimes  due  to  a  reverse  peristalsis,  and  by  more  than  one  intus- 
susception being  present. 

The  Clinical  Histoiy  varies  according  to  whether  the  condition 
is  acute  or  chronic. 


U 


Fig. 


496. — Diagram  of  Intus- 
susception. 


,  Intussusceptum  ;  b,  intussus- 
cipiens ;  I.,  ensheathing  layer; 
II. ,  returning  layer ;  III. ,  entering 
layer. 


INTESTINAL  OBSTRUCTION  1141 

Acute  Intussusception  occurs  most  frequently  in  infants  under  two 
years,  being  the  more  common  cause  of  obstruction  at  this  age.*  The 
onset  is  sudden,  the  child  being  attacked  with  severe  pain,  possibly 
localized  and  more  or  less  paroxysmal  at  first,  but  rapidly  becoming 
continuous  and  diffused  over  the  abdomen.  This  is  followed  by  vomit- 
ing, which,  however,  is  less  severe  than  in  acute  strangulation,  and 
not  so  often  faeculent.  The  patient  rarely  suffers  from  absolute  con- 
stipation ;  but  diarrhoea  and  the  discharge  of  blood-stained  mucus, 
perhaps  associated  with  tenesmus,  and  often  without  faeces,  are 
common.  Collapse  soon  supervenes,  and  in  the  worst  cases  this  may 
be  so  severe  as  to  kill  the  patient  within  twenty-four  hours;  other- 
wise a  fatal  issue  from  exhaustion  or  peritonitis  is  reached  within  a 
week.  On  examining  the  abdomen,  but  little  distension  or  tender- 
ness is  noted,  unless  acute  peritonitis  is  present ;  in  more  than  half 
the  cases  a  distinct  tumour  can  be  felt,  cylindrical  in  outline,  and 
sometimes  described  as  '  sausage- shaped,'  following  the  course  of  the 
intussusception  and  generally  curved,  owing  to  the  traction  of  the 
mesentery.  In  the  ileo-caecal  variety  it  extends  from  the  right  iliac 
fossa  across  the  brim  of  the  pelvis  to  the  left,  the  colon  being 
dragged  downwards.  This  may  be  associated  with  an  absence  of 
resistance  in  the  right  fossa,  which  feels  empty,  constituting  what  is 
known  as  the  '  signe  de  Dance.'  In  other  cases  the  tumour  may  be 
more  limited,  and  distinctly  moveable.  The  rectum  should  always  be 
carefully  examined,  and  preferably  under  an  anaesthetic  so  as  to 
permit  a  thorough  bimanual  examination  of  the  rectum  and  abdo- 
men to  be  made. 

A  natural  cure  occasionally  follows,  resulting  either  from  spon- 
taneous reduction,  or  from  sloughing  of  the  intussusception,  whilst 
the  peritoneal  cavity  is  shut  off  by  a  circle  of  plastic  lymph  uniting 
the  ensheathing  and  entering  layers  of  the  gut.  When  the  latter 
takes  place,  tlie  subsequent  condition  is  not  very  satisfactory,  owing 
to  the  formation  of  a  fibrous  stricture. 

The  association  of  intussusception  with  Henoch's  purpura  is  an 
interesting  phenomenon.  This  disease  is  characterized  by  a  purpuric 
eruption,  joint  pains,  vomiting,  and  intestinal  colic,  the  latter  prob- 
ably due  to  haemorrhage  into  or  from  the  intestinal  wall.  There  is 
no  regularity  in  the  evolution  of  the  symptoms,  and  when  the  intes- 
tinal phenomena  are  early,  the  diagnosis  from  intussusception  may 
be  difficult.  In  not  a  few  cases  intussusception  develops,  its  exis- 
tence being  suggested  by  the  severity  and  persistence  of  the  colic 
and  perhaps  by  tenesmus  and  loss  of  blood  per  anum,  and  confirmed 
by  the  discovery  of  a  tumour. 

Chronic  Intussusception  occurs  more  frequently  in  adults  than  in 
children,  the  onset  beitig  gradual  and  the  course  varying  widely  in 
different  cases.  The  patient  complains  of  intermittent  attacks  of 
pain  of  a  colicky  nature,  which  recur  at  intervals,  and  become 
more   frequent   and   prolonged    as  the  case  progresses.     Vomiting 

*  Out  of  187  cases  of  intussusception,  H.  L.  Barnard  found  72  per  cent,  were 
under  one  year  of  age. 


1 142  A  MANUAL  OF  SURGERY 

is  often  but  little  marked  during  the  intermissions.  The  bov/els  are 
irregular  in  their  action,  and  there  is  sometimes  a  blood-stained 
mucous  discharge.  The  general  condition  is  not  at  first  much 
affected,  but  as  the  case  progresses,  emaciation  and  general  asthenia 
may  supervene.  On  examination,  the  abdomen  is  found  to  be  flaccid 
and  free  from  tenderness,  although  visible  coils  of  intestine  may  be 
observed  in  some  cases,  and  perhaps  a  tumour  felt.  The  symptoms 
are  rather  those  of  subacute  enteritis  and  chronic  obstruction  than  of 
strangulation,  and  the  case  may  be  brought  to  a  fatal  termination 
either  by  an  acute  attack  of  obstruction  or  by  peritonitis.  It  may, 
however,  last  a  long  time  before  being  recognised. 

Treatment. — In  the  most  acute  forms  of  the  disease  but  little  can 
be  done,  owing  to  the  extreme  prostration  of  the  patient ;  but  in  the 
less  severe  and'  in  the  chronic  cases  the  results  are  generally  satis- 
factory if  the  condition  is  recognised. 

In  acute  intussusception  the  patient  should  be  at  once  placed  under 
the  influence  of  opium,  in  order  to  still  peristalsis  and  prevent  the 
increase  of  the  tumour.  Inflation  of  the  bowel  with  air,  or  the  injec- 
tion of  copious  enemata  of  warm  water  or  oil,  may  then  be  carefully 
undertaken.  No  undue  force  shoald  be  employed  in  this  proceeding, 
and  a  hand  placed  over  the  tumour  may  enable  the  surgeon  to  detect 
whether  or  not  it  has  been  successful.  It  is  performed  by  raising  the 
patient's  pelvis  and  inserting  into  the  rectum  a  catheter,  with  which 
is  connected  an  indiarubber  tube  and  funnel,  held  about  i^  or  2  feet 
above  the  abdomen.  Should  this  not  succeed,  laparotomy  should  be 
performed  without  delay,  and  the  condition  of  the  intussusception  in- 
vestigated. An  attempt  is  then  made  to  reduce  it  by  grasping  the 
tumour  in  one  hand  and  gently  trying  to  peel  off  the  ensheathing 
layer  from  the  upper  portion  of  the  bowel,  which  is  steadied  by  the  other 
hand.  In  about  half  the  cases  reduction  is  impracticable,  owing  to  the 
presence  of  adhesions,  and  then  if  the  general  condition  of  the  patient 
is  fairly  good,  the  intussusception  should  be  removed  and  the  divided 
ends  of  the  bowel  united  by  suture.  If,  however,  the  patient  is  in  a 
condition  of  profound  shock,  all  that  can  be  done  is  to  fix  the  bowel 
in  the  wound,  and  make  an  artificial  anus.  The  results  of  these  pro- 
cedures are  anything  but  encouraging,  as  it  has  been  shown  that  few 
children  recover  if  anything  more  than  simple  reduction  is  required 
during  a  laparotomy. 

Chronic  intussusception  is  more  favourable  in  its  prognosis.  It  is 
frequently  unrecognised, until  an  exploration  of  the  abdomen  is  made, 
and  hence  reduction  by  inflation  is  not  commonly  attempted.  In 
some  cases  the  tumour  may  be  reduced  by  simple  manipulation,  but 
as  a  rule  too  many  adhesions  are  present.  Excision  of  the  mass  should 
then  be  undertaken,  and  the  results  gained  have  been  very  encouraging. 

Diagnosis  and  Method  of  Examination  of  a  Case  of  Intestinal 
Obstruction. 

A  grave  responsibility  rests  upon  the  medical  attendant  in  every 
case  of  obstruction.     The  condition  is  incompatible  with  life  beyond 


INTESTINAL  OBSTRUCTION  1143 

a  few  days,  and  the  time  occupied  in  observing  the  patient  and  making 
up  one's  mind  as  to  the  nature  of  the  case  is  valuable  time  lost,.which 
may  ruin  the  patient's  chances  of  recovery.  There  are  three  things 
to  be  avoided  in  conducting  a  case  of  this  nature :  (i.)  Purgatives. — 
The  patient  has  probably  taken  plenty  before  sending  for  assistance, 
and  the  only  result  to  be  expected  is  an  increase  of  pain  and  vomiting, 
(ii.)  Opium  has  its  place  in  the  treatment  of  obstruction — viz.,  in 
relieving  the  agony  associated  with  its  onset ;  but  beyond  this  it 
merely  masks  symptoms,  and  can  do  no  good  but  comfortably  to  con- 
duct the  patient  to  the  grave.  It  causes  intestinal  paralysis,  and 
therefore  may  check  the  most  distressing  symptom,  vomiting,  but  it 
aggravates  the  condition  which  needs  treatment,  (iii.)  Delay  in  send- 
ing for  surgical  assistance  is  responsible  for  more  deaths  tlaan  is  the 
condition  itself.  When  once  the  gut  has  become  generally  paralyzed, 
there  is  but  little  hope  for  the  patient. 

In  the  investigation  of  a  case  various  problems  of  some  difficulty 
have  to  be  solved,  and  it  is  well  to  undertake  this  task  methodically. 

1.  The  medical  attendant  must  satisfy  himself  that  obstruction  is 
present,  and  not  merely  aggravated  constipation.  In  the  latter,  how- 
ever, flatus  passes  readily,  and  the  general  condition  is  not  much 
impaired.  In  obstruction  there  is  usually  a  complete  arrest  of  flatus, 
and  abdominal  pain  and  vomiting  often  point  to  the  existence  of  some 
serious  lesion. 

2.  It  is  essential  to  ascertain  whether  the  obstruction  is  dynamic  or 
mechanical.  The  differences  and  distinctions  between  these  have  been 
already  alluded  to  (p.  1129). 

3.  The  question  as  to  whether  the  lesion  is  acute  or  chronic  must 
next  be  settled.  Initial  severe  pain  and  collapse,  the  rapid  onset  of 
vomiting,  a  localized  spot  of  fixed  tenderness,  and  the  quick  depre- 
ciation of  the  patient,  all  point  to  some  acute  vascular  lesion  of  the 
intestinal  wall,  which  will  prove  fatal  in  a  few  days  unless  suitably 
treated.  On  the  other  hand,  chronic  cases  are  often  preceded  by 
constipation  and  other  troubles  of  defaecation ;  they  come  on  gradually, 
and  are  at  first  unaccompanied  by  constant  pain  and  vomiting, 
although  colic  of  a  severe  type  may  be  present.  The  examination  of 
the  abdomen  is  also  of  the  greatest  assistance ;  in  acute  cases  intes- 
tinal paralysis  dominates  the  picture  ;  in  chronic  cases,  vigorous  peris- 
talsis can  be  felt  and  often  seen,  unless  the  patient  has  been  left  too  long. 

4.  An  eff"ort  must  be  made  to  determine  the  site  and  nature  of  the 
lesion.    As  to  the  question  of  site,  the  following  points  may  be  noted  :* 

(fl)  When  the  ^lpper  part  of  the  small  intestine  is  involved,  the  vomit- 
ing is  early,  tumultuous,  and  persistent ;  the  vomit  is  biHous,  but  not 
faecal.  Abdominal  distension  involves  the  epigastrium,  and  particu- 
larly the  stomach.  The  lower  part  of  the  abdomen  may  be  retracted. 
Collapse  is  early  and  rapidly  increases.  The  thirst  is  terrible,  the 
urinary  secretion  slight  or  even  suppressed ;  gas  and  faeces  may  pass 
from  the  lower  bowel. 

{b)  When  the  lower  part  of  the  small  intestine  or  cceciim  is  involved, 

*  See  Tavel,  Revtie  de  Chirurgie,  August,  etc.,  1903. 


ii44  A  MANUAL  OF  SURGERY 

faeces  and  flatus  cannot  pass  ;  the  vomiting  becomes  offensive,  but 
scarcely  faecal ;  meteorism  is  marked,  and  involves  the  central  part 
of  the  abdomen,  the  flanks  not  being  affected.  In  chronic  cases 
peristalsis  is  very  evident. 

(c)  When  the  colon  or  rectum  is  the  site  of  obstruction  ;  the  symp- 
toms are  more  chronic  as  a  rule,  and  even  in  acute  cases,  such  as 
volvulus,  the  initial  collapse  is  slight.  Vomiting  is  later  in  appear- 
ing, but  may,  of  course,  become  faecal.  Meteorism  may  be  very 
marked,  and  involves  the  flanks  as  well  as  the  centre  ;  sometimes  it 
is  possible  to  recognise  that  the  lesion  is  not  lower  than  the  splenic 
flexure  by  distension  of  the  left  flank  being  absent. 

The  determination  of  the  nature  of  the  case  will  largely  turn  on  the 
patient's  previous  history,  and  not  uncommonly  one  has  to  admit  that, 
although  one  can  locate  the  site  of  mischief,  there  is  no  clue  as  to  its 
nature  beyond  the  generalizations  learnt  from  statistics. 

The  actual  examination  of  the  patient  is  carried  on  along  the 
following  lines : 

1.  The  Previous  History  of  the  case  should  be  carefully  gone  into, 
in  order  to  ascertain  whether  or  not  the  patient  has  suftered  from 
biliary  colic,  chronic  constipation,  acute  diffuse  or  localized  peri- 
tonitis, uterine  derangements,  syphilis  or  dysentery,  etc. 

2.  The  History  of  tlie  Present  Attack  should  then  be  ascertained, 
noting  especially  the  manner  of  onset,  whether  acute  or  gradual,  the 
duration  of  the  symptoms,  and  whether  or  not  preceding  subacute 
attacks  have  occurred  from  time  to  time. 

3.  The  more  prominent  Symptoms  must  then  be  considered. 

{a)  Collapse  is  due  partly  to  reflex  nervous  disturbance,  partly  to 
the  absorption  of  toxic  materials,  and  partly  to  withdrawal  of  fluid 
from  the  body  as  a  result  of  the  vomiting  ;  the  portal  area  is  also 
much  engorged,  and  this  adds  to  the  want  of  fluid  in  the  systemic 
circulation.  The  nervous  cause  is  most  active  in  the  early  stage  of 
acute  obstruction,  especially  in  infants,  whilst  the  toxic  is  largely 
responsible  for  the  exhaustion  seen  at  the  end  of  an  acute  attack  or 
in  the  chronic  variety.  Hence  collapse  is  early  in  acute  cases,  late 
in  chronic.  Moreover,  the  higher  the  lesion,  the  greater  the  shock, 
owing  to  the  fact  that  the  upper  portion  of  the  bowel  is  more 
intimately  associated  with  the  sympathetic  nervous  centres. 

(h)  Pain  is  a  very  marked  symptom,  being  usually  referred  at  first 
to  a  little  above  the  umbilicus,  and  is  more  severe  in  lesions  of  the 
small  intestine  than  in  the  colon.  It  varies  greatly  with  the  com- 
pleteness or  not  of  the  obstruction.  This  matter  has  been  especially 
emphasized  by  Treves,  who  has  pointed  out  that  when  the  obstruc- 
tion is  only  partial,  the  pain  is  intermittent ;  but  when  the  block  is 
complete,  the  pain  becomes  continuous.  Hence  in  acute  strangula- 
tion pain  is  almost  invariably  constant,  whereas  in  stricture  it  is 
markedly  intermittent  and  of  a  colicky  nature.  The  amount  of  pain, 
moreover,  varies  with  the  nervous  excitability  of  the  patient ;  it 
is  increased  by  anything  which  induces  peristalsis  {e.g.,  food  or 
purgatives),  and  it  is  diminished  on  the  supervention  of  gangrene. 


INTESTINAL  OBSTRUCTION  1145 

(c)  A  hdoniinal  tenderness  is  rarely  observed  in  the  early  stages,  being 
caused  by  the  onset  of  peritonitis. 

(d)  Vomiting  is  an  almost  invariable  accompaniment  of  obstruc- 
tion. Its  cause  has  been  already  discussed  (p.  1109).  When  the 
obstruction  is  situated  in  the  jejunum  or  upper  part  of  the  ileum, 
the  vomiting  is  never  absolutely  fsecal,  although,  if  it  has  been  tem- 
porarily checked  by  opium,  the  ejecta  may  be  exceedingly  offensive 
and  dark  in  colour,  owing  to  decomposition  ;  faecal  or  stercoraceous 
vomiting  can  only  come  from  an  obstruction  to  the  lower  ileum  or 
colon. 

(e)  Constipation,  although  usually  present,  is  not  necessarily 
absolute,  as  it  is  possible  for  the  lower  bowel  to  be  emptied  in  cases 
of  obstruction,  whilst  the  patient  sometimes  passes  a  motion  as 
gangrene  supervenes  or  death  is  approaching. 

4.  A  most  careful  Physical  Examination  must  now  be  instituted. 

{a)  An  inspection  of  the  uncovered  abdomen  should  first  be  made. 
The  amount  and  character  of  the  distension  is  observed,  and  whether 
or  not  it  is  situated  in  the  centre,  as  when  small  intestine  is  involved, 
or  in  the  flanks  when  the  obstruction  is  in  the  rectum  or  sigmoid 
flexure.  The  existence  of  visible  peristalsis  or  enlarged  coils  of 
intestine  should  be  noted ;  such  are  rarely  seen  in  the  acute  cases. 
but  may  be  very  evident  in  the  chronic  forms.  Sometimes  one  coil 
remains  persistently  distended  and  always  at  the  same  spot ;  its 
appearance  always  suggests  that  the  site  of  obstruction  is  not  far 
away.  The  rise  and  fall  of  the  abdomen  during  respiration  should 
be  watched  to  ascertain  whether  the  movements  are  equal  on  both 
sides,  or  if  any  prominence,  such  as  would  be  caused  by  a  tumour, 
is  noticeable.  The  general  condition  of  the  patient,  whether 
emaciated  or  not,  as  also  the  appearance  of  the  face  and  the  position 
in  which  he  lies,  should  be  observed. 

(h)  All  the  normal  and  abnornal  hernial  apertures  are  thoroughly 
investigated,  and  a  careful  examination  made  from  the  rectum  and 
vagina. 

{c)  The  abdomen  is  carefully  palpated,  so  as  to  ascertain  the 
existence  of  any  tumour  or  increased  resistance  of  the  abdominal 
walls. 

{d)  Peraission  may  also  throw  some  light  on  the  case. 

(e)  Finally,  some  information  may  be  gained  by  the  use  of  enemata. 
When  the  obstruction  is  low  down  and  not  far  from  the  anus,  it 
may  be  impossible  to  introduce  more  than  a  small  quantity  of  fluid, 
and  this  in  spite  of  modifying  the  position.  Too  much  reliance, 
however,  must  not  be  placed  on  this  sign.  It  is  also  desirable  to 
auscultate  the  colon  during  the  administration  of  a  large  enema ; 
it  is  sometimes  possible  to  hear  gurgling  sounds  as  far  round  as  the 
caecum,  indicating  that  the  large  intestine  is  free  from  obstruction. 
We  would  call  attention  here  to  the  fallacy  of  using  a  long  tube  in 
the  expectation  of  being  able  to  pass  it  into  the  sigmoid  flexure.  A 
careful  study  of  the  rectum  and  its  valves  w-ill  show  the  difficulty 
of  this,  whilst  the  use  of  the  genu-pectoral  position  renders  it 
unnecessary. 


CHAPTER  XXXVII. 
AFFECTIONS  OF  THE  RECTUM  AND  ANUS. 

The  rectum  from  the  anatomical  standpoint  consists  of  the  lowest  4  inches  of 
(he  intestinal  canal,  but  for  the  surgeon  it  represents  the  lower  6  or  8  inches 
which  can  be  reached  more  or  less  from  the  anus.  Examination  of  the  rectum 
is  carried  out  by  the  following  methods  : 

I.  Digital  Examination,  in  which  the  index  finger  is  inserted  through  the  anus. 
Soap  should  be  smeared  under  the  nail  and  into  the  semilunar  fold  at  its  baee,  so 


Fig.  497. — Examination  of  the  Rectum  by  Martin's  Proctoscope. 

The  patient  is  in  the  genu-pectoral  position,  so  that  when  the  proctoscope  is 
introduced  air  rushes  in  and  distends  the  rectum  ;  the  observer,  utilizing 
either  an  electric  head-lamp  or  a  laryngoscopic  mirror,  can  easily  see  the 
interior.  In  the  above  diagram  the  projection  of  Houston's  valves  is  clearly 
indicated. 


as  to  prevent  faecal  matter  from  lodging,  and  vaseline  may  be  applied  both  to 
the  finger  and  to  the  anus  to  facilitate  introduction.  It  is,  of  course,  advisable  to 
have  the  bowel  unloaded  by  purgative  or  enema  before  an  examination  is  made. 
The  patient  lies  on  the  left  side  in  the  gynaecological  position,  and  the  intro- 
duction of  the  finger  is  usually  less  painful  if  he  strains  down  at  the  same  time. 

1146 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1147 

A  bimanual  examination  can  be  conducted  with  the  finger  in  the  rectum,  and  the 
other  hand  pressed  deeply  over  the  patient's  hypogastrium.  Although  the  great 
majority  of  rectal  lesions  occur  within  the  lowest  inch  and  a  half  of  the  bowel, 
the  surgeon  must  never  omit  to  explore  the  upper  part  of  the  rectum,  as  an 
unsuspected  polypus  or  tumour  may  often  be  discovered  in  this  way  ;  the  pelvic 
parietes  should  also  be  included  in  the  scope  of  the  investigation. 

2.  The  introduction  of  the  whole  hand  has  been  recommended  by  some,  but 
the  hand  must  be  unusually  small  which  can  be  thus  utilized. 

3.  Visual  Examination  is  a  most  valuable  proceeding.  Martin's  proctoscope 
(Fig.  497)  is  the  most  suitable  appliance  to  use  for  this  purpose,  but  an  ordinary 
Fergusson's  speculum  answers  well.  The  patient  is  placed  in  the  genu-pectoral 
or  in  an  elevated  lithotomy  position ;  the  former  is  preferable,  in  that  it  allows 
intestines  and  uterus  to  drop  forwards  away  from  the  rectum.  Two  index 
fingers,  well  greased  and  held  back  to  back,  are  then  introduced  into  the  bowel, 
and  the  anus  stretched  in  several  axes,  so  that  its  muscular  tone  is  lost  for  a 
time.  The  proctoscope  can  then  be  introduced,  and  it  will  be  found  that  if  the 
patient  is  in  the  correct  position  the  rectum  becomes  ballooned  by  an  inrush  of 
air,  and  its  interior  can  be  clearly  seen  ;  a  head-lamp  or  a  laryngoscopic  mirror  is 
sometimes  useful  in  order  to  illuminate  the  interior.  Houston's  valves  stand  out 
clearly,  and  often  obstruct  the  view  of  the  upper  part,  but  they  can  usually  be 
pulled  aside  by  a  book,  or  pushed  aside  by  the  speculum,  or  even  if  necessary 
they  can  be  divided.  In  this  way  6  inches,  if  not  more,  of  the  bowel  can  be 
brought  under  the  eye  of  the  surgeon,  and  topical  applications  can  be  made. 

A  sigmoidoscope  may  be  employed  for  seeing  the  condition  of  the  upper  part  of 
the  rectum  and  of  the  lower  end  of  the  sigmoid  flexure.  It  consists  of  a  hollow 
straight  tube,  14  inches  long,  with  its  length  marked  on  the  outside  so  that  one 
may  know  how  far  it  has  been  introduced.  Suitable  arrangements  are  made  for 
distending  the  bowel  with  air,  and  for  illuminating  and  seeing  its  interior.  A 
blunt-ended  obturator  is  used  to  facilitate  its  introduction  in  the  first  instance,  but 
this  is  withdrawn  when  it  is  well  into  the  bowel. 

Congenital   Malformations — Imperforate  Anus    or   Rectum. — The 

lowest  portion  of  the  intestinal  canal  arises  from  the  union  of  two 
separate  divisions.  The  upper,  developed  from  the  lowest  portion  of 
the  primitive  hind-gut,  is  originally  in  communication  with  the  bladder, 
and  forms  a  joint  cavity  or  cloaca,  the  two,  however,  being  early 
separated ;  the  posterior  segment,  which  becomes  the  rectum,  extends 
down  into  the  pelvis,  to  be  joined  by  an  epiblastic  pit  or  involution 
growing  in  from  the  perineum  known  as  the  'proctodeum.'  Failures 
in  typical  development  may  be  due  either  (a)  to  the  proctodeum  being 
absent  or  stenosed ;  (b)  to  the  rectum  being  absent  (Fig.  498,  A)  or 
retaining  in  measure  its  cloacal  condition  and  opening  into  some  other 
viscus — e.g.,  the  bladder,  urethra,  vagina,  or  vulva  (Fig,  498,  B); 
or  {c)  to  want  of  union  between  the  upper  and  lower  segments 
(Fig.  498,  C).  The  following  are  the  chief  clinical  varieties  of 
malformation  met  with : 

(i.)  Absence  of  the  anus,  with  or  without  development  of  the 
rectum,  which,  if  present,  may  open  in  some  abnormal  situation. 
In  such  cases,  the  important  question  to  be  settled  by  the  practi- 
tioner is  the  existence  or  not  of  a  rectum,  and  this,  unfortunately, 
cannot  always  be  determined  without  an  open  exploration  through 
the  perineum ;  if,  however,  during  crying  and  straining  there  is  a 
distinct  bulge  in  the  middle  line  at  the  spot  where  the  anus  should 
be,  there  is  every  likelihood  of  the  viscus  being  present.  If  so,  it  is 
always  distended  and  club-shaped,  usually  lined  with  peritoneum  in 


II4S 


A  MANUAL  OF  SURGERY 


front,  and  often  below.  If  the  rectum  is  absent,  it  usually  ends  near 
the  pelvic  brim,  and  is  merely  represented  by  a  fibrous  cord  below 
that  level  (Fig.  498,  A),  whilst  the  bony  pelvis  is  often  atrophic  and 
its  outlet  much  reduced  in  size.  Thus  in  one  such  case  an  interval 
of  only  ^  inch  was  present  between  a  sound  passed  into  the  urelhra 
and  the  tip  of  the  coccyx. 

(ii.)  A  membranous  septum  may  persist  between  the  upper  and 
lower  segments,  placed  about  an  inch  from  the  anus,  and  allowing 
the  retained  meconium  to  push  it  downwards.  This  is  the  type  of 
malformation  most  commonly  observed  (Fig.  498,  C). 

(iii.)  An  anus  is  occasionally  present,  whilst  the  rectum  ends 
blindly  above  the  pelvic  brim,  or  opens  elsewhere. 

(iv.)  The  anus,  though  present,  may  be  contracted. 

The  Treatment  of  these  cases  must  be  instituted  at  as  early  a  date 
after  birth  as  possible,  so  as  to  prevent  intestinal  obstruction. 


Fig. 


ABC 

. — Three  Varieties  of  Malformation  of  Rectum.     (Tillmanns.) 


In  A  the  bowel  ends  at  the  brim  of  the  pelvis  in  a  cul-de-sac,  and  there  is  no 
evidence  of  an  anus  ;  in  B  the  anus  is  also  absent,  but  the  bowel  opens  into 
the  bladder ;  in  C  the  anus  and  bowel  are  only  separated  by  a  small  space. 


Anal  stenosis  is  readily  dealt  with  by  regular  dilatation  with 
bougies. 

Where  a  membranous  septum  persists  between  the  proctodeum 
and  rectum,  a  large  trocar  and  cannula  may  be  passed  through  it, 
and  the  meconium  allowed  to  escape ;  the  aperture  thus  made  is 
enlarged,  and  maintained  by  the  subsequent  passage  of  bougies. 

Where  the  anus  is  absent,  whether  there  is  any  indication  of  the 
presence  of  a  rectum  or  not,  a  perineal  incision  is  first  made  through 
the  site  of  the  anus,  and  carried  upwards  and  backwards  along  the 
concavity  of  the  sacrum  strictly  in  the  middle  line  for  not  more  than 
2  inches.  It  is  an  open  question  whether  it  is  justifiable  to  proceed 
further  by  removing  the  coccyx  and  part  of  the  sacrum  (Kraske's 
operation,  p.  1 173 ),  since  the  membranes  of  the  spinal  cord  extend 
much  further  down  in  the  infant  than  in  the  adult.  If  found,  the 
dilated  and  bulbous  cul-de-sac  is  drawn  down  as  far  as  possible,  and 
opened  towards  its  posterior  aspect ;  the  mucous  membrane  is  then, 
if  feasible,  stitched  all  round  to  the  skin  so  as  to  leave  no  surface 
to   granulate,   thereby  preventing    subsequent    stenosis.      In   cases 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1 149 

where  no  rectum  is  present,  colotomy  must  be  performed,  and  by 
preference  the  iliac  operation,  since  the  space  between  the  crest  of 
the  ilium  and  the  last  rib  is  exceedingly  small  in  an  infant.  When 
once  a  passage  for  the  fseces  is  established,  abnormal  openings  into 
the  bladder,  etc.,  usually  close  without  difficulty. 

Various  malformations  in  connection  with  the  post-anal  gut  have 
been  already  described  (p.  716). 

Injuries  of  the  rectum  are  usually  due  to  falling  on  some  pointed 
body,  such  as  a  stick  or  railing,  or  upon  a  piece  of  broken  china. 
They  are  sometimes  due  to  the  forcible  introduction  of  foreign  bodies 
by  lunatics  or  criminals.  They  may  merely  involve  the  mucous 
membrane,  or  may  penetrate  the  perineal  tissues,  enter  the  bowel, 
and  penetrating  the  upper  wall,  lay  open  the  peritoneal  cavity. 
Haemorrhage,  pain,  and  shock  follow,  and  acute  peritonitis  if  the 
serous  membrane  has  been  encroached  on.  Inflammatory  troubles 
may  involve  the  peri-rectal  tissues,  and  sinuses  may  result  from 
suppuration.  A  thorough  examination  must  be  made  under  an 
anaesthetic,  and  the  wounds  either  sutured  or  left  open  to  granulate. 
In  women  the  recto-vaginal  septum  may  be  torn,  but  the  surgeon 
need  be  in  no  great  hurry  to  interfere,  since  the  opening  usually 
closes  as  cicatrization  progresses ;  in  some  cases,  however,  where 
the  lesion  is  of  some  length,  and  the  margins  not  bruised  or  inflamed, 
immediate  suturing  may  be  desirable.  If  the  peritoneal  cavity  has 
been  laid  open,  a  laparotomy  is  usually  required  in  order  to  cleanse  it 
and  close  the  wound  ;  if,  however,  the  wound  is  small  and  the  rectum 
at  the  time  of  injury  empty,  it  may  be  justifiable  to  delay  interference 
till  some  sign  of  inflammatory  reaction  shows  itself;  a  piece  of 
sterilized  gauze  packing  in  the  rectal  wound  will  often  suffice  to  limit 
the  inflammatory  mischief.  Peri-rectal  complications  are  dealt  with 
as  they  arise. 

Foreign  Bodies  are  derived  from  various  sources.  Generally  they 
have  been  swallowed,  and  have  traversed  the  intestinal  canal.  Fish- 
bones and  small  tooth-plates  are  most  commonly  seen,  and  they 
usually  lodge  just  above  the  anus  in  one  of  the  so-called  '  pouches 
of  Morgagni.'  They  give  rise  to  severe  pain,  especially  on  de- 
faecation,  and  possibly  to  some  form  of  peri-rectal  abscess.  Large 
gall-stones  are  sometimes  lodged  in  the  lower  end  of  the  rectum,  just 
above  the  sphincter,  as  well  as  a  Murphy  button  when  it  has  been 
set  free.  Foreign  bodies  may  be  introduced  from  without,  and  cause 
various  forms  of  traumatic  inflammatory  lesions. 

Inflammation  of  the  Rectum  (Proctitis)  causes  pain  of  a  bearing- 
down  character,  a  sensation  of  fulness,  constantly  recurring  tenesmus, 
accompanied  by  a  discharge  of  mucus,  muco-pus,  or  blood.  It  may 
arise  from  any  local  source  of  irritation — e.g.,  the  presence  of  foreign 
bodies,  or  of  a  polypus,  parasites,  or  piles  ;  gonorrhoea  is  an  occa- 
sional cause — in  women  possibly  owing  to  infection  from  the  vaginal 
discharge,  in  men  probably  from  direct  infection.  In  dysentery  the 
rectum  is  often  involved  as  well  as  the  colon,  and  extensive  ulceration 
may   be  present.     If  the  inflammation  becomes  chronic,   a  simple 


II50 


A  MANUAL  OF  SURGERY 


fibrous  stricture  may  result.  Treatment. — Injections  of  lead  and 
opium  or  of  borax  may  be  used  locally,  whilst  the  patient  is  kept  in 
a  recumbent  position  and  on  a  low  diet,  the.  bowels  being  regularly 
opened  by  the  administration  of  laxatives  or  enemata.  If  much 
bleeding  is  present,  hazeline  will  often  serve  as  a  useful  styptic. 

Thread -worms  {Oxyuris  vennicularis)  are  the  most  constant  source 
of  irritation  of  the  rectum  in  infants  and  children.  They  give  rise  to 
pruritus  ani,  a  discharge  of  muco-pus,  and  many  reflex  phenomena. 
In  treating  such  a  case,  a  sharp  purgative  may  be  given  every 
morning  {e.g.,  pulv.  scamm.  co.,  grs.  v.),  and  salt  and  water  or  an 
infusion  of  quassia  used  as  an  injection. 

The  Billiarzia  hsemato'bia  is  occasionally  found  in  the  rectum  as 
well  as  in  the  urinary  passages  (p.  123 1).  It  gives  rise  to  fibro- 
adenomatous  polypi,  in  which  the  ova  can  be  readily  demonstrated  ; 
they  are  rounded  or  oval  bodies,  differing  from  those  found  in  the 
urine  in  that  they  possess  a  lateral  spine-like  projection,  whilst  in  the 
latter  it  is  terminal.  Considerable  tenesmus,  diarrhoea,  and  discharge 
of  blood  are  present,  and  the  haemorrhage  may  become  so  abundant 
as  to  destroy  the  patient's  life,  especially  when  urinary  symptoms 
are  co-existent.  They  occur  in  children  who  have  been  in  South 
Africa,  and,  unfortunately,  no  satisfactory  treatment  is  known. 

Eectal  and  Peri-rectal  Suppuration. — Many  forms  of  abscess  are 
found  in  and  about  the  rectum,  and  inasmuch  as  they  are  very  liable 
to  leave  behind  troublesome  fistulous  tracks,  it  is  important  that  tbey 
should  be  clearly  described.  As  regards  causation,  they  are,  of 
course,  due  to  germs,  and  these  are  derived  most  commonly  from  the 
bowel  as  a  result  of  the  impaction  of  foreign  bodies,  the  extension  of 
ulcerative  processes,  or  the  suppuration  of  piles.  Occasionally  the 
trouble  starts  from  the  skin  around  the  anus,  and  sometimes  the  pus 
reaches  the  peri-rectal  tissues  from  other  viscera— ^.g'.,  the  neck  of 
the  bladder,  prostate,  etc. — or  from  above,  in  connection  with  spinal 
or  pelvic  abscesses.  Not  unfrequently  the  abscess  is  attributed  to 
injury  or  to  cold,  as  from  sitting  on  a  damp  stone  or  a  draughty 
closet.  These  latter,  if  having  any  influence,  are  merely  the  final 
exciting  agents. 

1.  An  Anal  Abscess  forms  immediately  under  the  anal  integument, 
and  superficial  to  the  external  sphincter  (Fig.  499,  A.A.) ;  it  is  usually 
due  to  inflammation  of  one  of  the  numerous  sebaceous  follicles  in  that 
locality.  It  may  be  acute  or  chronic,  and  is  one  of  the  most  frequent 
causes  of  fistula-in-ano.  It  must  be  freely  opened  throughout  its 
whole  length,  and  packed. 

Occasionally  a  sebaceous  follicle  becomes  affected,  constituting  a 
boil,  and  may  infect  several  others.  If  these  can  be  dealt  with  early, 
the  trouble  may  be  limited,  but  if  neglected  a  somewhat  extensive 
anal  abscess  may  result. 

2.  A  Submucous  Abscess  (Fig.  499,  S.M.A.)  usually  forms  as  the 
result  of  a  suppurating  internal  pile.  The  pus  spreads  up  and  down 
under  the  mucous  membrane,  and  gives  rise  to  a  blind  internal 
fistula  (Fig.  501,  5).     It  is  usually  confined  to  one  side  of  the  bowel, 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS 


1151 


and  causes  great  pain  on  defaecation.  Digital  examination  is  ex- 
tremely painful.  Treatment  consists  in  draining  it  at  the  most 
dependent  spot,  close  to  the  anus,  but  it  may  be  necessary  to  slit  up 
the  undermined  mucous  membrane  in  order  to  insure  healing. 
Considerable  haemorrhage  may  follow  this  proceeding,  and  it  is  not 
easy  to  stop  except  by  firm  pressure. 

3.  Acute  Ischio-rectal  Abscess  is  due  to  infection  of  the  loose  fatty 
tissue  filling  the  ischio-rectal  fossa  (Fig.  499,  I.R.A.)  with  some 
pyogenic  organism,  reaching  it  either  through  the  perineum  or  from 
the  bowel.  The  B.  coli  is  usually  present,  and  in  consequence  the 
pus  has  the  ordinary  characteristic  ofifensive  odour.  A  red,  painful 
swelling  is  noticed  on  one  side  of  the  anus,  which  is  at  first  hard  and 
brawny,  but  soon  becomes  soft  and  fluctuating.  Defaecation  is  ex- 
ceedingly painful,  as  also  digital  exploration  of  the  bowel,  and  the 


Fig.  499, — Diagrammatic  Section  of  Abscesses  situated  near  the  Lower 
End  of  the  Rectum. 

L.A.,  Levator  ani ;  E.S.,  external  sphincter;  I.S.,  internal  sphincter;  I.R.A., 
ischio-rectal  abscess;  A. A.,  anal  abscess;  S.M.A.,  submucous  abscess; 
P.R.A. ,  pelvi-rectal  abscess. 

patient  is  unable  to  sit  with  any  comfort.  If  left  to  itself,  it  may 
burst  internally  or  externally,  or  in  both  directions,  and  a  fistula-in- 
ano  is  very  liable  to  follow.  Treatment. — In  the  early  stages  the 
part  should  be  well  fomented,  but  when  there  is  no  doubt  that  pus  is 
forming,  a  free  opening  should  be  made,  the  cavity  washed  out,  and 
packed  with  some  antiseptic  dressing.  If  taken  early  enough,  rapid 
recovery  may  ensue  without  the  bowel  becoming  involved,  but  when 
the  mucous  membrane  has  been  encroached  upon  or  perforated,  the 
wound  will  not  heal  without  division  of  the  sphincter.  A  T-shaped 
or  crucial  incision  is  perhaps  the  best  to  employ  in  the  early  stages, 
as  indicated  in  Fig.  500  ;  the  cross  limb  of  the  T  is  parallel  to  the 
fold  of  the  nates,  and  should  extend  through  the  whole  of  the  inflamed 
and  infiltrated  tissues. 

4.  Chronic  Ischio-rectal  Abscess  is  usually  met  with  in  run-down 


1152 


A  MANUAL  OF  SURGERY 


or  tuberculous  individuals  during  young  adult  life,  and  is  not  unfre- 
quently  a  complication  of  phthisis.  A  deposit  of  tuberculous  material 
replaces  the  fat  ordinarily  occupying  the  ischio-rectal  fossa,  and  this 
after  a  time  undergoes  caseation  or  forms  an  abscess,  which  gradually 
spreads  without  pain  or  other  inflammatory  disturbance,  until  it 
may  extend  very  widely  and  almost  entirely  surround  the  bowel. 
After  it  has  burst,  the  orifices  of  sinuses  may  be  found  at  a  con- 
siderable distance  from  the  anus.  The  Signs  and  Symptoms  are  those 
of  a  chronic  tuberculous  abscess.  An  indurated  and  painless  mass 
may  be  first  felt  in  the  fossa,  and  this  slowly  spreads,  softens,  and  is 
transformed  into  a  more  or  less  extensive  abscess  sac.  Operative 
Treatment  is  desirable  in  most  of  these  cases,  and  if  possible  in  the 
early  stages,  or  before  suppuration  has  occurred  ;  incision,  remov.al  by 


Fig.   500  — Situation  of  T-shaped  Incision  required  for  Opening 

AN    ISCHIO-RECTAL    AbSCESS. 


a  sharp  spoon  of  all  tuberculous  tissue,  the  application  of  pure  carbolic 
acid,  and  dressing  the  wound  with  gauze  infiltrated  with  iodoform 
are  the  essential  elements.  Where  extensive  sinuses  or  fistulae  exist, 
treatment  as  for  fistula-in-ano  must  be  adopted.  At  the  same  time, 
suitable  hygienic  treatment  is  instituted,  and  the  more  so  if  physical 
examination  of  the  lungs  or  bacteriological  examination  of  the 
sputum  indicates  the  co-existence  of  pulmonary  tuberculosis. 

5.  The  Pelvi-rectal  Abscess  (Fig.  499,  P.R.A.)  consists  in  a 
localized  collection  of  pus  in  the  loose  cellular  tissue  above  the 
levator  ani  between  it  and  the  rectum.  It  may  be  secondary  to 
rectal  lesions,  such  as  penetration  of  the  wall  above  the  internal 
sphincter  or  extension  of  ulceration  from  a  carcinoma  ;  but  not 
uncommonly  it  originates  from  pelvic  lesions,  and  may  be  caused  by 
pelvic  cellulitis,  or  suppuration  in  the  meso-rectum,  prostate,  etc. 
The  ordinary  phenomena  of  a  deep  abscess  are  produced,  and 
the  pus  may  burrow  downwards  through  the  levator  ani  to  the 
ischio-rectal  fossa,  or  may  travel  up  and  involve  the  pelvic  peri- 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1153 

toneum.  Sometimes  it  extends  laterally  and  may  almost  surround 
the  bowel,  causing  one  type  of  horseshoe  fistula.  Other  collections 
of  pus  may  find  their  way  into  this  region  from  different  parts — e.g., 
a  psoas  abscess  from  spinal  disease,  appendix  abscesses,  etc.  Rectal 
examination  indicates  the  existence  of  a  painful  swelling  high  up  in 
the  bowel.  As  soon  as  a  diagnosis  is  made,  the  abscess  should  be 
freely  laid  open  and  drained,  and,  if  possible,  by  an  incision  behind 
the  anus.  Of  course  an  abscess  which  is  secondary  to  a  tuberculous 
spine  is  an  exception  to  this  rule ;  in  this  every  effort  must  be  made 
to  prevent  the  necessity  for  an  opening  in  this  region,  as  infection  is 
certain  to  follow. 

6,  Occasionally  a  diffuse  form  of  cellulitis  involves  the  peri-rectal 
connective  tissue,  not  uncommonly  resulting  in  gangrene  {gangrenous 
periproctitis).  It  is  most  likely  to  be  seen  in  weakly  individuals  and 
old  people,  and  the  symptoms  are  very  asthenic  in  type.  The  sup- 
puration may  extend  above  the  levator  ani,  and  lead  to  deep  fistulous 
tracks.  The  parts  must  be  freely  opened  up,  the  gangrenous  tissue 
scraped  away,  and  the  raw  surfaces  treated  with  peroxide  of  hydrogen. 
The  wounds  are  then  packed  with  iodoform  gauze,  and  subsequently 
well  irrigated  twice  a  day.  Free  stimulation  is  always  required  in 
these  cases,  but  the  prognosis  is  very  bad,  death  being  probably 
caused  by  acute  toxaemia  or  pyaemia. 

Fistula-in-Ano. — The  term  '  fistula-in-ano '  is  somewhat  loosely 
applied  to  all  those  conditions  in  which  suppurating  tracks  are  found 
in  the  neighbourhood  of  the  anus  and  the  lower  end  of  the  rectum. 
Many  of  these  are  merely  sinuses  which  have  but  one  opening. 

The  Cause  of  fistula  is  usually  some  suppurative  condition — e.g.,  an 
Ischio-rectal  or  anal  abscess,  or  the  breaking  down  of  a  tuberculous 
deposit  in  the  neighbourhood  of  the  bowel ;  but  it  is  sometimes  the 
result  of  a  simple  or  malignant  stricture  of  the  gut,  the  inner  opening 
being  either  above,  in  the  substance  of,  or  below  the  cicatricial  mass. 
This  is  more  likely  to  be  the  case  when  multiple  fistulae  exist. 

Varieties. — i.  The  Complete  Fistula  is  one  in  which  there  are  open- 
ings both  externally  and  into  the  bowel.  When  following  an  anal 
abscess,  they  are  both  close  to  the  anus,  and  the  track  lies  imme- 
diately beneath  the  skin  and  mucous  membrane  (Fig.  501,  i).  When 
following  an  acute  ischio-rectal  abscess,  the  external  opening  is  a 
variable  distance  from  the  anus,  and  the  inner  not  more  than  i  inch 
up  the  bowel,  being  situated  in  relation  with  the  so-called  internal 
sphincter  (Fig.  501,  2) ;  occasionally  blind  submucous  or  sub- 
cutaneous extensions  are  met  with  branching  off  from  this  (2"^),  but 
not  so  frequently  as  when  the  fistula  follows  a  chronic  tuberculous 
abscess.  In  the  latter  case  the  skin  maybe  extensively  undermined, 
looking  blue  and  congested,  and  the  fistulous  tracks  may  burrow 
widely,  opening  even  on  the  thigh,  or  in  the  perineum  or  buttock. 
The  so-called  liorsesJwe fistula  passes  round  the  bowel,  usually  behind 
the  anus,  either  superficial  to  the  external  sphincter  or  beneath  it, 
and  opens  also  on  the  other  side.  Moreover,  the  mucous  membrane 
of  the  bowel  is  often  undermined,  and  stripped  from  the  muscular  coat 

73 


"54 


A  MANUAL  OF  SURGERY 


for  some  distance  above  the  internal  opening  by  sinuses  or  an  abscess 
cavity.  Occasionally  the  complete  fistula  which  follows  an  ischio- 
rectal or  pelvi-rectal  abscess  opens  some  way  up  the  bowel  as  well 
as' externally,  and  traverses  the  levator  ani(Fig.  501,  3),  constituting 
a  much  deeper  and  more  serious  lesion. 

In  any  of  these  conditions  secondary  tracks  may  form,  burrowing 
in  all  directions,  and  sometimes  the  opening  up  of  these  passages  is 
a  serious  matter.  Thus  they  may  run  forwards  to  the  scrotum,  or 
outwards  into  the  gluteal  region, 

2.  The  Blind  External  Fistula  (Fig.  501,  4)  is  the  term  applied  to  a 
sinus  resulting  from  the  opening  of  an  ischio-rectal  abscess  in  which 
no  communication  with  the  bowel  can  be  discovered.  A  probe  passed 
into  the  wound  can  often  be  felt  by  a  finger  in  the  rectum  with  only 
the  thickness  of  the  mucous  membrane  between.     In  dealing 'with 


Fig.  501. — Diagrammatic  Representation  of  Various  Forms  of 
Fistula-in-Ano. 

I,  Superficial  fistula  resulting  from  an  anal  abscess;  2,  a  complete  fistula,  not 
involving  the  internal  sphincter  ;  2",  secondary  track  burrowing  under 
mucous  membrane  ;  3,  complete  fistula  opening  above  the  internal  sphincter 
and  traversing  the  levator  ani ;  4,  blind  external  fistula;  5,  blind  internal 
fistula;  E.  S.,  external  sphincter;  I.  S.,  internal  sphincter;  L.  A.,  levator  ani. 

these  external  fistulae  the  possibility  of  the  original  cause  being  at  a 
distance  must  not  be  overlooked. 

3.  The  Blind  Internal  Fistula  (Fig.  501,  5)  is  constituted  by  a  sinus 
opening  into  the  bowel  just  above  the  anus.  Attention  is  usually 
drawn  to  the  condition  by  the  passage  of  pus  with  the  motions  or  in- 
dependently, and  perhaps  by  preceding  inflammatory  disturbance. 
The  orifice  can  sometimes  be  felt  by  digital  exploration  ;  on  the 
insertion  of  a  speculum  it  may  perhaps  be  seen,  and  can  be  examined 
by  a  straight  probe  or  one  bent  in  the  form  of  a  hook ;  it  is  often 
associated  with  considerable  undermining  of  the  mucous  membrane, 
and  if  chronic  with  stenosis  of  the  bowel. 

In  all  these  conditions  it  is  difficult  to  obtain  healing,  owing  to  the 


AFFECTIONS  OF  THE  RECTUM  AND  -ANUS  115S 

introduction  of  septic  material  from  the  bowel,  and  to  the  state  of 
unrest  in  which  the  parts  are,kept  by  the  continuous  movements, 
voluntary  and  involuntary,  of  the  sphincters. 

Operation. — The  bowels  must  have  been  completely  evacuated,  both 
by  means  of  castor  oil  or  some  suitable  purgative,  and  about  an  hour 
previous  to  operation  by  enema,  a  most  important  preliminary, 
not  only  for  the  comfort^ of  the  operator,  but  also  because  it  is 
very  desirable  that  no  further  action  should  be  required  for  some 
days.  The  patient  is  placed  in  the  lithotomy  position,  and  the 
perineal  and  anal  regions  shaved  and  purified.  A  probe  is  passed 
along  the  fistula  into  the  rectum,  and  guided  by  it  a  grooved  director, 
along  which  a  curved  pointed  bistoury  is  introduced,  and  the  inter- 
vening structures  divided.  In  a  superficial  fistula,  both  sphincters 
may  escape  division,  and  in  a  deep  one  both  may  be  involved ;  in  the 
majority  of  cases,  some  fibres  of  the  external  sphincter  are  divided. 
A  careful  search  is  made  for  pockets  or  tributary  branches  of  the 
main  track,  and  such,  if  found,  are  opened  up  and  scraped  out,  under- 
mined and  unhealthy  skin  being  snipped  away  with  scissors ;  it  is 
important,  however,  to  remember  that  the  sphincter  ought  never  to 
be  divided  in  more  than  one  place.  Bleeding-points  are,  if  necessary, 
tied,  and  the  cavity  is  carefully  dusted  with  iodoform,  and  lightly 
packed  with  oiled  lint  or  gauze  soaked  in  iodoform  and  glycerine. 
Pressure  by  a  graduated  compress  of  sterilized  wool  should  be  applied 
by  means  of  a  T-bandage. 

When  a  sinus  extends  for  some  distance  under  the  mucous  mem- 
brane from  the  upper  end  of  the  original  fistula,  it  may  not  be  always 
desirable  to  lay  it  open  to  its  whole  extent,  since  such  might  involve 
serious  haemorrhage  at  a  spot  where  it  cannot  well  be  checked.  It 
will  often  suffice  partly  to  divide  and  scrape  it,  and  then,  if  the  main 
fistula  has  been  satisfactorily  dealt  with,  it  will  probably  heal  without 
difficulty,  especially  if  syringed  out  occasionally  with  stimulating 
lotions. 

In  the  case  of  a  horseshoe  fistula,  the  sphincter  need  only  be 
divided  at  one  spot,  and  that  usually  in  the  middle  of  the  horseshoe. 
The  whole  traclc  must,  however,  be  opened  up,  the  cavity  scraped, 
loose  tags  of  skin  removed  by  the  scissors,  and  an  ordinary  dressing 
applied. 

A  small  superficial  fistula,  not  extending  beyond  the  anal  margin, 
can  sometimes  be  entirely  excised,  and  the  wound  closed  by  sutures, 
thereby  securing  healing  by  primary  union. 

After-Treatment. — The  bowels  should,  if  possible,  be  prevented  from 
acting  for  four  days,  and  most  scrupulous  care  taken  to  keep  the  parts 
clean.  The  deep  dressing  need  not  be  changed  for  the  first  twenty- 
four  or  forty-eight  hours,  provided  that  the  surrounding  skin  is  well 
flushed  with  a  warm  carbolic  solution.  When  the  plugs  are  removed, 
fresh  small  strips  of  gauze  soaked  in  iodoform  and  glycerine  are 
introduced  night  and  morning  after  the  wound  has  been  syringed. 
On  the  fourth  day  a  good  dose  of  castor  oil  should  be  given,  and 
subsequently  an  action  of  the  bowels  must  be  secured  daily.     The 


,156  A  MANUAL  OF  SURGERY 

wound  is  allowed  to  granulate,  and  care  taken  that  irregular  healing 
does  not  lead  to  a  re-formation  of  the  fistula.  With  this  object  in 
view,  it  is  often  advisable  to  pass  a  moderate-sized  bougie  from  Lime 
to  time  at  the  end  of  a  fortnight. 

When  the  incision  is  not  carried  very  deeply,  the  patient's  sphinc- 
teric  control  after  operation  is  unimpaired ;  but  if  the  internal 
sphincter  has  to  be  divided,  all  control  of  the  bowel  is  lost  for  some 
time.  As  cicatrization  progresses,  however,  it  is  gradually  restored, 
and  when  healing  is  complete,  control  is  usually  perfect  except  when 
the  patient  is  suffering  from  diarrhoea. 

The  presence  of  tuberculous  material  locally  and  in  the  lungs  must 
be  carefully  considered  and  taken  into  consideration  in  advising 
operation.  If  the  pulmonary  trouble  is  early,  there  is  no  necessity 
for  delaying  operation  ;  the  patient  will  derive  much  more  benefit 
from  sanatorium  treatment  if  his  fistula  has  been  first  cured,  or  put 
well  on  the  way  to  recovery.  In  the  later  stages,  however,  it  may 
be  advisable  to  leave  the  fistula  alone,  or,  at  any  rate,  only  to  do 
such  an  operation  as  shall  relieve  any  urgent  symptoms. 

Fissure  of  the  Anus. — This  is  a  most  painful  and  troublesome  com- 
plaint, met  with  most  commonly  in  men,  though  not  unfrequently  in 
women  of  a  neurotic  temperament.  It  is  occasionally  due  to  injury 
or  to  the  irritation  of  a  polypus,  but  more  often  to  the  passage  of 
large  scybalous  masses  in  patients  suffering  from  chronic  constipation. 
The  fissure  is  usually  single,  extending  through  the  posterior  border 
of  the  anus  toward  the  coccyx ;  a  '  sentinel '  external  pile  is  often 
situated  immediately  over  it,  and  the  crack  may  lead  to  a  definite  ulcer 
just  within  the  external  sphincter.  According  to  Ball  of  Dublin, 
it  is  due  to  one  of  the  valve-like  tags,  left  at  the  junction  of  the 
proctodeum  and  rectum,  being  caught  by  a  scybalous  mass,  and  torn 
from  its  upper  connections.  Each  time  a  motion  passes  the  sore  place 
is  reopened,  and  the  valve  pushed  further  on,  until  finally,  having 
become  swollen  and  oedematous,  it  appears  at  the  orifice  as  the  '  sen- 
tinel '  pile,  with  an  ulcerated  surface  behind  or  beside  it.  Sometimes 
several  fissures  are  met  with  in  the  same  individual,  and  then  a 
syphilitic  cause  is  probable,  especially  if"  they  are  placed  at  the  side 
or  front  of  the  anus. 

The  Symptoms  of  this  condition  are  very  distressing,  consisting  of 
burning  pain  during  and  after  defaecation,  which  often  lasts  for  hours. 
The  pain  is  usually  associated  with  tenesmus,  and  may  radiate  down 
the  thighs  or  up  the  back,  and  not  uncommonly  to  the  left  sacro-iHac 
joint ;  it  may  be  so  severe  as  to  lead  the  patient  to  refrain  from 
defsecation  for  prolonged  periods.  The  faeces  may  be  streaked  with 
blood  or  pus,  and  there  is  a  certain  amount  of  discharge  from  the 
anus.  On  examining  the  part,  the  sphincter  is  found  to  be  con- 
tracted spasmodically,  and  the  entrance  of  a  finger  is  forcibly  resisted. 

Treatment  in  the  earlier  stages  is  undertaken  by  regulating  the 
action  of  the  bowels  by  suitable  laxatives,  by  the  use  of  cocaine  sup- 
positories prior  to  defaecation,  and  by  improving  the  general  health. 
Sometimes  the  application  of  a  hamamelis  ointment,  combined  with 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1157 

the  Ung.  hydrargyri  nitratis  dil.,  is  most  effective  in  giving  relief.  In 
confirmed  cases  the  sphincter  has  been  forcibly  dilated,  and  the 
crack  or  ulcer  cauterized ;  but  by  far  the  most  satisfactory  treatment 
consists  in  dividing  its  base  with  a  straight  blunt-ended  bistoury, 
the  incision  at  the  same  time  including  the  superficial  fibres  of  the 
external  sphincter.  The  ulcer  and  the  edges  of  the  wound  are 
snipped  away  with  scissors,  to  facilitate  the  dressing  and  healing  of 
the  wound.  The  lower  bowel  should  in  all  cases  be  carefully  ex- 
plored with  the  finger,  especially  with  a  view  to  the  possible  existence 
of  a  polypus,  which,  if  undetected,  would  cause  a  recurrence  of  the 
mischief.  Rest  being  thus  obtained,  healing  soon  follows.  It  is 
sometimes  possible  to  close  this  small  wound  with  sutures  and  obtain 
primary  union. 

Pruritus  Ani  is  a  condition  characterized  by  intense  and  incessant 
itching  of  the  anus  and  its  surrounding  skin.  At  first  noticed  mainly 
at  night,  and  interfering  with  sleep,  it  may  in  time  become  persistent 
throughout  both  day  and  night,  preventing  the  patient  from  fixing  his 
attention  on  his  work,  and  wearing  him  out  through  want  of  sleep. 
Scratching  becomes  a  necessity,  and  yet  aggravates  the  condition. 
It  is  generally  due  to  parasites,  such  as  thread-worms,  or  to  some 
ulcerative  condition  of  the  anal  canal,  just  at  the  muco-cutaneous 
junction,  or  it  may  arise  from  some  neurosis  of  the  sensory  nerves. 
The  skin  looks  red  and  excoriated  ;  it  is  usually  swollen  and  thrown 
into  oedematous  folds,  which  radiate  from  the  anus  in  a  characteristic 
fashion. 

Treatment. — Any  parasites  present  must  be  destroyed,  and  ulcers 
of  the  anal  canal  must  be  carefully  looked  for  and  cauterized.  For 
cases  which  persist  in  spite  of  such  measures.  Sir  Charles  Ball  has 
devised  an  operation  which  has  proved  of  value,  and  consists  in 
dividing  the  terminations  of  all  the  sensory  nerves  to  the  part.  Two 
semi-elliptical  incisions  are  made  around  the  anus,  leaving  a  narrow 
pedicle  in  front  and  behind ;  the  wounds  are  deepened  to  expose  the 
sphincter,  and  the  flaps  raised  from  the  muscle  inwards  around  the 
anal  margin  and  up  to  the  muco-cutaneous  junction.  The  pedicles 
in  front  and  behind  are  undercut,  and  the  outer  margins  of  the 
incisions  also  to  an  extent  corresponding  to  the  area  of  irritation ;  the 
flaps  are  then  replaced  and  sutured.  The  immediate  result  of  such 
an  operation  is  complete  anaesthesia  of  the  skin  of  the  flaps ;  normal 
sensation  returns  after  a  time,  but  without  pruritus. 

Hsemorrhoids,  or  Piles,  consist  in  a  varicose  condition  of  the  veins 
surrounding  the  anus  and  lower  inch  or  two  of  the  rectum. 

The  character  of  the  blood-supply  of  this  portion  of  the  bowel,  and 
the  conditions  under  which  it  is  carried  on,  go  far  to  explain  the 
frequency,  of  this  affection.  The  circulation  in  the  pelvic  colon 
is  similar  to  that  in  the  intestine  generally,  the  vessels  being 
distributed  transversely  around  the  gut ;  but  in  the  rectum  they 
run  in  longitudinal  series  along  the  bowel,  being  connected  by 
transverse  branches,  which  form  a  plexus  around  and  just  above  the 


II58  A  MANUAL  OF  SURGERY 

anus.  Their  situation  in  the  loose  submucous  tissue,  where  there  is 
but  little'  support,  necessarily  exposes  them  to  great  and  sudden 
variations  of  pressure  before  and  after  defaecation.  Their  dependent 
position  at  the  lowest  part  of  the  portal  area,  together  with  the 
absence  of  valves,  and  the  fact  that  they  constitute  an  important 
communication  between  the  portal  and  general  systems,  and  thus 
afford  the  chief  means  of  escape  from  a  block  on  the  portal  trunk — 
all  these  reasons  may  be  looked  on  as  Predisposing  Causes  of  the  con- 
dition. In  addition  to  these  we  must  also  mention  a  sedentary 
occupation,  alcoholic  excess,  and  chronic  constipation,  which,  by 
leading  to  congestion  of  the  liver,  are  frequent  precursors  of  piles. 
They  are  exceedingly  common  in  young  people,  especially  in  men 
about  twenty  years  of  age  forced  to  lead  a  sedentary  life ;  up  to 
middle  age  the  tendency  diminishes,  but  in  elderly  individuals  many 
conditions — e.g.,  enlarged  prostate,  or  stone  in  the  bladder — arise 
which  favour  their  development.  Simple  stricture  of  the  rectum  or 
malignant  disease  may  so  interfere  with  the  return  of  blood  as  to 
determine  a  development  of  haemorrhoids.  Young  women  are  re- 
markably exempt  from  piles,  owing  probably  to  the  regularity  of  the 
menstrual  discharge;  but  uterine  conditions,  such  as  pregnancy, 
displacements,  or  tumours,  which  cause  obstruction  to  the  venous 
return,  are  liable  to  be  associated  with  them. 

A  varicose  condition  of  the  veins  in  the  neighbourhood  of  the  anus 
is  often  present  without  being  recognised  by  the  individual ;  but 
many  different  circumstances  may  bring  the  symptoms  into  promi-- 
nence  by  causing  an  attack  of  thrombosis,  such  as  the  use  of  drastic 
purgatives,  especially  aloes,  local  exposure  to  damp  and  cold,  as  by 
sitting  on  a  cold  wet  stone  or  in  a  draughty  closet,  or  sudden  con- 
gestion of  the  liver,  as  by  alcoholic  excess,  or  a  chill. 

Two  chief  varieties  of  piles  are  described — viz.,  the  external  and 
internal ;  but  frequently  a  combination  of  the  two  conditions  is 
present. 

External  Piles  are  found  at  the  margin  of  the  anus,  and  are  covered 
with  skin.  They  consist  of  a  small  central  vein  in  a  varicose  state, 
surrounded  by  a  development  of  subcutaneous  fibro-cellular  tissue, 
which  latter  is  much  more  abundant  than  the  vascular  element ;  in 
fact,  they  practically  consist  of  longitudinal  folds  of  skin  of  a  dark 
brown  colour  radiating  from  the  anus,  and  superficial  to  the  sphincter. 
In  the  usual  relaxed  state  in  which  they  are  found  they  give  rise  to 
no  Symptoms  beyond  a  little  pruritus,  and  perhaps  a  sense  of  fulness 
and  irritation  immediately  before  and  after  defaecation.  They  are 
very  liable,  however,  to  become  inflamed  from  local  irritation  or  cold, 
and  then  appear  as  tense,  bluish,  rounded  swellings,  exceedingly 
painful  and  tender,  and  often  preventing  the  patient  from  walking  or 
sitting  in  comfort.  In  such  a  state  the  vein  contained  in  tjie  pile  is 
distended  with  blood-clot.  Under  suitable  treatment  the  swelling 
subsides  in  a  few  days,  usually  leaving  the  fleshy  fold  more  bulky 
and  harder  than  previously,  owing  to  the  partial  or  complete  organi- 
zation of  the  thrombus. 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS 


"59 


The  Treatment  of  external  piles,  when  uninflamed,  is  very  simple. 
Constipation  must  be  relieved  ;  the  parts  should  be  kept  clean  and 
well  washed ;  a  hamamelis  ointment  or  extract  may  be  occasionally 
applied,  and  great  care  taken  not  to  irritate  the  anus  after  defaecation 
by  the  use  of  hard  paper — e.g.,  newspaper.  Very  soft  curl-paper, 
well  crumpled,  should  be  employed,  or  preferably  absorbent  wool. 
It  is  but  rarely  that  operative  measures  are  required  in  a  simple  case  of 
external  piles ;  where,  however,  external  and  internal  piles  co-exist, 
it  is  advisable  to  complete  any  operation  undertaken  for  the  latter 
condition  by  the  removal  of  the  more  prominent  fleshy  folds  sur- 
rounding the  anus.  This  is  accomplished  by  grasping  them  with 
forceps,  and  snipping  them  away  by  scissors  in  a  direction  radiating 
from  the  centre  of  the  anus,  the  resulting  wounds  being  sutured. 
For  inflamed  and  thrombosed  external  piles  the  patient  should  be 
kept  in  bed,  the  bowels  opened  by  a  copious  warm  enema,  and 
fomentations  applied.  If  the  pain  and  tension  are  very  great,  the 
tumour  should  be  incised  and  the  clot  turned  out ;  the  margins  of  the 
fold  may  then  be  cut  away,  and  the  wound 
dressed. 

Internal  Piles  consist  of  dilated  veins 
held  together  by  a  certain  amount  of  con- 
nective tissue,  and  covered  by  mucous 
membrane.  At  first  they  are  quite  soft  and 
compressible,  and  easily  emptied  on  pres- 
sure ;  but  when  they  have  existed  for  some 
time  the  connective  tissue  may  be  increased 
in  amount,  and  arterial  twigs  are  often 
found  running  into  the  mass. 

The  condition  is  limited  to  the  lower 
2  inches  of  the  bowel,  and  may  present  very 
varied  appearances  in  different  cases.  Thus, 

there  may  be  a  general  dilatation  of  the  veins  in  the  submucous  tissue 
without  the  formation  of  any  distinct  tumours.  The  mucous  mem- 
brane is  then  of  a  deep  claret  colour,  somewhat  thickened,  and  liable 
to  protrude  during  defaecation.  There  is  a  certain  amount  of  glairy 
mucous  discharge,  and  the  faeces  may  be  streaked  with  blood  ;  but, 
as  a  rule,  the  haemorrhage  is  not  great.  Such  a  condition  is  usually 
followed  by  a  definite  formation  of  haemorrhoidal  tumours,  and  not 
unfrequently  runs  on  to  prolapse. 

When  distinct  haemorrhoidal  masses  form,  they  may  be  of  two 
types:  {a)  The  longiUtdinal  or  fleshy  pile  (Fig.  502),  consisting  of  broad 
sessile  masses,  dusky  in  colour,  soft  and  compressible  in  consis- 
tency, and  covered  by  mucous  membrane,  which,  although  thin  and 
stretched,  still  remains  smooth  and  shiny,  like  the  skin  of  a  black 
grape.  Between  the  piles  depressions  are  found,  in  which  small 
portions  of  faeces  may  lodge  and  produce  irritation.  This  form 
generally  bleeds  but  little,  (b)  The  globular  or  bleeding  pile  is  single  or 
multiple,  and  as  a  rule  somewhat  pedunculated ;  the  surface  of  the 
tumour  is  roughened  and  granular,  like   a   strawberry,  due  to  the 


Fig.  502.— t-Internal 
Piles. 


ii6o  A  MANUAL  OF  SURGERY 

existence  of  dilated  capillaries.  When,  however,  a  portion  of  it  has 
been  repeatedly  protruded,  the  exposed  mucous  membrane  becomes 
hard,  and  practically  converted  into  skin,  and  the  columnar  epithelium 
may  be  replaced  by  the  squamous  type.  The  haemorrhage  may  be 
abundant,  and  comes  either  from  the  dilated  superficial  capillaries,  or 
occasionally  from  a  central  arterial  twig 

The  Symptoms  arising  from  internal  piles  are  often  not  very 
marked  until  haemorrhage  occurs  ;  but  there  is  usually  a  sense  of 
weight  or  fulness  about  the  anus,  with  sometimes  pain,  which  is 
increased  before  and  after  defaecation.  The  patient  feels  as  if  a 
foreign  body  were  present  in  the  bowel,  and  the  mass  not  unfre- 
quently  protrudes,  giving  rise  to  much  pain  and  inconvenience  until 
replaced  by  the  patient,  owing  to  the  grip  of  the  sphincter 
(Plate  VIII.).  Sooner  or  later  haemorrhage  is  almost  certain  to  be 
noticed,  coming  on  at  first  after  defaecation,  and  only  a  few  drops 
being  lost.  After  a  time,  however,  the  flow  increases,  and  may  con- 
tinue to  such  an  extent  as  to  cause  marked  anaemia.  If  the  case 
remains  untreated,  the  pain  and  inconvenience  increase ;  a  blood- 
stained mucous  discharge  from  the  rectum  is  noticed,  soiling  the 
linen ;  reflex  irritation  of  neighbouring  organs  is  produced,  and  a 
condition  of  nerve  prostration  from  pain  and  haemorrhage  may 
result.  In  cases  where  the  piles  are  due  to  portal  obstruction,  as  in 
cirrhosis  of  the  liver,  the  bleeding  may  be  beneficial,  and  must  not 
always  be  checked. 

Complications  of  Piles. — Inflammation  of  the  venous  ampullae  con- 
tained in  piles  leads  to  what  is  popularly  termed  an  '  attack  of  piles,' 
although  this  is  much  less  common  with  the  internal  than  the  ex- 
ternal variety,  and  the  fleshy  form  is  that  usuall}^  affected.  Evidences 
of  a  localized  phlebitis  manifest  themselves  in  the  shape  of  a  painful 
distension  and  swelling  of  the  parts,  which  become  blue  in  colour 
and  exquisitely  sensitive.  They  subside  with  or  without  suppura- 
tion ;  in  the  latter  case  a  spontaneous  cure  may  result,  whilst  in  the 
former  the  abscess  may  burst  into  the  bowel  or  may  burrow  exten- 
sively, and  even  give  rise  to  general  blood  contamination  and  pyemia. 
Strangulation  of  the  piles  by  the  sphincter  ani  may  follow  protrusion 
where  reposition  is  not  effected,  the  mass  becoming  painful,  tense, 
swollen,  and  livid  in  colour  ;  inflammation  running  on  to  ulceration 
and  sloughing  follows,  the  patient  suffering  from  sickness,  pain,  and 
toxgemia.     Pyaemia  may  ensue,  or  a  spontaneous  cure  be  effected. 

The  Diagnosis  of  piles  from  other  swellings  which  occur  in  the 
neighbourhood  is  not  difficult.  From  prolapse  they  are  recognised 
by  their  irregularity,  the  swelling  not  being  of  a  rounded  smooth 
annular  variety,  as  in  the  former  case  ;  the  two  conditions  are,  how- 
ever, often  associated.  From  polypus  piles  are  distinguished  by 
being  multiple  rather  than  single,  by  being  softer  and  more  com- 
pressible, by  their  situation  close  to  the  anus,  by  the  absence  of  a 
pedicle,  and  by  the  haemorrhage  being  usually  more  marked. 
Mucous  tubercles  and  condylomata  are  often  mistaken  for  external  piles, 
but  are  easily  recognised  by  being  symmetrically  placed,  owing  to 


PLATE   VI. 


^-^ 


Z^:;:^^ 


Prolapse  of  mucous  membrane  of  Rectum  and  Hfemorrhoidal  tumours  in  an  old 
standing  case  of  Piles.  This  case  was  treated  most  effectively  by  Whitehead's 
operation. 

\_To  face  page  1074. 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  ii6l 

infection  of  one  lip  of  the  gluteal  fold  from  the  other,  by  their  moist 
surface,  and  their  situation  at  a  little  distance  from  the  anus.  The 
consistency,  appearance,  and  history  of  an  epithelioma  should  effec- 
tually prevent  any  error  in  diagnosis. 

It  is  important  also  to  remember  that  blood  may  be  passed  per 
anum  from  many  other  conditions  besides  piles.  In  the  latter  case 
the  blood  is  of  a  bright  red,  florid  colour,  and  often  coats  the  faeces, 
whereas  if  it  originates  higher  in  the  intestinal  canal  it  is  dark  or 
tarry  in  colour  (nielana),  and  is  more  intimately  mixed  with  the 
excreta.  A  visual  and  digital  examination  of  the  rectum  should 
always  be  made  in  order  to  ascertain  the  exact  cause  of  the  bleeding. 

The  Treatment  of  internal  piles  is  both  general  and  local. 

General  Treatment  consists  in  removing  all  possible  sources  of 
venous  congestion,  in  regulating  the  bowels,  and  assisting  the 
functions  of  the  liver.  The  latter  may  be  effected  by  the  judicious 
administration  of  natural  mineral  waters,  such  as  Hunyadi  Janos 
and  Friedrichshall,  or  by  the  use  of  some  such  mild  aperients  as  the 
confections  of  senna  and  sulphur,  or  castor  oil ;  aloes  should  generally 
be  avoided.  At  the  same  time  the  food  is  regulated,  alcohol  forbidden, 
and  suitable  exercise  enjoined.  When  dependent  on  the  pressure 
of  a  gravid  uterus,  little  can  be  done  beyond  attending  to  the  regular 
action  of  the  bowels  until  the  child  is  born. 

Local  Treatment  in  the  earlier  stages  consists  merely  in  palliative 
measures.  Thus  the  parts  must  be  protected  from  injury  and  cold ; 
only  soft  paper  or  cotton-wool  used  after  defaecation  ;  and,  when 
protruding,  the  piles  should  be  sponged  with  cold  water  and  gently 
returned.  An  ointment  containing  an  extract  of  witch-hazel 
(hamamelis),  or  the  injection  of  a  hazeline  lotion  (i  in  8),  is  also 
advisable,  and  bleeding  from  piles  can  often  be  arrested  by  this 
means.  The  Ung.  gallae  c.  opio  of  the  Pharmacopoeia  is  often 
employed,  but  is  not  so  efficacious. 

When  there  is  much  pain  or  bleeding,  and  the  piles  have  attained 
some  size,  Radical  Treatment  by  operation  is  necessary.  Care  must 
be  taken  before  advising  it  to  ascertain  that  no  other  serious  disease 
of  the  rectum — such  as  cancer — -is  present,  and  that  the  piles  are  not 
dependent  on  hepatic  or  cardiac  disease,  when  an  operation  might  be 
injudicious  and  harmful.  In  all  cases  the  bowels  are  thoroughly 
emptied  by  a  dose  of  castor  oil  given  the  night  before  and  an  enema 
on  the  morning  of  the  operation,  whilst  the  patient  sits  over  hot 
water  for  half  an  hour  beforehand.  The  lithotomy  position  is  adopted, 
the  perineum  is  shaved  and  cleansed,  and  the  surgeon  thoroughly 
stretches  the  sphincter  by  introducing  the  two  index  fingers  and  then 
separating  them  forcibly,  by  this  means  bringing  into  view  the  whole 
of  the  diseased  area  of  mucous  membrane,  which  never  extends 
beyond  2  inches  from  the  anus.  The  following  plans  of  treatment 
are  those  chiefly  used  : 

I.  Removal  by  clamp  and  cautery,  as  introduced  by  the  late  Mr. 
Henry  Smith.  The  mucous  membrane  having  been  everted,  as  just 
described,  each  of  the  haemorrhoidal  tumours  is  grasped  by  a  pair 


Il62  A  MANUAL  OF  SURGERY 

of  ring- ended  catch  forceps,  and  thus  temporarily  secured ;  by  this 
means  the  scope  of  the  operation  required  can  be  readily  gauged. 
The  clamp  is  then  applied  to  each  mass  successively  in  a  direction 
corresponding  to  the  long  axis  of  the  gut,  great  care  being  taken  not 
to  include  the  external  skin.  The  clamp  is  tightened  by  the  screw 
attached  to  its  handle,  and  the  projecting  mass  of  the  pile  removed 
by  scissors.  The  cut  surface  is  then  thoroughly  seared  by  a  cautery 
at  a  dull  red  heat,  and  the  pressure  of  the  clamp  slowly  relaxed,  so 
as  to  ascertain  that  all  bleeding  has  ceased.  External  piles  may  be 
snipped  away  as  indicated  above  (p.  1159),  the  mucous  membrane 
re-inverted,  the  parts  dusted  with  iodoform,  and  a  carefully  graduated 
compress  of  antiseptic  wool  applied  with  a  T-bandage.  The  parts 
are  bathed  each  day  with  some  mild  antiseptic  lotion,  and  should  be 
healed  in  ten  to  fourteen  days.  The  use  of  the  catheter  may  be 
necessary  for  the  first  forty-eight  hours  after  a  severe  case,  owing  to 
retention  of  urine.  The  bowels  are  not  opened  until  the  fourth  or 
fifth  day,  and  then  a  good  dose  of  castor  oil — e.g.,  1  ounce  in  adults — 
should  be  administered.  It  is  better  to  allow  the  patient  to  sit  on  a 
commode  for  the  evacuation  of  the  bowels.  This  operation,  if  effici- 
ently carried  out,  is  absolutely  safe  and  free  from  danger,  and  suited 
to  cases  where  definite  hsemorrhoidal  tumours  are  present ;  any  com- 
plications from  infection,  haemorrhage,  etc.,  are  due  to  the  carelessness 
of  the  surgeon,  and  not  to  the  character  of  the  operation. 

2.  Ligature  is  an  operation  much  in  vogue  for  the  treatment  of 
piles,  and  if  carried  out  with  due  antiseptic  precautions,  is  followed 
by  a  large  amount  of  success.  The  haemorrhoidal  tumours  are 
grasped  by  forceps,  the  mucous  membrane  divided  around  them,  and 
the  base  ligatured  with  silk ;  the  mass  is  then  snipped  off,  and  the 
ligature  cut  short,  the  knot  being  allowed  to  separate  by  subsequent 
ulceration.  Sometimes  it  is  possible  to  suture  up  the  wound  caused 
by  the  excision  of  the  pile,  and  then  healing  is  more  expeditiously 
effected. 

3.  Excision  of  the  individual  piles  is  a  very  successful  procedure, 
and  consists  in  dividing  the  mucous  membrane  longitudinally  around 
the  pile,  which  is  then  removed,  bleeding  vessels  being  secured,  and 
the  wound  sutured  up.  Perhaps  the  best  way  of  affecting  this  is  to 
grasp  the  pile  longitudinally  with  a  pair  of  Kocher's  artery  forceps, 
and  then,  after  cutting  away  the  redundant  portion,  to  introduce  a 
continuous  catgut  suture,  including  the  forceps  and  the  mucous 
membrane  on  either  side.  The  forceps  is  removed  and  the  suture 
tightened,  thereby  preventing  bleeding ;  the  wound  is  effectively 
sealed,  and  the  bowels  may  be  allowed  to  act  at  an  early  date. 

4.  Where  the  haemorrhoidal  condition  is  general,  and  both  internal 
and  external  piles  are  present,  there  is  no  question  that  Whitehead's 
operation  is  much  the  best  that  can  be  employed.  It  consists  in  the 
total  removal  of  this  pile-bearing  area  in  the  same  way  as  for  excision 
of  the  rectum.  An  incision  is  made  round  the  margin  of  the  anus  at 
the  junction  of  the  skin  and  mucous  membrane,  exposing  thereby 
the  distended  veins,  which  together  with  the  mucous  membrane  arQ 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS 


1163 


separated  from  the  underlying  sphincter  by  successive  snips  of  the 
scissors,  and  cut  away,  all  bleeding-points  being  secured.  The  lower 
end  of  the  divided  mucous  membrane  is  united  by  suture  to  the  skin, 
the  stitches  passing  deeply  under  the '  surface  of  the  wound,  and  not 
merely  through  the  margins.  Excellent  results  have  followed  such 
treatment  in  suitable  cases. 


Eectal  Prolapse.— A  certain  tendency  to  eversion  of  the  mucous 
membrane  of  the  bowel  is  a  constant  and  normal  accompaniment 
of  the  act  of  defaecation ;  if,  however,  this  becomes  abnormally 
increased,  the  condition  may  be  maintained  after  the  evacuation  of 
the  bowels  is  concluded,  constituting  a  condition  of  prolapse.  At 
first  only  the  mucous  membrane  is  protruded,  and  this  is  known 
as  an  incomplete  prolapse  ;  if,  however,  the  condition  persists,  the 
whole  thickness  of  the  bowel,  mucous 
membrane,  submucosa,  and  even  the 
muscular  and  serous  coats,  may  become 
involved,  giving  rise  to  the  complete 
variety  (Fig.  503).  The  former  con- 
dition (sometimes  badly  termed  a  pro- 
lapsus ani)  is  more  commonly  met 
with  in  adults,  and  the  latter  (the  so- 
called  prolapsus  recti)  in  children  ;  but 
it  must  be  understood  that  the  latter 
is  always  preceded  by  an  incomplete 
stage,  limited  to  the  mucous  mem- 
brane, and  that  in  adults  complete  pro- 
lapse is  occasionally  observed. 

Causes. — -i.  It  may  be  produced  by 
a  simple  relaxation  of  the  tissues,  as 
met  with  in  weakly  individuals,  and 
those  who  have  been  much  exposed 
to  the  debilitating  effects  of  residence 
in  tropical  climates,  especially  when 
chronic  constipation  or  diarrhcea  has 
caused  the  evacuation  of  the  bowels  to  be  accompanied  by  straining 
efforts.  In  children  the  malnutrition  following  measles  and  whooping 
cough  may  predispose,  whilst  the  loss  of  fat  from  the  peri-rectal  cellular 
tissue  may  assist.  2.  Conditions  which  have  led  to  chronic  tenesmus 
or  violent  expulsive  efforts — e.g.,  piles,  chronic  constipation,  diar- 
rhcea, rectal  irritation,  as  from  worms  in  children — or  diseases  of 
neighbouring  organs,  such  as  vesical  calculus,  stricture,  or  enlarged 
prostate,  may  also  determine  prolapse. 

Symptoms  and  Diagnosis. — The  anal  orifice  is  occupied  by  a  smooth 
rounded  swelling,  red  or  purplish  in  colour,  covered  by  mucous 
membrane ;  this  protrusion  in  the  early  stages  can  be  easily  replaced 
by  a  little  pressure,  but  returns  if  the  patient  strains  or  coughs. 
When  the  swelling  is  of  large  size,  reduction  is  increasingly  difficult 
and   painful   from  infiltration  a,nd  fibrous  overgrowth  of   the   sub- 


B'lG.  503. — Longitudinal  Sec- 
tion OF  Complete  Prolapsus 
Recti.     (Tillmanns.  ) 

X  Indicates  the  serous  sac  in  the 
anterior  wall  due  to  protrusion 
of  the  peritoneum. 


ii64  ^  MANUAL  OF  SURGERY 

mucosa,  and  it  is  very  liable  to  become  inflamed  and  ulcerated  from 
friction.  Incontinence  of  faeces  is  also  a  common  result.  When 
the  whole  thickness  of  the  gut  is  protruded,  the  serous  lining  may 
accompany  the  tumour,  but  this  is  usually  limited  to  the  anterior 
surface,  and  into  the  sac  thus  formed  small  intestine  or  omentum 
may  pass,  and  even  become  strangulated  (Fig.  503,  x).  The  pro- 
lapse itself  may  also  be  constricted  if  allowed  to  remain  for  long 
unreduced  ;  the  mass  is  then  livid,  swollen,  and  intensely  painful, 
and  if  left  to  itself  may  slough  away,  and  thus  lead  to  a  spontaneous 
cure,  although  severe  septic  symptoms  may  supervene,  and  even 
perforative  peritonitis. 

There  should  be  but  little  difficulty  in  recognising  a  prolapse  ;  the 
only  condition  for  which  it  can  be  mistaken  is  an  intussusception 
protruding  from  the  anus  ;  in  such,  however,  the  finger  or  a  probe 
can  be  inserted  into  the  rectum  by  the  side  of  the  protruding  gut, 
which  is  impossible  with  a  prolapse. 

Treatment. — In  the  earlier  stages,  all  that  is  needed  is  the  removal, 
if  possible,  of  the  cause  of  the  tenesmus — e.g.,  dilatation  of  a  urethral 
stricture,  removal  of  a  vesical  calculus — or  the  regulation  of  the 
bowels  so  as  to  check  either  chronic  diarrhoea  or  constipation.  When 
piles  are  present,  they  should  be  treated  as  described  above,  and  the 
prolapse  will,  as  a  rule,  subsequently  disappear.  Thread-worms 
must  be  dealt  with  by  suitable  means  {q.v.).  Beyond  this,  cold  or 
astringent  injections  may  be  employed,  e.g.,  sulphate  of  iron  (i  to 
3  grains  to  i  ounce),  and  it  is  advisable  for  the  individual  to  acquire 
the  habit  of  having  the  daily  motion  at  bedtime,  whilst  children  are 
made  to  defsecate  lying  on  the  side,  one  buttock  being  pulled  up  for 
the  purpose.  The  prolapse  is  carefully  washed,  reduced  by  pres- 
sure with  the  fingers,  and  retained  by  strapping  the  nates  together, 
particularly  in  children,  or  by  applying  some  suitable  pad  and 
a  T-bandage.  Electric  treatment  to  tone  up  the  sphincter  and 
levatores  ani  may  be  of  assistance,  and  'in  children  palliative  treat- 
ment of  this  type  is  usually  successful.   . 

In  adults,  however.  Operative  Treatment  has  frequently  to  be 
undertaken. 

In  the  slighter  cases  of  incomplete  prolapse,  it  will  suffice  to 
diminish  the  size  of  the  anal  orifice  by  snipping  away  radiating  folds 
of  skin  and  mucous  membrane,  including  any  piles  that  may  be 
present.  In  worse  cases  it  may  be  advisable  to  remove  a  wedge  of 
the  posterior  wall  of  the  prolapse,  including  a  portion  of  the  sphincter, 
the  edges  being  brought  together  by  deep  stitches.  Where  such  has 
failed,  or  is  thought  insufficient,  the  prolapse  may  be  completely 
removed  by  the  following  procedure  :  The  patient's  buttocks  are  well 
raised,  so  as  to  prevent  any  protrusion  of  intestine  if  the  peritoneal 
cavity  is  opened.  An  incision  is  made  at  the  junction  of  the  skin 
and  mucous  membrane  at  the  anal  margin,  and  is  gradually  deepened. 
The  base  of  the  prolapse  is  divided  anteriorly  on  a  level  with  the 
anus,  the  opening  in  the  peritoneum  temporarily  packed  with  sterilized 
gauze,  and  the  remainder  of  the  mass  removed  by  scissors,  bleeding- 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1165 

points  being  secured  as  divided.  The  serous  cavity  is  then  carefully 
closed  by  sutures,  and  the  divided  end  of  the  bowel  united  to  the 
skin  at  the  anus.  No  motion  is  allowed  to  pass  for  a  week,  but  the 
anal  orifice  and  lower  gut  should  be  thoroughly  washed  out  twice  or 
thrice  daily  to  prevent  accumulation  of  septic  material.  Control 
over  the  bowel  is  usually  regained,  though  often  somewhat  slowly, 
and  the  after-treatment  is  likely  to  be  prolonged. 

The  ultimate  results  are  often  very  disappointing,  as  the  prolapse 
often  recurs  after  operation,  and  it  is  probable  that  operations  of  this 
type  should  be  entirely  discarded.  The  most  reasonable  proceedings 
are  those  directed  towards  fixation  of  the  rectum  (rectopexy)  either 
backwards  to  the  posterior  pelvic  wall,  or  from  above.  Various 
operations  of  this  type  have  been  described  and  practised,  with  some 
measure  of  success.  Thus  the  posterior  wall  of  the  rectum  may  be 
exposed  by  an  incision,  extending  from  the  tip  of  the  coccyx  to  the 
anal  margin ;  if  need  be,  the  posterior  wall  can  be  enfolded  in  the 
long  axis,  and  the  lumen  of  the  bowel  diminished  thereby.  Stitches 
are  then  introduced  transversely  through  the  rectal  wall  (avoiding 
the  mucous  membrane),  and  the  ends  are  passed  through  the  sacro- 
sciatic  ligaments  on  either  side  and  tied  firmly  over  a  pad  of  gauze, 
being  retained  in  situ  for  three  weeks.  The  rectum  is  thereby  fixed 
posteriorly,  and,  with  careful  after-treatment  as  to  the  action  of  the 
bowels,  good  results  may  follow.  As  a  modification  of  this  procedure, 
the  post-rectal  space  may  be  opened  up  and  packed  with  gauze, 
thereby  determining  cicatricial  fixation  of  the  bowel. 

Abdominal  operations  in  the  form  of  colopexy  have  also  been  under- 
taken, the  pelvic  colon  being  fixed  to  the  lateral  wall  of  the  pelvis  by 
stitches,  after  stripping  away  a  portion  of  the  parietal  peritoneum. 
The  former  method  of  fixation  is  the  more  desirable. 

Tuberculous  Disease  of  the  Rectum  occurs  in  the  form  of  ulcers, 
which  are  usually  multiple,  and  may  be  very  extensive.  Infection 
may  be  due  to  the  swallowing  of  infected  sputum,  but  is  probably 
the  result  of  dissemination  by  the  blood  ;  the  affection  is  often 
secondary  to  pulmonary  disease.  It  starts  in  the  submucosa,  and 
the  ulcers  which  follow  have  the  usual  features,  with  undermined 
edges  and  prominent  granulations.  There  is  usually  a  marked 
tendency  to  the  production  of  fistulas  by  extension  of  the  process 
outwards.  The  symptoms  are  those  of  rectal  irritability,  pain  on 
defaecation,  and  discharge  of  muco-pus  and  perhaps  blood.  Treat- 
ment is  generally  palliative,  the  rectum  being  emptied  by  enemata  or 
medicine  according  to  the  patient's  comfort,  and  possibly  healing 
ointments  introduced.  In  the  worst  cases,  colostomy  may  be  required 
in  order  to  put  the  bowel  at  rest.  Sanatorium  and  vaccine  treatment 
will  probably  be  required  in  addition. 

Syphilitic  Disease  of  the  Rectum  and  Anus. — The  rectum  and  anus 
are  attacked  by  syphilitic  disease  in  a  variety  of  ways,  the  most 
prominent  being  as  follows  : 

[a)  The  initial  lesion  or  primary  chancre  is  occasionally  met  with 
in  the  neighbourhood  of  the  anus. 


,l66  A  MANUAL  OF  SURGERY 

(b)  In  the  secondary  stage  mucous  tubercles  or  condylomata  are 
frequently  seen,  being  placed  either  at  the  anal  margin  or  sym- 
metrically on  either  side  of  the  gluteal  fold,  the  sores  on  one  side 
having  evidently  infected  the  other.  They  are  of  the  usual  type 
(p,  150),  and  are  treated  by  dusting  with  powdered  calomel,  and 
keeping  a  piece  of  dressing  between  the  lips  of  the  fold. 

(c)  In  the  tertiary  period  diffuse  syphilitic  disease  of  the  rectum  is  not 
uncommon,  occurring  most  often,  but  not  solely,  in  young  married 
women  of  the  poorer  classes.  It  is  a  somewhat  early  tertiary  mani- 
festation, and  usually  commences  within  easy  reach  of  the  finger, 
about  3  inches  from  the  anus.  It  starts  as  a  diffuse  gummatous 
infiltration  of  the  rectal  mucous  membrane  and  submucous  tissue, 
which  become  thickened  and  indurated,  ulceration  soon  following. 
These  phenomena  are  not  limited  to  the  rectum,  but  frequently 
spread  up  the  intestine  towards  the  sigmoid  flexure  and  down  to  the 
anus,  and  likewise  involve  the  recto-vaginal  septum  and  vagina, 
passing  down  the  latter  canal  to  invade  the  perineum  and  neigh- 
bouring structures,  so  that  in  a  neglected  case  the  whole  external 
genitals  and  anus  may  be  involved  in  an  irregular  hypertrophic  mass, 
somewhat  resembling  elephantiasis.  In  addition,  the  ulcerative  pro- 
cess may  extend  more  deeply,  leading  to  the  formation  of  fistulae, 
not  only  between  the  rectum  and  neighbouring  viscera  {e.g.,  vagina 

-or  bladder),  but  also  communicating  with  the  exterior.  From  the 
cicatrization  occurring  in  the  submucous  tissue,  contraction  of  the 
gut  results,  causing  syphilitic  stricture,  which  may  extend  for  some 
distance  up  the  bowel.  The  symptoms  consist  in  pain,  increased  on 
defaecation,  irritability  of  the  bowel,  and  discharge  of  blood  and  pus 
by  the  anus,  whilst  obstructive  phenomena,  or  alternating  attacks  of 
constipation  and  diarrhoea,  may  also  be  present.  On  examination, 
the  diffuse  ulceration  and  infiltration  of  the  part  are  suggestive  of 
malignant  disease,  but  the  patient's  age  and  history,  and  the  pain- 
lessness and  course  of  the  case,  are  usually  sufBcient  to  determine  the 
diagnosis.  The  general  health  remains  good  in  the  earlier  stages  of 
the  affection,  but  later  on  may  be  undermined  by  the  pain  and  constant 
purulent  discharge. 

Treatment  consists  in  administering  mercury  and  iodide  of  potas- 
sium, the  former  perhaps  in  the  shape  of  suppositories,  whilst  locally 
contraction  is  prevented  as  far  as  possible  by  the  regular  use  of 
bougies.  Possibly  thiosinamin  or  iodolysin  will  be  found  useful  in 
the  later  stages  to  assist  in  the  complete  removal  of  the  newly-formed 
cicatricial  tissue.  In  advanced  cases  colostomy  is  essential  in  order 
to  secure  rest  to  the  parts,  and  give  them  a  chance  of  healing.  Possibly 
in  a  few  instances  only  a  temporary  opening  of  the  bowel  may  be 
required,  but  where  much  contraction  exists  and  a  considerable 
tendency  to  obstruction,  the  artificial  opening  must  remain  per- 
manently. Sometimes  the  ulceration  persists  in  spite  of  colostomy, 
and  care  must  then  be  taken  to  prevent  the  retention  of  discharges  by 
the  occasional  passage  of  bougies. 

Fibrous  Stricture  of  tlie  Rectum  is  usually  met  with  in  women  over 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  .1167 

forty  years  of  age,  and  is  most  often  situated  2  or  3  inches  from  the 
anus,  or  as  high  as  its  junction  with  the  sigmoid  flexure.  In  this 
position,  it  is  generally  due  to  the  cicatrization  and  contraction  of 
ulcers  following  prolonged  diarrhoea  and  dysentery,  although  occa- 
sionally it  follows  tuberculous  or  syphilitic  disease.  Any  form  of 
chronic  proctitis — e.g.,  gonorrhoea — may  also  lead  to  it.  It  occurs 
sometimes  as  a  sequela  of  pelvic  cellulitis  and  suppuration,  from  the 
contraction  of  fibrous  bands  which  may  bind  the  rectum  backwards 
to  the  sacral  wall,  or  may  merely  constrict  it ;  the  stricture  is  in  these 
cases  usually  at  a  lower  point  than  in  the  former.  Repeated  attacks 
of  inflamed  piles  may  also  lead  to  stenosis  at  or  just  above  the  anus. 
A  stricture  sometimes  results  from  traumatism,  or  follows  operations 
involving  the  whole  or  at  any  rate  the  greater  portion  of  the  circum- 
ference of  the  bowel.  As  already  mentioned,  it  may  be  associated 
with  a  fistula,  especially  if  the  latter  has  existed  for  long,  and  is  then 
due  to  a  chronic  inflammatory  fibrosis  lighted  up  by  the  persistent 
irritation  of  the  stricture ;  the  inner  opening  is  then  found  in  the 
substance  of  the  stricture. 

The  earliest  Symptoms  of  stricture  are  often  alternating  attacks  of 
diarrhoea  and  constipation,  in  which,  of  course,  the  constipation  is 
primary,  and  the  diarrhoea  due  to  a  catarrhal  enteritis  arising  from 
the  irritation  of  the  retained  faeces.  Gradually  the  difficulty  in  pass- 
ing motions  becomes  more  and  more  marked  until  no  relief  is  obtained 
apart  from  medicine  ;  the  faeces  themselves  become  narrowed,  flat- 
tened, and  elongated,  something  like  pipe-stems,  or  small  masses 
like  shrimps  may  alone  succeed  in  passing.  This  is  associated  with 
pain  and  uneasiness  referred  to  the  lower  bowel ;  a  certain  amount 
of  blood  and  mucus  may  be  mixed  with  the  excreta,  and  sooner  or 
later  marked  dyspepsia  and  abdominal  distension  supervene.  If  the 
case  is  allowed  to  run  on  without  treatment,  absolute  obstruction  of 
a  chronic  type  may  result,  and  lead  to  a  fatal  issue ;  or  the  mucous 
membrane  of  the  bowel  above  the  stricture  becomes  ulcerated,  an 
abscess  forms,  and  subsequently  a  fistula,  through  which  a  certain 
small  amount  of  faecal  material  passes.  If  several  of  .these  fistulae 
are  established,  the  patient  may  finally  succumb  to  chronic  septic 
poisoning  and  exhaustion. 

An  examination  of  the  bowel  with  the  finger  may  reveal  a  smooth, 
regular  constriction  of  the  gut  as  if  a  band  had  been  tied  round  it, 
the  fibrous  mass  and  the  aperture  in  it  feeling  something  like  an  os 
uteri.  In  other  cases,  the  bowel  is  stenosed  for  some  distance,  and 
its  surface  more  or  less  ulcerated ;  whilst  if  due  to  pelvic  cellulitis,  it 
may  be  drawn  up  and  fixed  to  the  posterior  pelvic  wall.  When  the 
stricture  is  too  high  for  the  finger  to  reach,  the  gut  may  appear 
normal,  though  somewhat  dilated  (ballooning).  Sometimes  the 
stricture  is  smooth,  and  free  from  nodular  irregularities  and  excres- 
cences ;  often,  however,  it  is  ulcerated  and  irregular,  the  examination 
causing  great  pain.  The  gut  above  the  contraction  is  hypertrophied 
and  distended,  whilst  if  filled  with  retained  faeces,  the  mucous  mem- 
brane may  show  signs  of  inflammation,  or  even  stercoral  ulcers.     The 


ii68  A  MANUAL  OF  SURGERY 

gut  below  the  stricture  is  usually  dilated  (ballooned),  partly  from 
paralysis  of  its  walls,  and  partly  by  invagination  of  the  mass  from 
above. 

The  Treatment  in  the  early  stages  consists  in  keeping  the  bowels 
regular  and  the  motions  soft  by  means  of  laxatives,  such  as  castor  oil 
or  salines,  whilst  the  passage  of  the  excreta  is  assisted  by  enemata. 
The  diet  is  regulated,  and  the  strength  maintained,  if  need  be,  by 
tonics.  Locally,  the  stricture,  if  within  reach,  should  be  dilated  by 
means  of  bougies  passed  in  increasing  sizes  every  two  or  three  days, 
care  being  taken  that  the  point  of  the  instrument  engages  the 
stricture,  and  is  not  caught  against  folds  of  mucous  membrane  or 
turned  backwards.  The  utmost  gentleness  must  be  used,  in  order 
to  stretch  the  mucous  membrane,  and  not  tear  it.  Laminaria  or 
compressed  sponge-tents  are  of  use  in  some  cases,  followed  subse- 
quently by  bougies.  When  situated  low  down,  the  stricture  may 
be  notched  posteriorly,  or  slightly  nicked  in  several  places  with  a 
blunt-ended  bistoury,  and  bougies  then  passed.  There  is  always  a 
great  tendency  in  these  strictures  to  contract  again,  and  the  patient 
should  be  instructed  to  pass  a  bougie  for  himself  at  short  intervals. 
If  the  stricture  is  out  of  reach,  or  signs  of  obstruction  manifest 
themselves  in  spite  of  treatment,  colostomy  is  the  final  resource. 

Tumours  of  the  Rectum. — Polypus  Recti  occurs  most  frequently  in 
children,  and  consists  usually  of  an  adenoma  of  Lieberkiihn's  follicles, 
but  occasionally  of  simple  fibrous  tissue  covered  with  mucous  mem- 
brane. They  are  commonly  found  within  easy  reach  of  the  anus, 
and  present  an  appearance  something  like  a  small  cherry  with  a  long 
pedicle,  pendulous  and  freely  mobile.  The  Symptoms  caused  are 
irritability  of  the  bowel  and  the  passage  of  blood  by  the  anus,  which 
latter  when  occurring  in  a  child  without  symptoms  of  obstruction  is 
almost  pathognomonic  of  polypus.  The  tenesmus  excited  may  lead, 
as  mentioned  elsewhere,  to  prolapse  or  to  the  occurrence  of  an  intus- 
susception. It  is  occasionally  associated  with  a  fissure  of  the  anus, 
which  probably  arises  as  a  secondary  result  of  the  irritation  caused 
by  the  partial  extrusion  of  the  polypus  during  defaecation.  A  natural 
cure  can  be  effected  by  rupture  of  the  attenuated  pedicle,  which  is  at 
first  attended  by  a  certain  amount  of  haemorrhage.  Treatment. — 
The  polypus  is  cut  away  after  tying  or  twisting  its  pedicle,  or  the 
clamp  and  cautery  may  be  employed. 

Papilloma  of  the  rectum  is  a  rare  disease,  and  gives  rise  to  haemor- 
rhage from  and  irritability  of  the  bowel,  or,  if  large,  even  to  obstruc- 
tion. This  condition  is  not  always  limited  to  the  rectum,  but  may 
extend  through  the  greater  portion  of  the  intestine,  and  then  proves 
fatal  from  haemorrhage.  Treatment  consists  in  removal  by  ligature 
or  wire  snare,  where  practicable. 

Sarcoma  is  another  uncommon  disease  in  the  rectum.  It  occurs 
in  the  shape  of  a  large  fleshy  tumour  growing  from  the  submucous 
tissue,  and  projecting  into  the  lumen  of  the  gut  so  as  to  cause 
obstruction.  It  is  less  painful  than  cancer,  and  usually  occurs  at  an 
earlier  age.     The  symptoms  are  much  as  in  the  latter  disease,  and 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS 


1169 


the  treatment,  when  feasible,  is  the  same,  viz.,  extirpation  of  the 
growth,  but  it  will  very  probably  recur. 

Epithelioma  of  the  Anus — i.e.,  of  the  skin  covering  the  anal  margin 
— occurs  as  a  primary  development  similar  to  that  on  the  lip,  and  is 
then  of  the  squamous  type.  It  presents  the  usual  features — viz.,  an 
indurated  nodular  mass,  which  readily  ulcerates,  and  runs  the  typical 
course  of  such  a  disease,  infecting  the  inguinal  glands.  It  is  readily 
dealt  with  in  the  earlier  stages  by  an  operation  somewhat  similar  to 
that  for  excision  of  the  rectum. 


Fig.  504. — Carcinoma  of  the  Rectum.     (King's  College  Hospital  Museum. 
I,  Anus,  split  open  posteriorly  ;  2,  2,  margins  of  the  ulcerated  growth. 

Cancer  of  the  Rectum  appears  in  the  form  of  columnar  carcinoma, 
consisting,  as  described  elsewhere  (p.  216),  of  an  overgrowth  of 
Lieberkiihn's  follicles,  not  only  into  the  lumen  of  the  gut  (centri- 
fugal or  papillomatous  type  of  growth),  but  also  invading  the  deeper 
portions  of  the  bowel  wall,  infiltrating  the  submucous  and  muscular 
layers  (centripetal  growth).  A  vascular  fibro-cellular  stroma  is  found 
between  the  glandular  acini,  and  the  physical  characters  of  the 
tumour  are  largely  dependent  on  the  relative  amount  of  these  two 
elements.  Thus,  {a)  if  the  stroma  is  abundant  and  fibro-cicatricial, 
the  growth  is  comparatively  slow ;  the  tumour  is  hard  and  nodular ; 

74 


II70  A  MANUAL  OF  SURGERY 

it  usually  starts  on  one  side  of  the  bowel  as  a  malignant  wart-like  mass, 
but  gradually  encircles  the  gut,  and  is  always  likely  to  produce 
obstructive  phenomena  from  its  contraction  ;  ulceration  occurs  after 
a  while,  (b)  In  the  softer,  more  rapidly  growing  type,  the  stroma  is 
less  abundant,  and  merely  fibro-cellular  in  character.  The  tumour 
projects  into  the  bowel,  and  early  involves  the  whole  circumference ; 
ulceration  and  bleeding  are  constant  features,  and  the  pain  is  usually 
considerable.  There  is  always  greater  destruction  of  tissue,  so  that 
obstruction  to  the  onward  passage  of  faeces  is  much  less  likely  to 
occur  in  it  than  in  the  former  type,  where  cicatricial  contraction  is  a 
marked  feature.  The  ulcer  which  develops  in  the  bowel  is  of  the  usual 
malignant  type,  with  an  excavated  surface  and  raised,  indurated,  and 
everted  edges  (Fig.  504,  and  Plate  IX.) ;  it  bleeds  readily,  and  its 
investigation  is  very  painful.  Colloid  degeneration  is  occasionally 
seen  in  cancer  of  the  rectum. 

As  the  disease  progresses,  it  invades  surrounding  parts,  and  thus 
the  tumour  may  become  adherent  either  to  the  pelvic  walls  or  to  the 
bladder,  vagina,  or  prostate  ;  sometimes  the  iliac  vessels  or  sciatic 
nerves  are  compressed,  causing  oedema  or  neuralgia  respectively. 
Of  course  it  must  be  understood  that  this  invasion  is  in  part  inflam- 
matory, and  due  to  absorption  of  bacteria,  etc.,  from  the  ulcerated 
surface,  and  this  is  always  a  grave  addition  to  the  case.  Peri-rectal 
abscesses  and  fistulae  sometimes  form,  opening  externally  in  the 
ischio-rectal  fossae,  or  perhaps  internally  into  the  bladder  or  vagina, 
and  then  the  tumour  begins  to  develop  along  the  line  of  the  fistula, 
and  may  actually  form  a  mass  of  some  size  in  the  bladder. 

The  glands  in  the  meso-rectum  and  the  lumbar  glands  become 
enlarged,  but  for  a  time  this  may  be  merely  inflammatory  in  type, 
though  later  on  they  become  cancerous.  Anal  cancer,  of  course, 
leads  to  involvement  of  the  inguinal  glands.  Secondary  deposits 
may  also  be  found  in  the  liver,  but  this  is  more  comm^^on  when  the 
cancer  is  higher  up  the  bowel ;  the  disease  may  even  be  disseminated 
throughout  the  body,  though  this  is  decidedly  rare. 

The  Symptoms  of  the  disease  are  often  so  slight,  and  the  onset  so 
insidious  as  to  raise  no  suspicions  of  the  existence  of  any  growth 
until  it  has  attained  considerable  size.  The  patient  is  usually  an 
adult,  and  more  often  male  than  female.  At  first  there  may  be 
merely  some  slight  constipation,  requiring  an  increased  amount  of 
opening  medicine.  Then  may  come  more  definite  attacks  of  con- 
stipation, alternating  with  diarrhoea,  and  the  discharge  of  large 
quantities  of  mucus,  often  blood-stained.  A  sense  of  weight  or 
dragging  pain  is  noticed  in  the  rectum,  and  the  patient  after  defaeca- 
tion  feels  as  if  there  is  still  something  to  be  passed.  This  sensation 
increases  until  true  tenesmus  and  straining  at  stool  are  present, 
together  with  constant  pain,  which  may  radiate  up  the  back  and 
down  the  legs,  causing  sitting  on  any  hard  substance  to  be  painful. 
At  first  a  blood-stained  discharge  may  be  seen  on  the  faeces,  which 
become  flattened  and  pipe-like,  if  stenosis  is  present,  but  later  it 
passes  independently  of  the  motions.     On  examination,  an  ulcer- 


PLATE   VII. 


Malignant   disease   of   Rectum. 

The  growth  was  an  ulcerated  columnar  carcinoma  on  the  posterior  wall, 
situated  about  3  inches  from  the  anus,  and  had  extended  nearly  round  the 
whole  circumference  ;  it  caused  much  irritability  and  diarrhoea,  and  was 
removed  by  Kraske's  method,  without  interfering  with  the  anal  canal. 

S^To  face  page  1 1 16. 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1171 

ating,  crateriform  mass  is  met  with,  which  may  be  limited  to  one 
segment  of  the  gut  wall,  and  is  then  usually  firm,  and  perhaps 
associated  with  stenosis ;  or  it  may  surround  the  bowel,  and  feel  soft 
and  spongy,  readily  breaking  down  under  the  finger,  and  bleeding 
freely.  The  bowel  below  the  growth  is  usually  'ballooned,'  This 
examination  is  generally  painful,  as  also  the  process  of  defaecation, 
and  sometimes  the  patient  abstains  from  the  latter  for  lengthened 
periods  on  account  of  the  exquisite  agony  caused  thereby.  When 
the  anterior  wall  is  involved,  the  bladder  is  often  fixed  to  the  mass, 
and  micturition  becomes  painful ;  moreover,  every  time  the  bladder 
is  emptied  a  discharge  may  occur  from  the  bowel,  and  this  may 
continue  even  after  colostomy  has  been  performed.  Marked  cachexia 
supervenes,  the  digestion  becomes  impaired,  any  meal  causing  pain 
and  flatulent  distension  ;  natural  sleep  is  impossible,  and  if  a  recto- 
vesical fistula  forms,  the  patient's  troubles  are  further  aggravated  by 
the  passage  of  faeces  and  flatus  by  the  urethra. 

The  case  runs  a  more  or  less  rapid  course  to  the  fatal  issue,  which 
on  an  average  ensues  about  seventeen  months  after  the  onset  of 
symptoms,  if  no  operation  has  been  undertaken  (Jessop*),  and  may 
be  due  to  a  variety  of  causes.  Faecal  obstruction  occurs  in  about 
30  per  cent,  of  the  cases,  being  more  marked  in  the  chronic  forms, 
and  in  those  where  the  disease  starts  high  up  the  bowel,  on  account 
of  the  peristalsis  causing  invagination  of  the  mass  and  occlusion  of 
the  tube ;  whilst  if  ulceration  is  excessive,  or  the  disease  situated 
low  down,  obstruction  is  less  common,  invagination  being  here 
impossible,  and  peristalsis  being  expended  on  the  onward  passage  of 
the  faeces.  Exhaustion  from  haemorrhage,  pain,  sleeplessness,  or 
septic  absorption,  accounts  for  most  of  the  fatal  results,  whilst  septic 
peritonitis  following  the  perforation  of  stercoral  ulcers  above  the 
growth  occurs  in  a  few  instances. 

The  Treatment  of  cancer  of  the  rectum  consists  in  the  radical 
measure  of  excision  of  the  mass,  or  in  the  palliative  operation  of 
colostomy. 

Excision  of  the  Rectum,  or  proctectomy,  is  only  applicable  to  cases 
in  which  there  is  a  reasonable  prospect  of  the  whole  disease  being 
removed.  This  depends  not  so  much  on  the  upward  extent  of  the 
growth  as  on  the  question  of  fixation  to  surrounding  parts.  When 
the  mass  is  not  fixed  anteriorly  so  as  to  endanger  other  viscera  (e.g., 
the  prostate  or  bladder),  the  case  is  a  favourable  one  for  excision. 
Fixation  of  the  mass  laterally  or  behind  is  not  so  important,  although 
it  will  prevent  removal,  if  extensive.  Enlargement  of  glands  in 
the  meso-rectum  does  not  necessarily  contra-indicate  operation,  as 
they  may  be  included  in  the  scope  of  the  high  operation.  When  the 
lumbar  glands  are  involved,  or  the  liver,  excision  is  obviously  useless 
and  should  not  be  undertaken.  Formerly  it  was  considered  of  vital 
importance  to  avoid  opening  the  peritoneum  ;  but  at  the  present  day 
this  is  frequently  done,  and  with  no  untoward  result,  if  due  pre- 
cautions are  taken ;  so  that,  although  the  growth  may  be  situated 
*  British  Medical  Journal,  1889,  ii.,  p.  407. 


II72  A  MANUAL  OF  SURGERY 

^igh  up,  if  it  is  freely  moveable,  and  there  is  no  evidence  of 
secondary  deposits,  an  attempt  should  be  made  to  take  it  away.  It 
must  be  remembered  that  in  the  male  the  peritoneum  is  reached  on 
the  anterior  aspect  of  the  gut  about  2^  inches  from  the  anus  with  an 
undistended  bladder,  whilst  it  may  be  pushed  up  another  inch  when 
that  viscus  is  full ;  in  the  female  the  peritoneum  is  situated  about 
4  inches  from  the  anus,  being  reflected  to  the  posterior  aspect  of  the 
cervix  uteri.  Posteriorly,  the  lower  4  or  5  inches  of  the  bowel  are 
uncovered  by  serous  membrane  in  both  sexes. 

Excision  of  the  rectum  must  include  in  its  scope  not  only  the 
removal  of  the  growth,  but  also  of  a  considerable  margin  of  ap- 
parently healthy  intestinal  wall,  both  above  and  below,  together  with 
the  lymphatic  vessels  and  glands  draining  this  area  and  lying  in  the 
hollow  of  the  sacrum.  This  removal  can  be  effected  in  several 
ways,  and  the  choice  of  operation  depends  chiefly  on  the  character, 
position,  and  extent  of  the  growth,  but  also  to  some  degree  upon 
the  condition  of  the  patient.  The  actual  operations  are  known  as 
(i)  the  perineal  or  Langenbeck's  operation;  (2)  the  trans-sacral  or 
Kraske's  method ;  (3)  the  abdominal ;  and  (4)  the  combined 
abdomino-perineal  procedure,  where  the  growth  is  attacked  both 
from  above  and  below. 

I .  Perineal  Proctectomy,  or  Langenbeck's  Operation,  is  a  satisfactory 
procedure  in  cases  of  early  cancer  of  the  lower  part  of  the  rectum 
when  the  glands  in  the  hollow  of  the  sacrum  are  not  obviously 
involved.  In  most  cases  preliminary  colostomy  is  a  desirable  pro- 
cedure, especially  if  the  whole  circumference  of  the  bowel  for  a 
distance  of  3  inches  or  more  has  to  be  removed,  and  the  more  so  if 
the  anus  has  to  be  sacrificed.  The  passage  of  faeces  over  and  through 
the  raw  surface  of  the  wound  is  not  only  a  source  of  septic  con- 
tamination, but  also  causes  extreme  pain,  whilst  the  ultimate  issue 
of  the  operation  is  an  opening  which  is  almost  certain  to  become 
unduly  patulous  or  too  much  contracted,  and  there  is  always 
a  total  loss  of  control.  An  effective  anus  in  the  left  iliac  region 
obviates  all  these  difficulties,  whilst  the  preliminary  opening  of  the 
abdomen  gives  the  surgeon  an  opportunity  of  investigating  the  con- 
dition of  the  lumbar  and  sacral  glands,  and  of  ascertaining  the  extent 
of  the  growth  up  the  bowel,  and  whether  or  not  secondary  deposits 
are  present  in  the  liver. 

The  operation  itself  is  conducted  as  follows  : 

Low  Operation. — The  rectum  having  been  thoroughly  washed  out 
and  emptied,  and  the  patient  placed  in  the  lithotomy  position,  the 
perineum  is  shaved  and  purified,  and  the  posterior  wall  of  the  rectum 
and  anus  slit  open  in  the  middle  line  as  far  as  the  tip  of  the  coccyx. 
An  incision  is  now  made  all  round  the  anus  at  the  junction  of  the 
skin  and  mucous  membrane,  if  the  anus  is  healthy ;  when  diseased, 
the  incision  is  extended  beyond  the  margin  so  as  to  include  the 
growth.  The  rectum,  together  with  the  tumour,  is  then  separated 
from  surrounding  structures  by  scissors  and  fingers,  commencing 
posteriorly,  where  this  is  readily  effected,  dividing  the  levator  ani 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1173 

on  each  side,  and  working  gradually  upwards  and  to  the  front,  where 
greater  care  must  be  taken  to  protect  the  vagina,  prostate,  or 
membranous  urethra.  In  the  male,  a  bougie  or  catheter  may  be 
passed  into  the  urethra  with  advantage.  Bleeding-points  can  be 
secured  during  this  process  by  pressure-forceps.  The  upper  attach- 
ments of  the  gut  are  divided  either  by  scissors,  ecraseur,  or  clamp 
and  cautery.  Hagmorrhage,  which  is  generally  very  free,  is  arrested 
by  ligature  or  cautery,  and  the  gaping  wound  powdered  with  iodo- 
form, and  packed  for  twenty-four  hours  with  gauze,  the  posterior 
incision  not  being  closed  by  suture,  and  no  attempt  made  to  drag 
down  the  mucous  membrane.  Subsequently  the  wound  may  be  left 
without  any  internal  dressing,  an  external  pad  of  salicylic  wool 
sufficing ;  it  is  thoroughly  washed  out  two  or  three  times  a  day  with 
some  dilute  antiseptic,  such  as  sanitas  (i  in  10),  Condy's  solution,  or 
carbolic  acid  lotion  (i  in  60),  which  may  be  used  alternately ;  granula- 
tions gradually  cover  the  surface,  and,  as  cicatrization  progresses, 
the  mucous  membrane  is  by  degrees  approximated  to  the  skin  margin, 
and  the  patulous  cavity  diminished  in  size  until  healing  is  complete, 

2.  The  Trans-sacral  or  Kraske's  Operation  consists  in  the  removal 
of  the  growth  after  a  portion  of  the  coccyx  or  sacrum  has  been  cut 
away.  It  may  be  undertaken  in  cases  where  the  growth  extends 
upwards  from  the  lower  into  the  upper  parts  of  the  rectum,  but  is 
more  especially  suitable  to  cases  in  which  the  anal  canal  is  not 
involved,  and  the  lower  edge  of  the  growth  is  situated  3  or  4  inches 
up  the  bowel. 

The  question  of  a  preliminary  colostomy  has  again  to  be  con- 
sidered. In  this  operation  it  is  desirable  that  the  surgeon  should  aim 
at  a  restoration  of  the  canal,  so  that  the  patient  shall  afterwards  pass 
faeces  normally.  Whilst  admitting  that  this  is  not  the  usual  termina- 
tion of  the  case,  yet  it  is  sometimes  obtained,  and  therefore  a  colos- 
tomy is  prima  facie  undesirable.  It  can  always  be  established  at  a 
later  date  if  a  sacral  anus  or  faecal  fistula  in  the  sacral  region  persists 
and  is  troublesome.  If,  however,  the  patient  is  previously  suffering 
from  obstructive  phenomena,  and  probably  has  a  collection  of  hard 
faecal  matter  above  the  growth,  a  colostomy  is  essential  in  order  to 
clear  the  bowel ;  it  is  advisable,  however,  to  make  it  in  such  a  way 
that  it  may  be  subsequently  closed. 

Operation.— 'YYio.  patient  reclining  on  his  right  side,  an  incision  is 
made  in  the  median  line  from  just  behind  the  anus  to  the  middle  of 
the  sacrum,  but  without  opening  the  bowel.  The  coccyx  is  excised, 
and  the  great  sacro-sciatic  ligament  and  gluteus  maximus  are  de- 
tached from  the  left  side  of  the  sacrum.  Part  of  the  left  wing  of  the 
latter  bone  is  now  removed  by  chisel  and  hammer,  the  incision  being 
curved,  and  extending  from  the  median  line  below,  through  or  above 
the  fourth  posterior  sacral  foramen  to  the  under  border  of  the  third, 
and  then  to  the  left  border  of  the  bone  at  that  level  (Fig.  505,  a  h). 
The  loose  cellular  tissue  behind  the  rectum  is  thus  exposed,  and  the 
gut,  together  with  the  tumour  and  the  enlarged  glands  in  the  hollow 
of  the  sacrum,  is  freed  from  its  connections,  and  amputated  from  the 
sound  gut  above,  the  peritoneum  being  usually  encroached  on  in  this 


II74 


A  MANUAL  OF  SURGERY 


stage  of  the  proceedings.  A  strip  of  sterile  gauze  is  packed  in  to 
protect  the  cavity  from  infection,  and  the  opening  is  subsequently- 
sutured  up.  If  the  growth  extends  to  the  anus,  the  whole  length  of 
the  rectum  below  is  excised,  and  then  the  upper  segment  is  drawn 
down  after  being  mobilized  by  division  of  the  peritoneum  on  either 
side  of  the  meso-rectum,  and  sutured  to  the  skin.  If  the  sphincter 
and  lower  inch  or  two  are  free  from  disease,  they  are  left  in  situ,  and 
carefully  sutured  to  the  lower  end  of  the  upper  segment,  although  it 
is  very  probable  that  complete  union  will  not  occur.  The  wound  is 
carefully  washed  out,  and  stuffed  with  gauze  sprinkled  with  iodoform; 
even  if  the  peritoneal  sac  has  been  opened,  no  harm  will  usually  come 
of  it.  The  results  which  have  followed  this  severe  operation  are,  on 
the  whole,  encouraging.  Should  partial  union  of  the  upper  and 
lower  segments  occur,  and  merely  a  fistula  be  left,  it  may  be  possible 
to  close  this  by  a  secondary  operation. 


Fig.  505. — Pelvis  seen  from  Behind  to  indicate  the  Lines  of  Section 

OF  THE  Sacrum  and  Coccyx  in  Kraske's  Operation. 

a  b,  Kraske's  original  operation  ;  a  c,  Bardenheuer's  modification. 

Vafious  modifications  of  Kraske's  proceeding  have  been  suggested, 
one  of  the  best  being  that  performed  by  Bardenheuer.  The  sacrum 
is  exposed,  sawn  across  just  below  the  third  foramina  (Fig.  505,  a  c), 
and  the  portion  thus  detached  is  totally  removed.  By  this  means 
a  much  more  extensive  view  is  obtained  of  the  pelvic  contents,  and 
the  scope  of  the  operation  increased.  In  all  such  procedures  the 
importance  of  preserving  the  third  sacral  nerves  which  supply  the 
bladder  must  be  kept  in  mind. 

3.  The  Abdominal  Operation  is  only  possible  when  the  lower  3  or 
4  inches  of  the  bowel  are  free  from  disease.  Its  object  is  to  remove 
the  upper  segment  of  the  rectum,  part  of  the  pelvic  colon,  and  of  the 
attached  mesentery  with  its  lymphatic  glands  and  cellular  tissue,  and 
to  restore  the  continuity  of  the  bowel  by  suturing  the  ends  together 
from  above.  The  operation  is  conducted  in  the  Trendelenburg 
position,  and  the  rectum  must  be  previously  thoroughly  irrigated 


AFFECTIONS  OF  THE  RECTUM  AND  ANUS  1175 

with  lysol  or  some  other  antiseptic.  The  abdomen  is  opened  in  the 
middle  hne,  and  the  intestines  drawn  down  out  of  the  way  and  pro- 
tected. A  full  examination  of  the  parts  is  then  feasible,  and  a  final 
determination  reached  as  to  the  character  of  the  operation  required. 
The  rectum  immediately  below  the  disease  is  carefully  clamped  and 
cut  across ;  the  lower  segment  is  temporarily  guarded.  The  peri- 
toneum on  either  side  of  the  upper  segment  is  now  divided,  and  the 
tissues  of  the  meso-rectum  freed  therefrom.  A  portion  of  the  sigmoid 
suitable  for  approximation  to  the  lower  end  is  selected,  and  by 
dividing  the  peritoneum  of  the  meso-sigmoid  on  its  outer  side  the 
loop  is  freely  mobilized.  The  gut  is  clamped  above,  and  the 
diseased  segment  removed,  the  vessels  supplying  it  being  secured  by 
ligatures,  and  this  may  even  include  the  main  branches  of  the  inferior 
mesenteric  artery.  The  upper  and  lower  segments  are  then  united 
by  sutures,  either  within  the  pelvis  or  by  invaginating  the  two, 
through  the  anus  and  performing  the  anastomosis  outside,  with 
subsequent  reposition.  An  effort  is  made  to  restore  the  continuity  of 
the  peritoneum  by  suturing,  and  it  may  be  wise  to  insert  a  large 
drainage-tube  through  the  anus  so  as  to  reach  above  the  line  of 
suture  and  allow  flatus  to  pass.  In  weakly  patients  it  is  sometimes 
undesirable  to  prolong  the  operation  by  attempting  the  restoration  of 
the  canal,  and  in  stout  patients  it  may  be  impossible  to  effect  this 
owing  to  the  amount  of  fat  present.  Under  such  circumstances  it  is 
wise  to  complete  the  operation  by  the  formation  of  a  terminal 
artificial  anus  in  the  left  iliac  fossa,  and  by  completely  suturing  up 
the  anal  segment  of  the  bowel. 

4.  The  combined  Abdomino-perineal  Operation  is  chiefly  used  as 
an  alternative  to  the  perineal  or  to  Kraske's  method,  and  has  the 
great  advantage  of  permitting  a  wider  removal  of  lymphatic  vessels 
and  glands.  The  abdomen  is  opened  usually  through  the  left  rectus, 
with  the  patient  in  the  Trendelenburg  position.  After  due  examina- 
tion, the  bowel  above  the  growth  is  divided  in  a  suitable  position ; 
the  lower  end  is  completely  closed,  whilst  the  upper  has  a  Paul's 
tube  tied  into  it,  and  is  fixed  in  the  wound  so  as  to  form  a  permanent 
colostomy.  The  peritoneum  of  the  mesentery  of  the  distal  segment 
is  then  divided  on  each  side  close  to  its  parietal  attachment,  and  the 
bowel  with  all  the  tissues  behind  it  lying  in  the  hollow  of  the  sacrum 
is  peeled  downwards  to  the  pelvic  floor,  care  being  taken  to  guard 
.the  ureters  and  main  iliac  vessels.  The  peritoneum  of  Douglas's 
pouch  is  then  incised  transversely,  and  the  separated  bowel  and  the 
tissues  connected  with  it  are  pushed  down  below  it,  and  covered  over 
by  suturing  together  the  divided  segments  of  peritoneum.  The 
abdomen  may  then  be  closed,  and  the  rest  of  the  operation  is  con- 
ducted in  the  left  lateral  position  as  in  the  perineal  procedure.  After 
the  bowel  has  been  removed,  the  perineal  wound  may  be  entirely 
closed,  special  care  being  directed  to  securing  together  the  divided 
segments  of  the  levator  ani. 

Occasionally  it  is  possible  to  avoid  the  formation  of  a  colostomy  by 
carrying  the  lower  end  of  the  divided  sigmoid  flexure  downwards^ 
and  fixing  the  lower  end  in  the  perineum, 


11,76  A  MANUAL  OF  SURGERY 

-  The  mortality  after  all  these  operations  is  high,  reaching  at  least 
to  26  per  cent. ;  this  is  largely  due  to  the  grave  risks  of  infection, 
and  in  a  less  degree  to  the  severity  of  the  procedure.  Perhaps  the 
abdominal  methods  which  include  the  formation  of  an  artificial  anus 
have  some  advantage  by  reducing  the  chances  of  faecal  contamination. 
The  tendency  to  recurrence  is  also  considerable,  but  even  should 
this  occur  the  recurrence  is  often  less  painful  than  the  primary 
disease  owing  to  the  previous  removal  of  the  nerve  terminals. 

Excision  of  the  rectum  is  only  practicable  in  a  small  percentage  of 
the  cases  of  cancer  which  come  under  observation ;  usually  the 
disease  has  progressed  too  far  by  the  time  that  the  patient  is  first 
seen  by  the  surgeon.  Practitioners  and  students  alike  must  be 
warned  emphatically  of  the  importance  of  making  a  thorough 
examination  of  the  rectum  in  all  cases  where  haemorrhage  or  dis- 
charge occurs,  or  persistent  discomfort  is  complained  of. 

As  already  stated,  if  the  radical  operation  is  not  feasible,  Colostomy 
is  sometimes  justifiable  as  a  means  of  relief  to  the  patient's  symptoms. 
Cases  where  excision  cannot  be  attempted  may  be  divided  into  two 
groups  according  to  the  character  of  the  symptoms — i.e.,  whether 
obstructive  or  irritative  phenomena  predominate. 

1.  When  the  main  trouble  arises  from  difficulty  to  the  onward 
passage  of  the  bowel  contents,  much  benefit  will  be  derived  from  an 
early  colostomy,  (a)  It  allows  the  patient  to  indulge  in  solid  food, 
and  thus  assists  in  maintaining  the  general  health ;  (b)  it  frees  him 
from  the  pain  arising  from  the  passage  of  faeces  over  the  ulcerated 
surface,  but  not  from  that  due  to  the  growth  and  traction  of  the 
tumour  upon  surrounding  nerves ;  (c)  it  may  possibly  retard  the 
growth  of  the  disease  by  eliminating  the  irritating  action  of  the  faeces; 
(d)  it  removes  all  chance  of  intestinal  obstruction  from  the  growth 
itself;  and  (e)  it  diminishes  the  absolute  risk  of  the  operation  by 
undertaking  it  when  the  patient  is  comparatively  well  and  hearty,  and 
when  there  is  no  urgency.  Formerly,  when  performed  for  obstruction 
alone,  the  death-rate  was  about  30  or  40  per  cent. ;  in  an  early  iliac 
operation  it  is  now  practically  nil,  or  at  most  3  or  4  per  cent. 

2.  In  the  ulcerative  type,  where  there  is  but  little  tendency  to 
stenosis,  colostomy  will  do  but  little  good,  as,  although  it  may  prevent 
faeces  from  irritating  the  surface  of  the  growth,  yet  the  discharge  of 
muco-pus  and  blood  will  continue  unchecked,  causing  tenesmus  and 
constant  calls  to  empty  the  bowel  below  the  artificial  opening.  The 
additional  attention  required  by  the  colostomy  wound  may  make  the 
patient's  life  a  burden  to  him. 

For  details  as  to  colostomy,  see  p.  1035. 

Should  the  patient  refuse  colostomy,  or  should  it  be  contra- 
indicated,  treatment  consists  in  limiting  the  diet  to  such  materials  as 
strong  broths,  arrowroot,  etc.,  with  some  stimulant,  so  as  to  give  as 
little  faecal  remains  as  possible,  and  to  enable  him  to  do  without  an 
action  of  the  bowels  for  about  a  week  at  a  time.  The  strength  is 
husbanded  by  keeping  him  in  bed,  and  pain  is  checked  by  the 
administration  of  morphia. 


CHAPTER   XXXVIII. 
SURGICAL  AFFECTIONS  OF  THE  KIDNEYS. 

The  kidneys  are  placed  on  either  side  of  the  middle  line,  and  extend  from  the 
nth  rib  above  to  midway  between  the  last  rib  and  the  iliac  crest  below,  the  right 
kidney  being  somewhat  lower  than  the  left  owing  to  the  presence  of  the  liver. 
The  hilum  is  situated  opposite  the  spinous  process  of  the  first  lumbar  vertebra, 
and  the  upper  ends  of  the  organs  are  nearer  to  the  spine  than  the  lower. 

Manual  examination  of  the  kidney  is  made  with  the  patient  lying  on  the  back, 
with  the  legs  raised,  the  head  supported  by  a  pillow,  and  the  mouth  open.  The 
surgeon,  kneeling  or  standing  at  the  side  of  the  couch,  places  one  hand  under  the 
loin  and  presses  it  upwards,  whilst  the  other  is  gently  but  firmly  pressed  back- 
wards in  the  lumbar  region,  especially  during  expiratory  movements.  Unnatural 
mobility,  enlargement  or  displacement  downwards  of  the  organ,  will  be  thereby 
detected,  as  also  irregularities  in  outline  or  modification  of  tension. 

An  enlarged  kidney  is  recognised  by  the  following  general  characters  :  A 
swelling  is  noticed  in  the  loin,  which  is  shaped  more  or  less  like  the  kidney, 
a  notch  being  occasionally,  though  rarely,  felt  on  the  inner  border,  and  the  outer 
margin  being  rounded.  The  flank  is  always  dull  on  percu.ssion,  the  note  remain- 
ing unaltered  whatever  the  patient's  position,  and  intestine  never  finding  its  way 
behind  the  tumour  The  passage  of  the  colon  in  front  of  the  kidney  not  unfre- 
quently  gives  rise  to  a  band  of  resonance  over  its  anterior  surface ;  the  bowel, 
however,  soon  gets  pushed  aside  by  the  growth  of  the  tumour.  On  the  right  side 
it  is  not  unusual  for  the  renal  dulness  to  be  continuous  with  that  due  to  the  liver  ; 
thTe  is  always  distinct  resonance  below  and  to  the  inner  side  of  the  mass  towards 
*he  pelvis,  thereby  distinguishing  it  from  a  pelvic  swelling.  The  mass  moves 
slightly  on  respiration,  though  less  distinctly  than  the  liver  or  spleen. 

On  the  left  side  it  has  to  be  distinguished  from  an  enlarged  spleen  ;  the  latter 
vibcus  hugs  the  anterior  abdominal  wall,  and  has  no  gut  in  front  of  it,  whilst  the 
loin  is  usually  resonant. 

It  is  not  uncommon,  however,  to  find  cases  where  physical  examination  of  this 
type  reveals  but  little,  and  although  one  may  suspect  the  kidneys  of  being  the 
cause  of  some  modification  of  the  urinary  secretion — e.g.,  hasmaturia  or  pyuria — 
it  maybe  difficult  to  be  certain  as  to  the  origin  of  the  blood  or  pus,  or  from  which 
kidney  it  is  derived.  Again,  it  is  essential  to  make  certain  as  to  the  existence  and 
functional  value  of  the  second  kidney  before  its  fellow,  which  may  be  apparently 
diseased  beyond  hope  of  repair,  is  removed.  Many  different  methods  have  been 
suggested,  but  most  of  them  are  unsatisfactory,  (i. )  The  mere  detection  of  a 
kidney  hy palpation  is  worth  nothing,  as  though  of  normal  size  its  functional  value 
may  be  tiil.  (ii.)  Opett  exploration  through  a  lumbar  or  abdominal  incision  is  more 
satisfactory,  as  the  condition  of  the  renal  vessels  and  of  the  ureter  can  also  be 
ascertained.  It  is  readily  undertaken  during  the  early  stages  of  a  proposed 
nephrectomy,  by  incising  the  peritoneum  and  slipping  the  hand  across  the 
abdomen,  but  even  then  mistakes  may  be  made,  (iii.)  Catheterization  of  the  tireters 
is  a  satisfactory  method  of  procedure,  but  has  two  disadvantages.  In  the  first 
place,  it  is  difficult  to  effect,  and  certainly  in  the  male  requires  special  instruments 
and  considerable  practice  ;  whilst,  in  the  second  place,  the  ureter  may  be  infected 
by  the  catheter  passing  through  the  bladder,  which  is  often  in  a  state  of  inflamma- 

1177 


1 1 78 


A  MANUAL  OF  SURGERY 


tion.  (iv.)  The  first  of  these  objections  also  holds  good  in  connection  with  the 
method  of  temporarily  clamping  the  lower  end  of  the  ureters,  or  rather  of  the  fold 
of  mucous  membrane  extending  from  the  orifice  towards  the  trigone.  By  this 
plan  the  secretion  of  each  kidney  in  turn  can  be  obtained,  (v.)  A  fairly  satis- 
factory method  consists  in  the  use  of  one  of  the  segregators  or  separators,  several 
types  of  which  are  now  in  the  market.  Luys'  segregator  (Fig.  506)  acts  very 
efficiently.  The  bladder  is  first  thoroughly  irrigated,  and  the  instrument  intro- 
duced. The  indiarubber  septum  is  then  drawn  up  into  place,  and  the  urine 
collected  from  the  two  sides  as  it  enters  the  bladder.  To  act  effectively  the 
curved  end  must  be  pressed  well  backwards  against  the  posterior  vesical  wall,  and 
the  patient  must  be  in  the  sitting  position,  (vi.)  A  small  injection  of  methylene 
blue  {vide  infra)  is  given,  and  the  passage  of  the  discoloured  urine  from  the  ureter 
into  the  bladder  watched  by  means  of  the  cystoscope. 

Finally,  it  may  be  desirable  to  estimate  the  activity  of  the  renal  function  for 
both  kidneys  or  for  each  separately.    A  number  of  methods  have  been  suggested, 


Fig.  506. 


-Ldys'  Segregator  in  Position  for  Collecting  Separately  the 
Urine  escaping  from  the  Two  Ureters. 


The  indiarubber  septum  can  be  seen  stretching  across  the  bladder  cavity,  and  the 
curved  beak  fits  down  firmly  into  the  '  bas  fond '  of  the  bladder,  so  that  the 
urine  will  at  once  pass  into  the  opening  on  either  side  of  the  septum,  and  so 
up  to  the  collecting  glasses.  The  screw-head  of  the  instrument  controls  the 
septum,  which  is,  of  course,  only  stretched  into  position  after  the  introduction 
of  the  instrument. 

of  which,  however,  one  can  only  give  the  briefest  notice  here.*  (i.)  Cryoscopy 
consists  in  the  estimation  of  the  freezing-points  of  the  urine  and  of  the  blood 
respectively.  The  former  varies  between  —  i"30  and  -2-30  C,  but  is  easily 
modified  by  excessive  drinking  or  sweating  ;  and  therefore  is  unreliable.  The 
latter  occurs  with  some  constancy  at  0-56°  C.  ;  if  one  kidney  is  damaged,  no 
change  occurs  ;  but  if  the  function  of  both  kidneys  is  defective,  then  the  freezing- 
point  is  lowered  below  o-6o°  C.  (ii.)  The  Methylem-blue  test  is  based  on  the  fact 
that  when  a  solution  of  this  substance  is  injected  into  a  muscle  it  is  absorbed 
into  the  blood  as  a  colourless  product,  but  is  eliminated  both  in  the  bile  and 
urine.  In  the  latter,  part  of  it  appears  as  a  blue  or  bluish-green  colouring  matter, 
part  as  a  colourless  product  (chromogen)  which  can  be  made  apparent  by  boiling 
with  acetic  acid.  If  5  minims  of  a  10  per  cent,  solution  is  injected  into  a 
healthy  person,  chromogen  appears  in  fifteen  minutes,  and  the  blue  colour  in 


*  For  fuller  details,  see  Thomson  Walker's  Hunterian  Lectures  on 
Function  in  Health  and  Disease,'  Lancet,  March  16  and  23,  1907. 


The  Renal 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


1179 


half  an  hour.  About  half  of  the  methylene  blue  is  eliminated  in  the  twenty-four 
hours,  but  it  is  often  five  or  seven  days  before  it  disappears  entirely.  In  disease 
of  the  kidneys  involving  defective  function  the  elimination  of  this  substance  is 
late  in  appearing,  and  prolonged  beyond  the  normal  period.  This,  of  course, 
can  be  estimated  for  each  kidney  separately  by  catheterism  of  the  ureters, 
(iii.)  The  Phloridziit  test.  If  ro  minims  of  a  solution  of  phloridzin  (i  in  200)  are 
injected  beneath  the  skin,  sugar  appears  in  the  urine  of  a  healthy  person  in 
fifteen  to  twenty  minutes,  and  the  glycosuria  lasts  for  two  to  three  hours,  the 
total  output  of  sugar  being  between  i  and  2-50  grammes.  Where  the  function  of 
the  kidneys  is  defective,  the  amount  eliminated  is  much  diminished,  or  it  may  be 
entirely  absent. 

The  kidneys  may  be  exposed  by  two  chief  routes,  viz.,  the  lumbar  and  the 
abdominal. 

The  Lumbar  incision  (Fig.  507,  B)  commences  at  a  point  corresponding  to  the 
outer  border  of  the  erector  spinas,  and  1  inch  below  the  last  rib,  extending  down- 
wards and  outwards  in  the  direction 
of  the  fibres  of  the  external  oblique 
towards  the  anterior  superior   iliac 
spine.    The  posterior  portions  of  the 

abdominal   muscles   and   the   fascia 

lumborum  are  divided  seriatim,  and 

the    fatty    tissue    surrounding    the 

kidney  is   thus   easily  reached   and 

opened.     Variations  of  the  incision 

must  be  made  to  suit  the  particular 

requirements  of  the  case. 

In   the  Abdominal    operation   the 

kidney  is  exposed   from    the   front, 

either  through  the  linea  semilunaris 

or  some  other  suitable  incision  ;  the 

peritoneal  cavity  is  opened  or  not, 

as  maybe  thought  necessary.     If  the 

peritoneum  is  opened,   the  colon  is 

displaced  inwards  and  held  aside,  as 

also  the  other  intestines,  by  cloths 

soaked  in  warm  salt  solution  ;    the 

peritoneum    covering  the   posterior 

abdominal  wall  is  incised  to  the  outer 

side  of  the  colon,  and  the  organ  thus 

exposed.   When,  however,  the  kidney 

is  enlarged,  it  is  often  unnecessary  to  open  the  peritoneal  cavity,  the  colon  and 

other  peritoneal  contents  being  displaced  inwards. 


Fig. 


507. — Diagram  to  Illustrate 
Lumbar  Incisions. 


A,  For  lumbar  colotomy ;  B,  for  exposing 
the  kidney. 


Congenital  Affections  of  the  Kidney. — Many  different  malforma- 
tions and  displacements  are  met  with  affecting  this  organ. 

The  chief  Malformations  are  as  follow  :  {a)  Complete  absence  of 
one  organ,  a  very  rare  condition,  and  {b)  congenital  atrophy  of  one 
kidney,  it  being  represented  by  a  mass  of  fatty  tissue  ;  in  both  cases 
the  other  kidney  is  correspondingly  enlarged  and  hypertrophied. 
{c)  The  kidneys  may  be  fused  together,  either  constituting  one  large 
organ  in  the  median  line,  and  more  or  less  normal  in  shape,  or  some- 
times constituting  the  so-called  horseshoe-shaped  variety,  the  con- 
vexity being  directed  downwards.  The  latter  condition  is  not  very 
uncommon,  being  present  once  in  about  1,100  bodies  examined;  it  is 
usually  associated  with  an  increased  number  of  ureters  or  renal 
vessels,  {d)  Deep  lobulation  of  the  kidney,  as  in  some  animals, 
is  occasionally  seen,  especially  if  the  organ  is  displaced ;  this  may 


liSo  A  MANUAL  OF  SURGERY 

be  carried  to  such  an  extent  as  to  divide  it  into  two  or  more 
portions,  (e)  The  ureter  and  pelvis  may  be  double,  this  malforma- 
tion affecting  the  pelvis  alone,  or  extending  as  far  as  the  bladder. 
(/)  The  renal  artery  may  arise  from  the  aorta  in  two  or  more  main 
branches. 

The  majority  of  these  malformations  are  of  very  little  clinical 
importance,  except  in  the  operation  of  nephrectomy,  when  they  may 
necessitate  some  modification  of  the  usual  proceedings. 

Congenital  Displacement  of  the  Kidney  occurs  about  once  in  every 
thousand  individuals,  the  organ  being  either  depressed,  so  as  to  lie 
over  the  sacro-iliac  synchondrosis  or  sacral  promontory,  or  raised 
above  its  normal  position.  The  left  kidney  is  more  frequently 
affected  in  this  way  than  the  right,  and,  when  lying  in  the  iliac  fossa, 
the  descending  colon  is  usually  displaced  inwards,  so  that  the  rectum 
starts  to  the  right  of  the  middle  line.  The  adrenal  bodies  retain 
their  normal  position,  and  do  not  move  with  the  kidney. 

Cystic  disease,  sarcoma,  and  hydronephrosis  may  also  occur 
congenitally,  and  will  in  turn  be  described  below. 

Floating  and  Moveable  Kidney. — The  normal  kidney  is  not  a  fixed 
organ,  but  moves  up  and  down  on  respiration,  although  usually  such 
movement  cannot  be  detected  on  palpation.  It  is  therefore  necessary 
to  define  as  precisely  as  possible  what  is  meant  clinically  by  the  terms 
'  moveable '  and  '  floating '  kidney.  Three  stages  of  abnormal  mobility 
may  be  described :  (i.)  A  palpable  kidney  is  one,  the  lower  half  or  more  of 
which  can  be  definitely  felt  on  deep  inspiration,  (ii.)  A  moveable  kidney 
is  one  in  which  the  examining  hand  can  define  the  upper  end  of  the 
organ,  and  can  restrain  it  from  returning  to  its  old  position  during . 
expiration,  (iii.)  A  floating  kidney  is  one  which  can  be  moved  freely 
about  the  abdomen  in  all  directions,  and  even  across  the  middle  line 
in  some  cases.  Formerly  this  last  term  was  applied  to  a  supposed 
congenital  lesion,  in  which  the  kidney  was  attached  to  the  posterior 
abdominal  wall  by  means  of  a  mesentery ;  it  is  more  than  doubtful 
whether  such  a  condition  exists. 

In  the  earlier  stages  the  movements  occur  within  the  fatty  capsule 
which  surrounds  the  organ,  but  later  on  mild  attacks  of  inflammation 
attach  the  fatty  to  the  fibrous  capsule,  and  the  kidney  with  its 
associated  fatty  envelope  moves  behind  the  peritoneum.  Two  forms 
of  movement  are  possible  :  (i.)  An  up-and-down  or  in-and-out  move- 
ment in  one  plane  (cinder-sifting  movement),  the  kidney  merely 
swinging  on  its  pedicle ;  or  (ii.)  a  movement  of  torsion  may  accom- 
pany this,  either  round  a  transverse  axis  when  the  lower  end  of 
the  kidney  becomes  prominent,  or  round  a  vertical  axis  when  the 
outer  convex  border  swings  forwards.  In  the  latter  case  kinking 
of  the  ureter  or  renal  vessels  is  very  likely  to  ensue. 

Moveable  kidney  occurs  more  frequently  in  women  than  in  men 
(lo  to  i),  and  more  often  on  the  right  than  on  the  left  side  (12  or  13 
to  i),  partly  because  the  renal  vessels  are  longer  on  this  side  than  on 
the  other,  and  partly  because  the  descending  colon  is  more  fixed  than 
the  ascending. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  iiSi 

Causes. — The  kidney  is  placed  between  the  layers  of  the  peri- 
nephric fascia,  which  in  turn  are  derived  from  a  splitting  of  the 
fascia  transversalis.  In  children  this  perinephric  capsule  is  attached 
closely  to  the  kidney  front  and  back  without  any  intervening  fat ; 
but  as  development  proceeds,  fat  is  packed  in  around  the  kidney 
in  increasing  amount,  and  hence  in  stout  subjects  the  perinephric 
capsule  is  considerably  distended,  and  the  kidney  is  firmly  supported. 
In  addition  to  this,  however,  the  tension  of  the  peritoneum,  the  main- 
tenance of  the  intra-abdominal  pressure,  and  the  support  of  the 
muscular  abdominal  parietes,  have  much  to  do  in  keeping  it  in 
place.  Anything  that  seriously  modifies  these  three  factors  may  lead 
to  displacement  and  mobility  of  the  organ.  Parturition  accounts 
for  some  cases ;  firstly,  because  of  the  sudden  diminution  of  the 
intra-abdominal  pressure,  and,  secondly,  owing  to  the  resulting 
pendulous  and  relaxed  state  of  the  abdominal  muscles,  especially 
if  the  patient  too  early  resumes  the  erect  posture,  or  undertakes 
physical  work  without  efficient  external  support ;  hence  it  is  more 
frequent  among  the  poor  than  amongst  the  rich.  It  may  also  follow 
the  removal  of  large  abdominal  tumours  which  stretch  the  abdominal 
walls,  or  rapid  emaciation,  whereby  the  perinephric  fat  is  absorbed, 
whilst  tight-lacing  or  traumatic  influences  may  be  responsible  for 
some  cases.  It  is  frequently  associated  with  that  form  of  displace- 
ment downwards  of  the  abdominal  viscera  which  is  known  as 
Glenard's  disease,  or  enteroptosis  (p.  1032).  Constipation  is  an  im- 
portant element  in  the  production  of  moveable  kidney,  and  probably 
acts  by  the  loaded  caecum  dragging  upon  the  anterior  layers  of  the 
perinephric  fascia,  and  thus  displacing  it  forwards. 

Symptoms. — A  moveable  kidney  is  often  discovered  by  accident,  and 
may  be  entirely  free  from  symptoms.  In  some  cases  the  patient  comes 
under  observation  because  she  has  observed  a  moveable  lump  in  the 
abdomen,  which  on  handling  is  painful,  the  pain  being  often  associated 
with  nausea  and  vomiting.  In  other  cases  pain  and  vomiting 
bring  the  patient  under  observation,  the  doctor  discovering  the  move- 
able kidney.  The  pain  is  referred  to  -the  back,  or  perhaps  shoots 
along  the  ureter  to  the  groin,  testis,  or  labium  majus.  Vomiting  is  a 
significant  sign,  and  the  surgeon  should  never  omit  to  examine  the 
loins  in  cases  of  obstinate  vomiting  with  no  apparent  cause.  Periodical 
exacerbations  of  these  symptoms,  with  a  temporary  diminution  in 
the  amount  of  urine,  result  from  kinking  of  the  ureter  (DieU's  crises) ; 
sudden  relief,  followed  by  an  increased  flow  of  urine,  possibly  contain- 
ing some  muco-pus,  indicates  that  the  organ  has  returned  to  its  normal 
situation.  Repeated  attacks  of  this  type  may  result  in  pyelitis  and 
hydronephrosis.  On  examining  the  abdomen,  a  moveable  tumour  can 
often  be  observed  with  ease  if  the  abdominal  parietes  are  not  loaded 
with  fat,  and  on  manipulation  pain  and  vomiting  may  be  induced. 
The  adoption  of  the  genu-pectoral  position  will  sometimes  enable  a 
moveable  kidney  to  be  more  certainly  felt,  whilst  a  distinct  loss  of 
resistance  is  noticed  external  to  the  erector  spinae  on  the  affected 
side. 


Ii82  A  MANUAL  OF  SURGERY 

The  patient  is  usually  of  a  neurotic  type,  but  possibly  this  may 
result  in  part  from  the  mobility  of  the  organ  which  necessarily 
involves  a  certain  amount  of  traction  upon  the  sympathetic  centres 
in  the  abdomen.  Evidence  of  the  displacement  of  other  abdominal 
viscera  is  often  found,  so  that  the  detection  of  a  moveable  kidney 
does  not  necessarily  explain  the  whole  case,  or  indicate  operation. 
After  many  an  operation  for  moveable  kidney,  the  symptoms  (pain, 
vomiting,  etc.)  have  persisted,  even  though  the  organ  remained 
anchored  to  the  abdominal  wall. 

Treatment. —  In  the  great  majority  of  cases  of  moveable  kidney 
operation  is  not  required,  and  indeed  it  is  usually  unwise  to  tell  the 
patient  that  such  a  condition  is  present.  If  it  associated  with  marked 
debility,  bodily  or  nervous,  and  perhaps  with  general  enteroptosis, 
a  rest-cure  in  bed  for  six  weeks,  with  abdominal  and  general  massage 
and  an  abundance  of  milk  and  fatty  foods,  will  do  much  to  steady 
the  kidney  and  improve  the  general  condition.  The  application  of  a 
carefully-fitted  kidney  support  will  then  suffice  to  keep  her  comfort- 
able, This  may  consist  of  an  abdominal  truss,  with  an  end  shaped 
like  a  cup  to  fit  over  the  kidney,  or  of  an  air-cushion  fitted  into  an 
abdominal  belt.  The  cushion  should  be  triangular  in  shape,  its  sides 
corresponding  to  the  costal  border,  Poupart's  ligament,  and  the  linea 
semilunaris  ;  it  is  put  on  in  the  recumbent  posture,  and  for  choice 
with  the  pelvis  raised. 

The  indications  for  operation  are — (i)  Extreme  mobility,  so  that 
the  organ  cannot  be  fixed  by  a  support ;  (2)  extreme  tenderness,  so 
that  a  support  cannot  be  tolerated,  and  even  ordinary  handling  causes 
discomfort  and  perhaps  vomiting  ;  (3)  the  recurrence  of  acute  attacks 
of  pain  and  vomiting  (Dietl's  crises) ;  and  (4)  the  supervention  of 
hydronephrosis  or  pyelitis. 

N ephvorrhaphy  or  Nephropexy  is  the  name  applied  to  the  operation 
for  fixing  the  kidney.  It  is  obvious  that  a  rounded  body  like  the 
kidney  with  a  smooth  fibrous  capsule  is  not  easily  fixed,  and  the 
more  so  since  the  renal  parenchyma  has  great  absorbent  power,  so 
that  sutures,  even  of  silk,  passed  through  its  substance  are  readily 
disintegrated  and  absorbed ;  hence,  although  the  kidney  may  seem 
to  be  efficiently  immobilized  at  the  completion  of  the  operation,  it 
readily  becomes  loose  again.  There  are  only  two  certain  methods  of 
fixing  the  organ,  (i.)  The  wound  down  to  the  kidney  is  left  open 
and  packed  with  gauze,  so  that  healing  occurs  by  granulation ;  the 
cure  is  certain,  but  tedious,  and  a  lumbar  hernia  may  follow,  (ii.)  The 
plan  now  usually  adopted  is  to  expose  the  organ  through  the  loin. 
The  fatty  covering  is  opened,  and  as  much  of  it  as  possible  removed. 
A  portion  of  the  true  fibrous  capsule  is  now  dissected  up  and  fixed 
to  the  abdominal  parietes  so  as  to  expose  the  raw  and  slightly 
bleeding  cortex.  Many  methods  of  dealing  with  the  capsule  have 
been  suggested,  but  it  matters  little  which  is  employed.  The  follow- 
ing plan  suggested  by  Mr.  W.  Billington,  of  Birmingham,*  has  been 
extensively  tested,  and  gives  excellent  results.  A  lateral  incision  is 
*  British  Medical  Journal,  November  30,  1907. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1183 

employed,  extending  from  just  above  the  last  rib  nearly  vertically 
down  to  the  crista  ilii ;  the  muscles  are  divided ;  the  last  dorsal  nerve 
is  retracted  and  protected ;  and  the  kidney  in  its  fatty  capsule  ex- 
posed and  cleared.  The  upper  half  of  the  fibrous  capsule  is  then 
dissected  up  from  the  posterior  surface  and  carried  round  the  last 
rib  to  serve  as  a  sling  to  the  kidney  ;  the  apex  of  this  flap  is  secured 
to  its  own  base.  Two  silkworm-gut  stitches  are  passed  under  the 
capsule  of  the  lower  half  of  the  organ  in  a  semicircular  fashion,  and 
carried  through  the  muscles  and  skin  at  the  upper  angle  of  the 
incision,  being  finally  tied  over  a  pad  of  gauze  and  retained  in  situ 
for  three  weeks.  The  wound  is  then  closed  in  the  usual  way,  and 
dressed,  special  care  being  taken  to  exercise  pressure  over  the  right 
iliac  fossa  below  the  kidney  by  a  suitable  pad  of  sterilized  wool. 
The  organ  is  thus  firmly  fixed,  but  it  is  wise  to  keep  the  patient 
in  bed  for  four  or  five  weeks  subsequently,  to  allow  of  consolidation, 
and  afterwards  a  binder  or  belt  should  be  worn  for  a  time. 

Injuries  of  the  Kidney  are  usually  due  to  crushes  of  the  body,  as 
between  the  buffers  of  railway  cars,  or  when  a  cart  passes  over  the 
abdomen,  or  from  blows  or  falls.  Considerable  haemorrhage  follows, 
both  into  the  substance  of  the  kidney  or  its  pelvis,  and  into  the  peri- 
nephric fatty  tissue,  and  this  even  when  the  capsule  has  not  been 
torn.  The  integrity  of  this  structure  is  a  point  of  great  importance, 
since  it  limits  to  some  extent  the  bleeding  and  prevents  urinary 
extravasation  ;  the  kidney  may  be  crushed  to  a  pulp  without  any 
external  haemorrhage,  and  under  these  circumstances  clots  are  likely 
to  pass  down  the  ureter,  and  may  obstruct  it  and  lead  to  its  subse- 
quent occlusion.  When  the  anterior  portion  of  the  capsule  is  torn, 
the  peritoneum  may  also  be  involved,  especially  in  children,  and  then 
evidences  of  intraperitoneal  bleeding  may  manifest  themselves,  and, 
indeed,  if  the  kidney  is  extensively  lacerated,  fatal  haemorrhage  may 
result,  though  this  is  unusual.  Rupture  of  the  posterior  surface  of 
the  kidney  opens  up  the  perinephric  cellular  tissue,  which  becomes 
infiltrated  with  blood  and  urine,  and  suppuration  is  almost  certain  to 
follow,  resulting  in  pyaemia,  or  at  a  later  date  in  exhaustion  from 
chronic  septic  poisoning.  Not  unfrequently  other  severe  injuries  are 
present,  such  as  fracture  of  the  pelvis,  spine,  or  skull,  bruising  or 
tearing  of  intestine  or  liver,  and  from  these  associated  lesions  serious 
phenomena  may  arise. 

The  Symptoms  consist  in  severe  shock,  followed  by  nausea,  vomit- 
ing, pain  in  the  loin,  shooting  down  into  the  testis  or  thigh,  localized 
tenderness  and  perhaps  swelling  over  the  injured  organ,  and  haema- 
turia.  The  amount  of  blood  lost  in  this  way  varies  considerably ;  in 
the  slighter  cases  the  haematuria  is  of  short  duration,  but  in  more 
extensive  lesions  it  may  be  severe  and  so  persistent  as  to  threaten  life. 
The  passage  of  clots  down  the  ureter  gives  rise  to  renal  colic,  and 
obstruction  of  that  duct  may  lead  to  total  suppression  of  the  secre- 
tion on  the  affected  side.  The  bladder  may  in  some  cases  become 
greatly  distended  with  clots,  the  blood  coagulating  after  it  has  entered 
the  viscus.    Haemorrhage  into  the  perinephric  tissues  is  indicated  by 


Ii84  A  MANUAL  OF  SURGERY 

the  formation  of  a  swelling  in  the  loin,  and  laceration  of  the  peri- 
toneum is  followed  by  distension  of  the  abdomen,  increasing  anaemia 
from  persisting  haemorrhage,  and  the  onset  of  peritonitis.  The 
development  of  a  perinephritic  abscess  is  recognised  by  fever,  rigors, 
increased  pain  in  the  loin,  and  the  usual  phenomena  of  deep  3up- 
puration  (p.  1192). 

The  Treatment  usually  required  is  to  keep  the  patient  quiet  in  bed, 
with  an  icebag  or  Leiter's  tubes  applied  to  the  loin ;  pain  may  be 
relieved  by  strapping  the  side  or  by  applying  a  firm  bandage.  Per- 
sistent haemorrhage  necessitates  the  administration  of  ergot,  tannic 
acid,  or  turpentine  ;  but  if  it  is  threatening  the  patient's  life,  an 
exploratory  incision  is  required,  and,  if  need  be,  removal  of  the 
organ,  although  it  is  sometimes  possible  to  stitch  up  a  limited  rent, 
the  sutures  being  passed  deeply  through  the  glandular  tissue.  Some- 
times the  blood  does  not  escape  externally,  and  then  the  rapid  de- 
velopment of  a  swelling  in  the  loin,  with  increasing  anaemia  and 
rapidity  of  pulse-rate,  would  indicate  that  operation  is  desirable. 
Distension  of  the  bladder  must  be  relieved,  the  clots  being  washed 
out  through  a  large-eyed  catheter.  The  occurrence  of  peritonitis  or 
of  a  perinephritic  abscess  will  call  for  suitable  surgical  measures, 
the  injured  viscus  being  dealt  with  according  to  its  condition. 

Rupture:  of  the  Ureter  is  a  rare  accident,  usually  due  to  direct  violence, 
but  occasionally  happening  during  pelvic  operations,  such  as  removal 
of  the  uterus.  When  the  result  of  a  subcutaneous  injury,  it  cannot  be 
recognised  at  once,  but  extravasation  of  urine  takes  place,  leading  to 
the  formation  of  a  perinephritic  abscess.  This  is  incised  sooner  or 
later,  and  on  exploring  the  cavity  it  may  be  possible  to  detect  the 
rent  in  the  ureter,  but  more  frequently  its  situation  cannot  be  found, 
and  then  a  doubt  will  necessarily  exist  as  to  whether  the  lesion  in- 
volves the  ureter  or  the  pelvis  of  the  kidney.  In  either  case  a  urinary 
fistula  in  the  loin  results,  which  may  possibly  close  after  a  time ;  if 
the  fistula  persists,  nephrectomy  will  be  required,  and  then  the  sooner 
such  an  operation  is  undertaken  the  better.  In  a  few  favourable 
cases  it  has  been  possible  to  suture  the  rent  in  the  ureter  by  the  fol- 
lowing plan  :  The  lower  end  of  the  divided  ureter  is  closed,  the  exposed 
mucous  membrane  being  tucked  in  by  sutures  passing  through  the 
muscular  coat ;  the  upper  end  is  then  implanted  into  a  longitudinal 
opening  made  in  the  side  of  the  lower  segment,  and  accurately 
stitched  in  position. 

Two  cases  probably  of  this  nature  came  under  treatment  at  hospital.  Bu-th 
occurred  in  young  boys,  and  both  were  due  to  cab  accidents.  In  the  first,  after 
the  preliminary  shock  had  passed  off,  nothing  special  was  noted  for  about  ten 
days,  when  on  sitting  up  sharp  pain  was  experienced  in  the  side,  and  this  was 
followed  by  a  retroperitoneal  collection  of  fluid,  together  with  some  amount  of 
fever.  On  incision  a  large  quantity  of  limpid  urine  escaped,  with  but  very  little 
pus — an  interesting  illustration  of  the  fact  that  healthy  urine  does  comparatively 
little  damage  to  tissues  into  which  it  is  extravasated.  The  finger  introduced  into 
the  wound  passed  beyond  the  middle  line,  and  the  ureter  could  be  felt  traversing 
the  cavity  ;  but  the  rent  could  not  be  found.  Drainage  was  provided,  and  for  a 
time  a  urinary  fistula  persisted  ;  finall}',  the  wound  healed  completely.     In  the 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1185 

second  case  the  inflammatory  phenomena  were  more  marked,  but  an  incision 
was  not  made  until  the  twelfth  day  ;  here  also  the  lesion  could  not  be  found 
and  drainage  was  resorted  to,  but  without  avail,  nephrectomy  being  subsequently 
required.     Both  children  recovered. 

Hydronephrosis  is  a  condition  characterized  by  distension  of  the 
pelvis  and  calyces  with  urine,  as  a  result  of  some  obstruction  to 
its  exit. 

Causes. — (I)  It  may  be  congenital  in  origin.  It  must  be  borne  in 
mind  that  the  body  of  the  kidney  is  developed  from  the  metanephros, 
and  that  the  ureter  unites  subsequently  with  it  to  form  its  excretory 
duct ;  such  union  is  occasionally  defective  at  the  upper  end,  well- 
marked  obstruction  occurring  at  the  junction  of  the  ureter  with  the 
infundibulum  of  the  pelvis.  Similar  trouble  sometimes  arises  from 
the  ureter  becoming  kinked  over  an  abnormally-placed  renal  artery. 
It  is,  however,  more  frequently  due  to  an  impervious  condition  of  the 
urethra,  or  to  the  existence  of  a  membranous  septum  therein  ;  both 
kidneys  are  then  necessarily  affected.  The  amount  of  distension  in 
some  of  these  cases  is  such  as  to  interfere  seriously  with  parturition 
until  the  abdomen  has  been  tapped.  The  infants  are  often  born  dead, 
or  succumb  shortly  after  birth,  (ii.)  Acquired  forms  of  obstruction 
are  by  no  means  uncommon,  and  may  be  arranged  under  the  follow- 
ing heading :  (a)  Blocks  within  the  urinary  passages  from  the 
presence  of  stones,  parasites,  foreign  bodies,  or  even  blood-clot ;  {h) 
changes  of  structure  affecting  the  walls  of  the  urinary  passages — e.g., 
inflammatory  swelling  of  the  mucosa,  cicatrices,  stenosis,  or  tumours  ; 
{c)  kinking  of  the  ureter  in  cases  of  floating  kidney ;  and  {d)  the  pressure 
of  extrinsic  tumours  or  cicatrices,  as  after  pelvic  cellulitis,  or  from 
uterine  or  rectal  cancer.  Hydronephrosis  may  be  unilateral  or 
bilateral ;  in  the  former  case  the  obstruction  arises  within  the  ureter, 
or  from  some  vesical  condition  involving  its  entrance  into  the  bladder ; 
in  the  latter  case  the  cause  is  generally  to  be  looked  for  below  this 
spot. 

It  must  be  clearly  understood  that  a  sudden  and  absolute  block 
never  leads  to  hydronephrosis.  Should  it  occur  as  the  result  of  im- 
paction of  a  calculus  in  one  of  the  ureters  or  of  ligature  of  the  ureter, 
as  has  occurred  in  hysterectomy,  the  secretion  on  that  side  is  totally 
suppressed  as  soon  as  the  tension  within  the  pelvis  and  calyces  is 
sufficiently  high.  Atrophy  of  the  renal  epithelium  follows  after  a 
time,  but  if  the  obstruction  is  relieved  within  six  weeks  of  its  in- 
cidence, the  secretion  of  urine  will  probably  be  re-established.  Should, 
however,  the  obstruction  be  intermittent  or  incomplete,  so  that  some 
of  the  urine  escapes,  thereby  relieving  the  pressure,  hydronephrosis 
develops.  Sudden  and  complete  occlusion  of  the  urethra  likewise 
results  in  dilatation  of  the  bladder  and  rupture  either  of  that  viscus 
or  of  the  urethra,  whilst  a  gradually  increasing  obstruction  is  always 
likely  to  lead  to  hydronephrosis. 

Pathological  History. — The  earliest  result  of  obstruction  to  the 
flow  of  urine  consists  in  dilatation  of  the  ureter  and  pelvis,  which  is 
soon    followed   by  expansion   of   the    calyces.      The   pyramids  are 

75 


ii86 


A  MANUAL  OF  SURGERY 


flattened,  and  the  cortex  expanded  and  thinned,  so  that  the  whole 
kidney  looks  larger  than  usual  (Fig.  508).  A  certain  amount  of 
interstitial  infiltration  of  the  cortex  is  always  present ;  the  urine' 
secreted  in  the  early  stages  is  usually  abundant  and  of  low  specific 
gravity. 

If  the  obstruction  continues,  the  renal  tissue  becomes  more  and 
more  atrophied,  until  finally  it  disappears  entirely,  the  kidney  being 
represented  by  a  thin-walled  multilocular  cyst.  At  any  stage  septic 
phenomena  may  supervene,  giving  rise  to  pyonephrosis  (vide  infra). 

The  Clinical  History  varies  considerably  with  the  method  of  onset 
and  the  cause  of  the  trouble.  Frequently  all  that  happens  is  a  pain- 
less enlargement  of  the  affected  organ  ;  if  both  kidneys  are  involved, 
there  may  be  at  first  some  increase  in  the  amount  of  urine  secreted, 

which  is  pale,  limpid,  and  of  a 
low  specific  gravity  ;  after  a  time 
the  quantity  diminishes,  and 
finally  anuria  and  uraemia  follow, 
especially  if  septic  changes  super- 
vene, as  is  so  commonly  the  case. 
When  only  one  kidney  is  affected, 
the  excretion  may  remain  normal 
in  quantity  and  quality,  owing 
to  compensatory  hypertrophy  of 
its  fellow.  An  elastic  swelling, 
fluctuant  if  of  considerable  size, 
is  produced  by  hydronephrosis  ;  it 
presents  all  the  physical  signs  of 
a  renal  tumour  (p.  11 77),  and  its 
formation  may  be  associated  with 
pain,  vomiting,  and  increased  fre- 
quency of  micturition.  Finally, 
a  perinephritic  abscess  may  de- 
velop, owing  to  ulceration  of  the 
pelvis  or  ureter,  and  if  this  bursts 
externally,  the  cyst  may  even- 
tually discharge  through  the  loin.  Occasionally  the  size  of  the 
tumour  varies  considerably  from  time  to  time,  as  a  result  of  the 
obstruction  being  temporarily  overcome  by  the  pressure  of  retained 
urine  behind  it. 

When  due  to  a  congenital  stricture  of  the  upper  end  of  the  ureter 
or  to  a  kink  over  a  branch  of  the  renal  artery,  there  is  usually  a 
history  of  occasional  attacks  of  painful  swelling  on  the  affected  side, 
which  has  disappeared  when  the  patient  rested.  Urinary  symptoms 
may  accompany  this,  but  it  is  often  supposed  to  be  a  bilious  attack, 
or  a  mild  appendicitis.  Some  pyelitis  may  follow,  but  sooner  or  later 
an  acute  attack  supervenes,  which  does  not  improve,  and,  if  left,  sup- 
puration and  perforation  will  follow.  Such  cases  are  by  no  means 
uncommon. 

The   Treatment    of   hydronephrosis   should  in  the  first  place  be 


Fig.  508. — Hydronephrosis.  (From 
Specimen  in  Bristol  Hospital 
Museum.) 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  mj 

directed  to  removal  of  the  cause,  if  practicable,  and  where  the 
obstruction  exists  in  the  prostate  or  urethra,  no  other  treatment  is 
feasible.  In  some  cases  of  congenital  hydronephrosis  due  to  mal- 
formation of  the  upper  end  of  the  ureter,  it  is  possible  to  transplant 
it  and  thereby  relieve  the  obstruction ;  or  the  pinhole  orifice  of  the 
ureter  may  be  exposed  within  the  pelvis,  and  divided  longitudinally, 
with  subsequent  stitching  open  of  the  margins.  This  type  of  uretevo- 
plasty  is  sometimes  very  successful.  In  the  later  stages,  where  sup- 
puration is  threatening  or  present,  nephrectomy  will  probably  be 
required.  Acquired  unilateral  hydronephrosis  may  be  dealt  with  by 
aspiration  as  a  temporary  measure  ;  but  this  is  rarely  satisfactory, 
and  usually  needs  to  be  followed  by  an  exploratory  incision  (nephro- 
tomy), by  means  of  which  it  may  be  possible  in  a  few  cases  to  reach 
and  deal  with  the  obstruction.  In  the  majority,  however,  the  block 
is  situated  so  low  down  that  it  cannot  be  reached,  and  the  condition  is 
often  so  aggravated  that  nephrectomy  is  the  only  reasonable  treatment. 

Nephritis,  or  inflammation  of  the  kidney,  is  an  affection  which 
occurs  in  many  different  conditions,  and  is  suitably  discussed  in 
medical  text-books.  The  presence  of  albuminuria  is  of  considerable 
significance  to  surgeons,  and  in  all  cases  demanding  surgical  inter- 
ference the  urine  should  be  carefully  tested.  It  will  be  further  dis- 
cussed at  p.  1232. 

In  addition,  we  must  note  that  surgical  interference  has  been 
utilized  in  cases  of  chronic  Bright's  disease.  Edebohl*  of  New  York 
and  others  have  completely  removed  the  capsule  of  both  kidneys  in 
some  of  these  patients.  The  technique  is  simple,  and  needs  no 
special  description,  but  the  operation  is  often  difficult  in  fat  oedema- 
tous  subjects.  It  is  claimed  that  this  operation,  or,  perhaps  better, 
nephrostomy  (p.  1190),  is  most  suitable  to  young  people  with  post- 
scarlatinal chronic  nephritis,  and  may  save  life  when  suppression 
of  urine  follows  catheterism  or  exposure  to  cold.  The  further 
history  of  these  procedures  will  be  watched  with  much  interest. 

Pyogenic  Infections  of  the  Kidney  and  Ureter  may  develop  from 
many  distinct  sources,  and  give  rise  to  several  allied,  though  distin- 
guishable, clinical  conditions.  Thus,  (i.)  the  infective  material  may 
reach  the  kidney  from  the  blood  in  the  shape  of  emboli,  as  in  pyaemia, 
causing  a  diffuse  inflammation  of  the  renal  substance  with  a  develop- 
ment of  many  scattered  abscesses  {aciite  suppitrative  interstitial  nephritis), 
or  of  one  larger  abscess.  Sometimes  a  focus  of  disease  pre-exists  in 
the  kidney  {e.g.,  stone,  tubercle,  or  cancer),  and  the  superadded  infec- 
tion adds  much  to  the  gravity  of  the  symptoms,  (ii.)  When  once  the 
kidney  substance  is  involved,  the  trouble  is  only  too  likely  to  spread 
to  the  pelvis,  causing  a  suppurative  pyelitis  (or  inasmuch  as  the  renal 
parenchyma  is  already  invaded,  a  suppurative  pyelonephritis) ;  and 
thence  the  mischief  spreads  down  the  ureter,  and  may  perhaps  infect 
the  lower  urinary  passages,  constituting  a  condition  of  descending  pyelo- 
nephritis, (iii.)  A  common  method  of  origin  consists  in  pyogenic 
organisms  spreading  upwards  from  the  bladder  to  the  ureter  and 
*  Medical  Record,  March  28,  1903. 


Ii88  A  MANUAL  OF  SURGERY 

kidney.  This  may  arise  from  a  primary  cystitis,  but  is  seen  most 
frequently  in  the  affection  which  used  to  be  termed  '  surgical  kidne}',' 
and  follows  in  the  train  of  many  diseases  accompanied  by  cystitis 
— e.g.,  stricture  of  the  urethra,  enlarged  prostate,  stone  in  the  bladder, 
etc.  It  will  be  remembered  that  the  ureter  passes  through  Lhe 
bladder  in  an  oblique  direction,  and  is  guarded  by  strong  sphincteric 
muscular  fibres,  and  thereby  the  spread  of  infection  upwards  is 
rendered  more  difficult.  It  is  probable,  however,  that  the  mucous 
membrane  lining  the  orifice  becomes  itself  inflamed,  and  a  small 
plug  of  mucus  develops  within  it,  through  which  the  germs  are  able 
to  pass  upwards.  In  other  cases  they  certainly  find  their  way  via 
the  lymphatics  of  the  mucous  membrane,  which  are  continuous  in 
the  ureter  and  bladder.  When  the  phenomena  caused  by  this  infec- 
tion from  below  are  limited  to  a  suppurative  condition,  it  is  known  as 
an  ascending  pyelonephritis  ;  but  if  to  them  is  added  an  element  of  dis- 
tension, due  to  the  cause  being  of  an  obstructive  type,  then  the 
distended  suppurating  kidney  is  known  as  2l  pyonephrosis,  (iv.)  Some- 
times the  infection  reaches  the  urinary  passages  from  neighbouring 
organs,  as  in  disease  of  the  rectum  or  even  of  the  appendix ;  in 
the  former  the  bacteria  are  disseminated  by  the  lymphatics ;  in 
appendicitis  an  abscess  may  open  into  the  kidne)^  or  ureter,  or  the 
latter  structure  may  be  involved  in  the  inflammatory  deposit.  In 
the  female  infection  may  easily  spread  along  the  short  urethra  from 
the  vulva. 

The  organisms  usually  present  are  staphylococci,  streptococci,  or 
the  B.  coli,  which,  as  will  be  seen  later,  is  constantly  associated  with 
inflammation  of  the  bladder. 

I.  Pyelitis  is  the  term  applied  to  an  inflammation  involving  the 
pelvis  of  the  kidney,  the  calyces,  and  perhaps  the  ureter.  The  chief 
causes  from  which  it  arises  are:  {a)  The  presence  of  a  calculus,  or 
the  passage  of  uric  acid  crj^stals  in  gouty  individuals  ;  {h)  tuberculous 
disease,  either  starting  primarily  in  the  kidney,  or  extending  upwards 
from  the  bladder ;  {c)  extension  of  septic  inflammation  from  the 
bladder  and  urethra ;  {d)  malignant  disease  of  the  kidney  ;  {e)  occa- 
sionally in  floating  or  moveable  kidney ;  (/)  the  ingestion  of  irritating 
drugs — e.g.,  cantharides,  turpentine,  and  even  cubebs  or  copaiba  ; 
{g)  the  presence  of  foreign  bodies,  such  as  needles,  bullets,  and  para- 
sites— e.g.,  the  Bilharzia  hamatobia  or  the  Strongylus  gigas ;  (li)  a  pysemic 
embolus  ;  and  {i)  possibly  cold.  In  the  milder  cases  and  in  the  early 
stages  it  may  be  a  simple  catarrhal  inflammation,  but  it  is  almost 
certain  to  become  purulent  if  it  lasts  long. 

Wha'ever  the  cause,  the  pathological  phenomena  are  the  same, 
consisting  in  the  lining  membrane  becoming  congested  and  thickened, 
and  secreting  a  muco-purulent,  or  even  purulent,  discharge.  Owing 
to  the  swelling  of  the  mucous  membrane,  the  entrance  to  the  ureter 
is  encroached  on,  and  a  certain  amount  of  distension  of  the  pelvis 
and  calyces  (hydronephrosis)  follows.  Where  micro-organisms  are 
present,  as  in  cases  due  to  distension  from  the  bladder,  the  kidney  is 
likely  to  be  involved  in  the  process  (pyelonephritis),  or  the  condition 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1189 

may  be  followed  by  a  urinary  abscess  in  the  loin  or  suppurative 
perinephritis. 

The  Symptoms  of  pyelitis  consist  of  pain  and  tenderness  over  the 
affected  kidney,  increased  frequency  of  micturition,  and  the  intey- 
niittent  discharge  of  pus  in  acid  urine.  The  intermissions  are  due  to 
the  inflammatory  swelling  of  the  mucous  membrane,  which  tem- 
porarily blocks  the  upper  entrance  to  the  ureter,  and  necessitates  a 
certain  degree  of  pressure  of  the  urine  and  pus  accumulated  in  the 
pelvis  of  the  kidney  in  order  to  overcome  the  obstruction.  Neces- 
sarily, where  pyelitis  follows  chronic  cystitis,  the  acid  reaction  is 
neutralized  if  the  urine  in  the  bladder  has  become  alkaline  ;  in  such 
cases  a  nocturnal  elevation  of  temperature  is  usually  noted. 

The  Treatment  of  pyelitis  is  mainly  directed  to  the  cause.  Where 
such  is  removeable  {e.g.,  calculus  or  foreign  bodies),  an  operation  is 
advisable.  In  the  ascending  type,  which  originates  in  the  bladder, 
treatment  should  be  first  directed  towards  the  latter  viscus.  In  the 
simple  catarrhal  variety  the  patient  is  kept  warm,  and  his  diet  restricted 
to  bland  fluids  ;  urotropine,  alkalies,  and  sedatives  are  prescribed.  If 
these  measures  fail  and  the  condition  becomes  painful  and  purulent, 
the  affected  kidney  should  be  explored,  as  a  stone  may  possibly  be 
present,  and  the  pelvis  drained  temporarily  (nephrostomy). 

2.  Pyelonephritis,  or  inflammation  of  the  pelvis  of  the  kidney 
together  with  the  renal  parenchyma,  is  almost  invariably  suppurative 
in  type,  and  either  due  to  extension  upwards  from  the  lower  urinary 
organs,  or  to  a  local  lesion  of  pelvis  or  kidney,  such  as  calculus  or 
tuberculous  disease. 

In  almost  all  cases  of  pyelitis  a  certain  degree  of  renal  congestion 
is  present ;  but  when  the  condition  becomes  confirmed,  and  especially 
when  infective  matter  is  present  in  the  calyces,  it  is  certain  to  light  up 
a  subacute  interstitial  nephritis.  In  the  latter  stages  bacteria  invade 
the  pyramids  and  travel  upwards  along  the  lymphatics  or  renal  tubules, 
giving  rise  to  abscesses,  either  scattered  through  the  connective  tissue 
of  the  organ  or  within  its  tubules,  in  either  case  seriously  damaging 
its  excretory  function.  In  both  instances  it  is  possible  for  many  of 
these  minute  foci  of  pus  to  run  together  and  form  a  large  collection, 
which  in  time  becomes  recognisable  from  outside  ;  but  more  usually 
the  patient  dies  of  toxaemia  or  uraemia  before  that  stage  is  reached. 
When  the  affection  ascends  from  the  bladder,  it  may  commence 
suddenly  and  with  acute  symptoms,  and  then  probably  results  from 
some  surgical  operation  or  simply  from  catheterism  in  a  patient 
whose  bladder  is  in  a  highly  septic  condition.  The  organisms  find 
their  way  upwards  along  the  lymphatics  in  the  mucous  lining  of  the 
ureters,  and  soon  infect  the  pelvis  ;  the  walls  of  the  ureters  may  in 
such  cases  be  studded  with  miliary  abscesses. 

Clinical  History. — ^In  acute  cases  the  symptoms  probably  com- 
mence with  a  severe  rigor,  associated  with  pain  in  the  loins  or  back, 
headache,  vomiting,  great  thirst,  and  probably  some  amount  of 
drowsiness,  perhaps  passing  into  a  condition  of  coma.  The  rigor 
may  be  repeated,  or  the  fever  may  remain  high  without  exacerba- 


II90  A  MANUAL  OF  SURGERY 

■tions,  but  if  uraemia  is  present  or  threatening,  the  temperature  may 
be  subnormal.  The  kidneys  are  felt  to  be  enlarged  and  tender,  and 
the  urine  is  usually  diminished  in  amount,  and,  indeed,  may  be  sup- 
pressed entirely;  if  any  passes,  it  is  high  coloured  and  contains 
albumen  and  perhaps  blood,  with  some  amount  of  pus,  which  is 
probably  derived  largely  from  the  lower  portion  of  the  urinary  track. 
The  prognosis  of  the  worst  cases,  which  supervene  on  old  bladder 
trouble,  is  nearly  hopeless,  the  patient  being  almost  certain  to  die  of 
uraemia,  especially  as  both  kidneys  are  generally  affected.  In  less 
acute  cases,  occurring  perhaps  in  young  people,  secondary  to  a 
bacillary  cystitis,  the  symptoms  often  improve  in  a  few  days  and 
quiet  down ;  but  the  urine  is  swarming  with  bacilli,  and  recurrence 
of  the  trouble  is  not  uncommon.   Abscess  may  sometimes  supervene. 

In  the  more  chronic  cases,  the  symptoms  are  those  of  pyrexia,  at 
first  only  slight,  but  gradually  increasing  and  taking  on  the  hectic 
type,  with  some  amount  of  pyrexia.  The  kidney  is  slightly  enlarged 
and  tender  ;  the  urine  contains  epithelial  cells  from  the  pelvis  or  renal 
casts,  and  may  be  acid  in  the  early  stages,  but  is  usually  alkaline  in 
the  late.  As  the  condition  increases,  the  temperature  rises ;  the 
patient  wastes ;  appetite  and  digestive  functions  flag ;  slight  delirium 
supervenes  at  night ;  and  unless  the  cause  can  be  removed  or  dealt 
with  effectively,  death  from  uraemia  is  likely  to  follow.  If,  however, 
effective  treatment  of  the  cause  is  possible,  recovery  may  follow,  but 
the  kidney  is,  of  course,  permanently  damaged,  and  some  degree  of 
sclerosis  is  certain  to  ensue. 

Treatment. — In  the  chronic  variety,  the  cause  must  first  be  dealt  with, 
but  the  surgeon  must  not  forget  that  an  acute  attack  may  be  easily 
lighted  up  by  injudicious  instrumentation  or  operations.  Hence  it  is 
often  desirable  to  drain  and  wash  out  the  bladder  first,  as  by  a  perineal 
cystotomy,  rather  than  to  dilate  or  divide  a  stricture  of  the  urethra. 
An  enlarged  prostate  or  calculus  must  be  removed,  but  it  may  be 
desirable  to  wash  out  or  drain  the  bladder  for  a  few  days  before 
undertaking  such  operations,  so  as  to  diminish  the  risks  of  infection. 
At  the  same  time  the  patient  is  kept  in  bed,  and  encouraged  to  drink 
plenty  of  bland  fluids.  If  the  urine  is  swarming  with  the  B.  coli, 
an  autogenous  vaccine  of  that  organism  is  desirable,  and  must  be 
continued  for  some  time  in  gradually  increasing  doses.  In  the  acute 
form  the  patient  is  kept  warm  in  bed,  and  plenty  of  fluid,  such  as 
milk  or  barley-w^ater,  is  given;  stimulants  are  avoided,  as  also 
opium.  Hot-air  baths,  wet  packs,  and  the  hypodermic  injection  of 
pilocarpine,  will  suffice  to  get  the  skin  to  act  well,  and  watery  pur- 
gatives, such  as  jalap  and  scammony,  are  needed  for  the  bowels. 
The  loins  are  fomented  or  cupped,  but  if  the  urinary  secretion 
is  not  re  -  established,  or  if  it  is  suppressed,  or  if  the  phenomena 
of  suppuration  supervene,  incision  of  the  kidney  and  drainage  of  the 
pelvis  (nephrostomy)  are  essential.  It  is  sometimes  remarkable  to 
observe  how  rapidly  the  symptoms  improve  after  such  a  procedure, 
and  how  quickly  the  urinary  secretion  is  re-established. 

3.  Pyonephrosis  is  the  term  applied  to  indicate  the  association  of  a 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1191 

chronic  pyelonephritis  with  distension  of  the  pelvis  and  ureter,  as  a 
result  of  obstruction  to  the  passage  of  urine.  When  unilateral,  it 
is  commonly  due  to  the  presence  of  a  calculus,  or  of  tuberculous 
disease,  the  obstruction  being  caused  by  the  swelling  of  the  ureteral 
mucous  membrane  ;  if  the  affection  is  secondary  to  obstruction  in  the 
lower  urinary  passages,  it  is  usually  bilateral.  The  lining  membrane 
of  the  pelvis  is  inflamed,  thickened,  and  perhaps  ulcerated ;  decom- 
posing urine  and  pus  collect  in  the  dilated  pelvis  and  calyces,  and  a 
soft,  friable,  phosphatic  calculus  may  develop,  even  in  cases  where 
the  originating  cause  is  not  of  a  calculous  nature.  Obstruction  to 
the  outlet  may  lead  to  such  an  accumulation  of  pus  as  to  constitute 
an  abscess  of  the  kidney,  whilst  a  certam  amount  of  perinephritis 
is  always  present. 

The  Clinical  Signs  are  very  similar  to  those  of  pyelonephritis,  but 
to  them  are  added  those  of  an  enlarged,  tender,  and  painful  kidney, 
and  a  more  or  less  abundant  pyuria,  usually  intermittent.  The 
temperature  is  somewhat  raised,  especially  at  night,  from  the  ab- 
sorption of  toxic  products ;  the  patient  steadily  loses  ground,  and 
becomes  emaciated  ;  the  tongue  is  dry,  the  appetite  diminished,  and 
nausea  and  vomiting  are  sometimes  present.  The  urine  is  generally 
scanty  in  amount,  and  if  both  kidneys  are  involved,  the  excretion 
gradually  diminishes,  leading  to  a  fatal  issue  from  uraemia,  unless  the 
patient  dies  previously  from  toxaemia  or  pyaemia. 

Treatment. — Where  both  kidneys  are  involved  as  a  result  of  some 
urethral  or  prostatic  affection,  no  special  treatment  directed  to  the 
kidneys  is  feasible ;  but  if  the  condition  is  unilateral,  and  not 
secondary  to  disease  of  the  lower  urinary  organs,  nephrotomy  should 
be  undertaken,  and  any  removeable  cause  dealt  with.  Failing  this, 
the  cavity  may  be  drained,  or  even  nephrectomy  performed. 

4.  Abscess  of  the  Kidney  may  follow  any  of  the  conditions  already 
alluded  to,  in  which  bacteria  gain  access  to  the  organ  from  below,  the 
pus  then  collecting  in  the  pelvis  and  dilated  calyces.  It  also  occurs 
in  connection  with  pyaemia  and  sometimes  develops  after  the  general 
infective  fevers.  In  acute  interstitial  nephritis  the  abscesses  are 
multiple  and  at  first  small,  being  located  between  the  tubules  or 
sometimes  within  them  ;  the  pyramids  then  have  a  streaky-v/hite 
appearance  due  to  their  infiltration  with  pus,  and  the  abscesses  form 
in  the  cortical  substance  at  their  base.  Larger  collections  are  caused 
by  the  amalgamation  of  several  of  the  smaller.  In  pyaemia  the 
abscesses  are  preceded  by  infarcts,  which  appear  immediately  beneath 
the  capsule  as  wedge-shaped  areas  of  a  chocolate  colour,  which  turns 
a  yellowish-white  as  suppuration  occurs.  The  kidney  becomes 
enlarged  and  tender,  and  can  usually  be  felt  from  outside,  but 
fluctuation  is  rarely  to  be  detected.  The  abscess  may  burst  into  the 
pelvis  and  discharge  through  the  ureter,  but  when  due  to  an  ascend- 
ing pyelonephritis  from  obstruction  this  is  not  likely  to  be  the  case. 
The  inflammation  is  more  liable  to  spread  outwards  through  the 
kidney  substance,  and  give  rise  to  a  suppurative  perinephritis.  The 
general  symptoms  produced  are  similar  to  those  present  in  acute 


1,92  A  MANUAL  OF  SURGERY 

pyelonephritis.  Treatment  of  an  abscess  of  the  kidney  consists  in 
nephrostomy  for  drainage  purposes,  or  perhaps  nephrectomy. 

The  more  chronic  varieties  are  probably  tuberculous  in  origin,  and 
may  then  attain  considerable  dimensions,  all  that  is  noted  being  the 
lumbar  swelling,  whilst  pyuria  is  not  necessarily  present,  owing  to  the 
ureter  becoming  blocked. 

5.  Perinephritis  cannot  be  recognised  unless  suppurative  in  nature; 
•it  results  either  from  infected  wounds  or  from  ulceration  involving  the 
walls  of  the  pelvis  and  calyces,  or  from  the  transmission  of  micro- 
organisms from  the  interior  of  a  suppurating  kidney  or  pelvis  without 
any  breach  of  surface.  A  perinephritic  abscess  may  also  arise  from 
inflammation  spreading  from  the  intestine,  appendix,  pleural  cavity, 
spine,  ribs,  or  elsewhere. 

The  Symptoms  may  be  acute  or  chronic  in  nature.  In  acute  peri- 
nephritis, signs  of  deep  suppuration  in  the  loin  are  produced — viz.,  an 
indurated  painful  swelling,  associated  with  fever,  and  perhaps  pre- 
ceded by  rigors.  The  body  is  held  stiff  and  rigid,  with  an  inclination 
towards  the  affected  side.  Fluctuation  may  sometimes  be  detected 
when  pus  has  formed,  but  the  abscess  is  often  so  deeply  placed  that 
it  is  difficult  to  recognise  at  first ;  it  is  likely  to  point  at  the  side  of 
the  erector  spinae,  or  may  burrow  forwards  between  the  abdominal 
muscles,  and  find  an  exit  on  the  anterior  abdominal  wall.  Occasion- 
ally it  bursts  into  the  peritoneal  or  pleural  cavities,  or  into  the  intes- 
tine. If  it  comes  to  the  surface,  it  is  preceded  by  congestion  and 
oedema  of  the  skin.  Chronic  perinephritis  gives  rise  to  no  characteristic 
symptoms  until  an  abscess  forms  which  is  large  enough  to  be  felt. 
Sometimes  it  is  of  a  simple  type,  and  does  not  suppurate  ;  but  the 
kidney  becomes  adherent  to  surrounding  parts,  and  to  such  an  extent 
as  to  render  nephrectomy  difficult  and  dangerous. 

Treatment  in  the  suppurating  variety  consists  in  giving  exit  to  the 
pus  through  an  incision  at  the  outer  border  of  the  erector  spinae ;  the 
cavity  is  then  carefully  examined,  and  the  cause  of  the  suppuration, 
if  possible,  determined,  and  treated  according  to  the  requisites  of  the 
case. 

Tuberculous  Disease  of  the  Kidney  occurs  in  one  of  three  forms. 
{a)  It  may  arise  in  the  course  of  acute  general  tuberculosis,  when 
miliary  tubercles  are  found  studding  the  organs,  but  giving  rise  to  no 
special  symptoms.  The  patient  is  usually  a  child.  Treatment,  of 
course,  is  impracticable. 

{b)  It  may  extend  upwards  from  a  similar  affection  of  the  bladder, 
and  then  almost  invariably  involves  both  kidneys.  The  mucous 
membrane  of  the  ureter  becomes  thickened  and  transformed  into 
oedematous  granulation  tissue  containing  tubercles,  and  that  of  the 
pelvis  and  calyces  is  similarly  affected  ;  finally,  the  renal  parenchyma 
itself  becomes  infiltrated  with  tuberculous  tissue  spreading  from  the 
pyramids.  The  patients  are  usually  young  adult  males,  and 
this  fact  is  explained  by  their  liability  to  genital  tuberculosis. 
Clinically,  enlargement  of  both  kidneys  is  noticed,  arising  partly 
from   the   deposit   of  tubercle   within   the   organ   and   partly  from 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


"93 


.obstruction  within  the  ureter.  The  symptoms  caused  by  the  renal 
mischief  cannot  at  first  be  distinguished  from  those  due  to  the  vesical 
trouble.  Perinephritic  abscess  occasionally  follows,  and  the  patient 
dies  from  exhaustion,  toxic  absorption,  or  uraemia.  Treatment  in 
these  cases  is  of  no  avail. 

(c)  Primary  Tuberculosis  of  the  kidney  is  generally  unilateral,  and 
commences  as  a  deposit  of  tubercle  in  the  cortex  or  at  the  base  of 
one  of  the  pyramids.  It  may  early  involve  the  pelvis,  and  give  rise 
to  an  ulcerative  pyelitis,  or  may  invade  the  renal  parenchyma  more 
particularly,  replacing  it  by  caseous  masses,  which  in  chronic  cases 
may  become  calcified,  and 
even  cast  a  shadow  on  the 
radiographic  screen.  In  the 
former  case  a  tuberculous 
pyonephrosis  follows,  and 
the  process  spreads  for 
some  distance  down  the 
ureter,  and  even  infects  the 
bladder  (Fig.  509).  A 
tuberculous  ureter  is  always 
thickened  and  hard,  due 
to  the  infiltration  of  the 
mucous  membrane ;  obstruc- 
tion to  the  flow  of  urine  and 
to  the  escape  of  discharge 
ensues,  and  in  old-standing 
cases  the  ureter  contracts 
and  drags  upon  its  outlet  in 
the  bladder,  which  can  be 
seen  to  be  retracted.  Sup- 
puration of  a  chronic  type 
sometimes  occurs  in  the 
kidney,  and  large  quantities 
of  pus  may  be  dammed  back 
behind  the  thickened  ureter. 
Suppurative  perinephritis 
may  also  supervene,  and  give 
rise  to  an  abscess  which 
bursts  externally. 

The  Symptoms  are  at  first  indefinite.  The  patient  is  usually  a 
young  adult,  and  rather  more  frequently  a  male  than  a  female.  He 
complains  of  increased  frequency  of  micturition,  and  unilateral  pain 
in  the  loin,  neither  of  which  conditions  is  improved  by  rest,  remaining 
the  same  at  night  as  in  the  day,  and,  indeed,  sometimes  being  worse. 
The  pain  is  generally  of  an  aching  character,  and  more  or  less 
constant,  although  exacerbations  may  occur,  taking  on  the  type  of 
mild  renal  colic,  in  consequence  of  the  passage  of  fragments  of 
disintegrated  mucous  membrane,  or  of  caseous  material.  The  urine 
is  acid,  and  usually  contains  a  certain  proportion  of  pus,  in  which  on 


Fig  509. — Tuberculous  Kidney,  showing 
Thickening  of  Mucous  Membrane  of 
Pelvis  and  Ureter.  (From  Specimen 
in  College  of  Surgeons'  Museum.) 


II94  A  MANUAL  OF  SURGERY 

examination  the  B.  tuberculosis  can  sometimes  be  detected.  More 
frequently  they  are  not  detected,  unless  the  urine  is  centrifugalized, 
and  cultivation  or  inoculation  of  the  deposit  may  then  demonstrate 
the  presence  of  the  bacilli.  Haematuria  is  not  marked,  even  if 
present  at  all.  In  the  earliest  stages  albuminuria  is  sometimes 
present  with  any  evidence  of  pus.  On  examination  the  kidney  may 
be  found  to  be  slightly  enlarged,  but  is  not  tender,  except  in  the  later 
stages,  when  it  constitutes  a  tumour  of  considerable  size,  which  may 
contain  a  large  quantity  of  pus  and  even  a  phosphatic  concretion. 
Loss  of  flesh,  night  sweats,  and  a  nocturnal  rise  of  temperature,  are 
present  in  the  later  stages. 

The  Diagnosis  of  primary  renal  tuberculosis  is  usually  a  matter  of 
doubt,  if  the  presence  of  bacilli  in  the  urine  cannot  be  demonstrated, 
since  the  symptoms  are  very  similar  to  those  of  renal  calculus.  The 
age  of  the  patient  and  his  personal  and  family  history  may  be  of 
importance,  and  he  should  be  carefully  examined  for  evidences 
of  tuberculous  disease  elsewhere,  especially  in  the  genital  organs. 
A  bacteriological  examination  of  the  urine  will  often  decide  the 
case.  The  chief  points  of  distinction  clinically  are  that  the  symptoms 
are  less  influenced  by  exercise  or  rest,  and  there  is  less  hasmaturia  or 
renal  colic  than  when  a  calculus  is  present,  whilst  the  kidney  is 
usually  not  so  tender  on  manipulation ;  of  course  the  condition  is 
much  less  common  than  that  of  stone.  Radiography  will  determine 
the  presence  or  absence  of  a  stone,  but  also  of  calcified  caseous 
deposits.  Cystoscopy  may  reveal  the  existence  of  tuberculous 
ulcers  in  the  bladder  close  to  the  ureteral  orifice  in  the  earlier  stages, 
or  of  a  retracted  ureter,  when  the  latter  has  become  transformed  into 
a  solid  cord.  In  cases  of  doubt  the  final  distinction  is  made  by 
exploring  the  organ  through  an  incision  in  the  loin.  In  calculus  the 
surface  is  uniformly  even  arid  dark  red,  and  if  any  areas  of  softening 
are  present,  they  are  of  a  bluish-red  colour ;  the  pelvis  and  upper 
end  of  the  ureter  are  usually  lax  and  distended.  The  tuberculous 
kidney  is  generally  mottled  in  colour  and  pallid-looking,  whilst  hard, 
scattered,  caseous  nodules  may  be  felt,  which  become  fluid  on 
pressure,  or  on  incision  give  exit  to  caseous  pus.  The  condition 
of  the  ureter  is  also  diagnostic ;  in  calculus,  if  altered  at  all,  it  is  thin 
and  dilated;  in  tubercle  it  is  thickened  and  indurated,  and  this 
condition  may  sometimes  be  detected  on  rectal  or  vaginal  examination. 

Treatment. — In  the  earliest  stages  the  routine  anti-tuberculous 
treatment  (p.  175)  may  be  employed,  creosote  (TT\^xv.  or  TT(_xx.,  t.d.s.) 
being  perhaps  useful  as  a  drug,  and  tuberculin  in  small  doses  being 
valuable.  Operation  must  not  be  delayed  too  long,  however,  owing 
to  the  grave  results  that  may  follow  from  extension  of  the  mischief. 
If  on  exploration  of  the  kidney  the  disease  is  found  to  be  strictly 
limited  and  the  pelvis  unaffected,  it  may  be  possible  to  cut  or  scrape 
away  the  diseased  tissues,  carefully  purifying  the  cavity  by  liquefied 
carbolic  acid,  and  packing  the  wound  thus  formed  with  gauze.  In 
other  cases  it  may  be  possible  to  excise  wedge  shaped  areas  of  the 
renal  cortex,  securing  the  wounds  by  sutures.     In  the  majority  of 


PLATE    X. 


Renal  Stones. 

pelvif  'CrLarge  branched  calculus,  firmly  held  in  the  calyces  of  the 
uric  acid  ^Th;";?rf'  °^  ^'T  ''°"!-  .^'-"'-  ^—^^^  f^^^^tted  stones  of 
w"re^r:ive^dVn"rrlrh:^^^  collection  ^..  ...W  ;  six 

[To /ace  page  1194. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS 


"95 


instances,  however,  the  disease  will  have  spread  much  too  extensively 
through  the  ureter,  pelvis,  and  calyces  for  such  conservative  treat- 
ment, or  the  kidney  may  consist  of  a  series  of  cysts  filled  with 
offensive  pus.  If  the  surgeon  is  tolerably  certain  that  the  other 
kidney  is  healthy,  nephrectomy  should  be  performed,  care  being 
taken  to  divide  the  ureter  below  the  farthest  limit  of  the  disease,  the 
incision  being  suitably  prolonged  (p.  1205).  The  occurrence  of  a 
perinephritic  abscess  necessitates  an  incision  in  the  loin,  and  through 
this  opening  the  kidney  can  be  explored  and,  if  necessary,  removed. 

Renal  Calculus. — Renal  Calculi  are  usually  met  with  in  individuals 
suffering  from  lithiasis,  as  indicated  by  the  passage  of  sand  or  gravel 
in  the  urine.  The  general  causes  of  this  condition  are  detailed 
elsewhere  (p.  1229).  All  renal  concretions  are  primarily  excreted  in 
a  crystalline  form  from 
the  renal  tubules,  but 
under  ordinary  circum- 
stances are  sufficiently 
small  to  find  their  way 
into  the  pelvis  of  the 
kidney,  and  thence  along 
the  ureter  to  the  bladder. 
If,  however,  they  are  ob- 
structed in  their  onward 
course,  either  on  account 
of  their  size  or  shape,  or 
some  narrowing  of  the 
tubules,  they  may  become 
lodged  in  the  kidney  sub- 
stance or  in  one  of  the 
calyces,  and  by  the 
gradual  deposit  of  the 
same  material  increase 
in  size  until  large  enough 
to  give  rise  to  symptoms 
(Fig.  510).  Renal  calculi 
are  usually  not  of  great  bulk ;  occasionally,  however,  the  whole  of 
the  pelvis,  and  some  of  the  calyces,  may  be  occupied  by  a  concretion, 
which  takes  the  shape  of  the  cavity  in  which  it  lies.  When  many 
calculi  are  present  in  the  pelvis  of  a  kidney,  they  are-  usually 
faceted  (Plate  X.).  Chemically  they  consist  either  of  uric  acid  or 
urate  of  ammonium  ;  sometimes,  however,  they  are  composed  of 
oxalate  or  acid  phosphate  of  lime. 

The  Pathological  Phenomena  connected  with  renal  calculi  vary  with 
their  size,  shape,  number,  and  position.  If  situated  in  the  substance 
of  the  renal  paien;hyma,  they  may  give  rise  to  but  little  trouble, 
being  more  or  less  encapsuled  in  a  cavity  lined  by  granulation  tissue 
and  surrounded  by  a  dense  fibrous  capsule.  Sometimes,  however, 
ulceration  of  the  wall  and  suppurative  perinephritis  may  follow ;  the 
calculus  may  even  find  its  way  into  the  abscess  cavity,  and  be 


Fig.   510.— Calculous  Kidney.     (College 
OF  Surgeons'   Museum.) 


II96  A  MANUAL  OF  SURGERY 

discharged  spontaneously  or  removed  through  the  loin,  a  urinary 
fistula  perhaps  resulting.  If  the  calculus  is  held  in  place  in  one 
of  the  calyces  by  its  branched  shape,  thereby  limiting  its  mobility, 
a  suppurative  pyelonephritis  follows,  by  which  the  kidney  substance 
is  seriously  damaged,  the  pelvis  may  become  dilated,  and  possibly 
perinephritis  ensues,  with  or  without  suppuration,  and  the  forma- 
tion of  a  urinary  fistula.  When  occupying  the  pelvis  of  the  kidney, 
calculi  set  up  a  suppurative  pyelitis,  and  from  the  obstruction  to  the 
flow  of  urine,  caused  partly  by  the  thickening  of  the  mucous  mem- 
brane, and  partly  by  the  calculus  engaging  the  orifice  of  the  ureter, 
produce  dilatation  of  the  pelvis  of  the  kidney,  and  the  phenomena  of 
hydro-  or  pyo-nephrosis.  If  the  calculus  passes  down  the  ureter,  it 
gives  rise  to  the  symptoms  of  renal  colic.  When  small  and  smooth, 
it  usually  reaches  the  bladder  without  much  difficulty,  and  is  then 
voided  with  the  urine,  or  remains  as  a  vesical  calculus.  Occasionally, 
owing  to  its  size  or  irregular  shape,  it  becomes  impacted  in  the 
ureter,  usually  at  its  upper  end,  giving  rise  to  acute  obstruction  and 
the  cessation  of  the  urinary  secretion  on  that  side,  followed  in  time 
by  disorganization.  If  the  kidney  thus  affected  is  the  only  one 
available  for  excretory  purposes,  or  if  both  ureters  are  similarly 
obstructed,  the  patient,  if  unrelieved,  dies  in  a  few  days  from 
suppression  of  urine  (calculous  amivia).  In  other  cases  the  stone 
ulcerates  through  the  wall  of  the  ureter,  giving  rise  to  a  retroperi- 
toneal urinary  abscess,  or  possibly  to  suppurative  peritonitis.  If  the 
ureter  is  only  partially  obstructed  by  the  calculus,  the  changes  which 
take  place  in  the  kidney  are  more  gradual,  and  result  in  hydro-  or 
pyo-nephrosis. 

The  typical  Symptoms  arising  from  renal  calculus  are  as  follows : 
The  patient  complains  of  pain  in  the  loin,  more  or  less  persistent, 
and  often  paroxysmal  in  nature,  which  is,  however,  always  increased 
on  exercise  or  jolting ;  it  is  frequently  referred  to  distant  regions,  but 
most  commonly  follows  the  course  of  the  genito-crural  nerve,  giving 
rise  to  pain  in  front  of  the  thigh,  accompanied  by  retraction  of  the 
testicle ;  in  the  female  it  is  also  experienced  in  the  labium  majus  ; 
sometimes  it  extends  down  the  back  of  the  thigh.  It  is  almost 
invariably  associated  with  haematuria,  and  often  with  pyuria,  the 
amount  of  blood  or  pus  being  increased  on  exertion.  Frequency  of 
micturition  is  a  prominent  symptom,  whilst  if  the  pelvis  is  enlarged 
the  kidney  may  be  tender  and  distinctly  palpable.  If  the  calculus 
is  lodged  in  the  renal  parenchyma,  the  urinary  secretion  may  be  but 
little  influenced,  although  the  characteristic  pain  is  well  marked ;  the 
patient  also  finds  that  at  night  he  can  only  gain  relief  by  lying  on  the 
affected  side,  and  on  manual  examination  the  kidney,  though  some- 
what tender,  is  not  much  enlarged.  When  the  calculus  lies  in  the 
pelvis  or  one  of  the  calyces,  the  typical  phenomena  described  above 
are  produced  ;  but  it  is  then  noticed  that  at  night  the  patient  lies  on  the 
sound  side,  since  the  organ  is  both  enlarged  and  tender. ,  On  the  other 
hand,  it  is  an  undoubted  fact  that  stones  even  of  large  size  may  exist 
for  years  in  the  kidney  without  giving  rise  to  any  symptorns  whatever, 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1197 

The  passage  of  a  calculus  down  the  ureter  is  accompanied  by  the 
symptoms  known  as  Renal  Colic.  They  consist  of  excruciating  pain 
of  a  paroxysmal  nature,  which  comes  on  suddenly,  and  is  referred 
both  to  the  loin  and  along  the  course  of  the  genito-crural  nerve.  It 
is  always  associated  with  vomiting  and  severe  shock,  the  patient 
often  lying  on  the  floor  writhing  in  agony,  with  cold  perspiration 
standing  in  beads  on  his  forehead.  The  temperature  is  subnormal, 
and  the  pulse  weak  and  rapid.  Strangury  is  usually  present,  the 
patient  suffering  from  frequent  paroxysmal  efforts  to  pass  water,  but 
only  succeeding  in  evacuating  a  small  amount,  and  that  generally 
blood-stained.  After  lasting  for  a  variable  period,  the  pain  suddenly 
ceases,  as  a  result  of  the  passage  of  the  calculus  into  the  bladder,  or 
of  its  slipping  back  into  the  pelvis  of  the  kidney. 

Impaction  in  the  Ureter  may  occur  either  about  2  inches  below 
the  pelvis  of  the  kidney,  or  near  the  brim  of  the  pelvis,  or  near  the 
vesical  orifice,  sometimes  even  protruding  through  it.  In  thin 
persons  it  has  been  detected  on  palpation  through  the  abdominal 
wall,  and  when  low  down  has  been  felt  on  rectal  or  vaginal 
examination.  Persistent  pain  and  haematuria  extending  over  days 
or  weeks  should  certainly  suggest  the  presence  of  a  ureteral  calculus, 
and  the  more  so  if  with  each  succeeding  attack  the  pain  and  tender- 
ness are  located  lower  down.  The  result  may  be  that  the  stone  will 
ulcerate  through  into  the  retroperitoneal  tissue,  and  be  discharged 
in  an  abscess ;  or  more  frequently  the  kidney  is  disorganized,  and 
perhaps  the  patient's  life  destroyed  through  the  resulting  renal 
incompetence.* 

Calculous  anuria  is  the  term  applied  to  a  cessation  of  the  urinary 
secretion  which  follows  the  blocking  of  one  or  both  ureters  with 
calculi,  the  opposite  kidney  in  the  former  case  being  absent,  atrophied, 
or  diseased.  The  condition  is  usually  lighted  up  by  some  physical 
effort,  which  presumably  dislodges  the  calculus.  It  is  ushered  in  by 
sudden  pain  in  the  loin,  which  often  passes  away  in  the  course  of  two 
or  three  days.  The  anuria  is  rarely  complete  at  first,  a  few  ounces 
of  pale  limpid  urine  being  passed  at  intervals,  whilst  occasionally 
distinct  polyuria  is  present.  Sooner  or  later  definite  uraemic  pheno- 
mena supervene ;  the  most  usual  period  is  seven  or  eight  days  after 
the  onset,  but  incomplete  obstruction  or  a  pre-existing  condition  of 
hydronephrosis  may  delay  matters.  The  onset  of  uraemia  is  indicated 
by  persistent  vomiting,  a  slow,  full  pulse  becoming  irregular,  con- 
traction of  the  pupils,  and  muscular  tremors.  Coma  and  convulsions 
are  rarely  seen,  and  there  is  no  dyspnoea ;  the  temperature  is  sub- 
normal. 

The  Diagnosis  of  renal  calculus  is  often  a  matter  of  uncertainty  in 

*  Sometimes  a  calculus  will  remain  in  the  ureter  for  a  considerable  period, 
acting  as  a  ball-valve,  and  permitting  a  certain  amount  of  urine  to  pass.  It  may 
increase  in  size  and  reach  considerable  dimensions.  The  author  recently  recorded 
a  case  [Proceedings,  Royal  Society  of  Medicine,  vol.  iii.,  No.  3,  Clinical  Section, 
p.  63)  in  which  he  had  removed  a  stone  from  the  lower  end  of  the  ureter  weigh- 
ing 803  grains.  The  ureter  above  it  was  dilated  like  a  coil  of  intestine,  and  filled 
with  pus. 


II98  A  MANUAL  OF  SURGERY 

the  absence  of  a  history  of  the  passage  of  gravel  or  of  the  occurrence 
of  renal  colic.  It  is  most  likely  to  be  mistaken  for  tuberculous 
disease ;  the  differential  diagnosis  between  the  two  conditions  has 
already  been  considered  (p.  1194).  The  final  determination  of  the 
presence  or  not  of  a  renal  or  ureteral  calculus  is  now  usually  made 
by  skiagraphy,  which  has  made  such  advances  that  it  may  be  relied 
on  with  almost  absolute  certainty,  except,  perhaps,  in  the  case  of 
small  pure  uric  acid  calculi,  Mr.  A.  D.  Reid,  radiographer  to  King's 
College  Hospital,  is  responsible  for  the  following  account  of  his 
methods  and  results : 

Recent  improvements  in  radiographic  technique  have  made  the  diagnosis  of 
urinar}'  calculi  much  more  reliable  than  formerly,  so  that  it  is  now  possible  in 
the  majority  of  cases  to  make  an  absolute  positive  diagnosis,  both  as  to  the 
existence  of  calculi  and  also  as  to  their  number,  size,  and  position.  One 
great  exception  still  remains  owing  to  the  fact  that  piire  uric  acid  calculi  cast  no 
shadow  on  the  radiographic  screen  or  plate,  although  the  quality  of  the  negative 
may  be  faultless.  A  large  stone  of  this  character  held  in  the  hand  in  front  of  the 
screen  cast  no  shadow  deeper  than  the  muscles  of  the  thenar  eminence.  Oxalate 
calculi,  or  those  formed  of  phosphates,  cystine,  or  of  a  mixed  composition,  ought 
in  all  cases  to  be  demonstrable. 

The  differential  diagnosis  of  the  shadows  of  calculi  from  those  produced  by 
other  conditions  which  may  appear  on  the  plates  has  been  rendered  easiei:  by 
the  more  perfect  detail  which  can  now  be  obtained  in  the  skiagram.  In  most 
cases  it  is  possible  to  show  the  outline  of  the  kidney,  as  well  as  the  stones  con- 
tained in  it  (Fig.  511),  and  one  can  thus  eliminate  the  shadows  produced  by 
calcified  mesenteric  glands,  bowel  contents,  or  appendicular  concretions  (Fig.  469). 
Gall-stones,  as  a  rule,  cast  no  shadow,  but  we  have  seen  one  or  two  pases  where 
some  abnormal  change  in  the  gall-stone  made  it  visible,  and  this  might  lead  to  a 
mistake  in  diagnosis. 

The  positive  diagnosis  of  ureteral  calculi  (Figs.  512  and  513)  is  sometimes  more 
difficult,  as  they  have  to  be  distinguished  from  phleboliths,  calcified  pelvic 
glands,  appendicular  concretions,  bowel  contents,  calcified  appendices  epiploicse, 
and  calcified  uterine  fibroids,  whether  pedunculated  or  sessile.  It  maybe  neces- 
sary to  pass  an  opaque  bougie  up  the  ureter  and  repeat  the  skiagram  before  a 
diagnosis  can  be  made.  Pelvic  glands  are  nearly  always  circular  and  frequently 
multiple,  although  it  is  not  uncommon  to  find  a  single  calcified  gland  opposite 
and  internal  to  the  ilio-pectineal  eminence  on  one  or  both  sides.  Calcified 
inguinal  glands  are  easily  recognised  by  their  superficial  position  on  stereoscopic 
examination.  Bowel  contents  are  excluded  by  repeating  the  skiagram  after 
effective  purgation,  and  indeed  this  is  a  course  that  should  always  be  followed 
except  in  cases  which  are  absolutely  characteristic.  Calcified  fibroids  simu- 
lating ureteral  or  vesical  calculi  can  generally  be  detected  on  clinical  examination. 

The  essentials  for  obtaining  satisfactory  results  in  the  detection  of  calculi  in 
the  urinary  tract  consist  of — (i)  Efficient  apparatus  for  exciting  the  X-ray  tube, 
capable  of  giving  a  heavy  discharge  with  the  minimum  of  inverse  current ;  this 
requires  either  a  transformer,  or  a  coil  with  mechanical  or  electrolytic  inter- 
rupter, with  valve  tubes  inserted  in  the  circuit ;  (2)  an  X-ray  tube  capable  of 
allowing  the  passage  of  the  necessary  heavy  current ;  (3)  some  form  of  com- 
pressor which  will  keep  the  parts  immobile  during  the  passage  of  the  current ; 
(4)  adequate  purgation  of  the  patient  before  examination. 

Too  much  stress  cannot  be  laid  upon  the  importance  of  effective  immobiliza- 
tion of  the  area  of  examination.  A  short  exposure  adds  to  the  patient's  comfort 
and  reduces  the  blurring  of  the  shadows  from  the  action  of  secondary  rays  ;  but 
no  clear  or  distinct  outline  can  be  expected  if  the  parts  are  not  immobilized. 
It  is  best  accomplished  by  the  use  of  some  form  of  tubular  diaphragm  fitted  to 
the  tube  shield  ;  this  can  be  attached  either  to  the  side  of  the  couch  on  runners. 
or  to  a  superimposed  stage.     For  the  renal  region  the  patient  is  placed  on  a 


Fig.  511. — Skiagram  of  Multiple  Renal  Calculi  and  Calcareous 
Mesenteric  Glands.     (A.  D.  Reid.) 

The  outline  of  the  lower  pole  of  the  kidney  can  just  be  seen,  and  above  it  a  number 
of  calculi  in  the  kidney.  The  two  lower  shadows  were  demonstrated  at  opera 
tion  to  be  due  to  calcified  mesenteric  glands. 


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76 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1203 

couch  with  a  rigid  top,  the  knees  are  flexed,  and  the  shoulders  are  raised  on  a 
cushion,  so  that  the  back  may  be  quite  flat,  resting  on  the  plate  placed  below. 
A  series  of  small  cushions  filled  with  cotton-wool  and  of  graduated  size  is  inter- 
posed between  the  patient  and  the  compressor,  the  smallest  being  nearest  to  the 
skin.  It  is  possible  by  this  means  to  dislodge  the  greater  part  of  the  intestine 
from  the  front  of  the  kidney,  and  the  compressor  when  applied  firmly  over  the 
cushions  will  reduce  the  amount  of  tissue  to  be  traversed  by  the  rays  to  a 
minimum.  At  the  same  time  the  pressure  fixes  the  kidney  and  allows  an  accurate 
outline  of  it  to  be  obtained.  If  this  is  carefully  and  slowly  done,  the  incon- 
venience caused  to  the  patient  is  comparatively  slight.  The  plate  should  include 
not  only  the  renal,  but  also  a  good  part  of  the  upper  ureteral  region.  For  the 
lower  ureteral  or  vesical  region  the  patient  is  laid  flat  on  the  back,  and  the  com- 
pressor applied  over  the  cushions  arranged  centrally.  The  tube  should  be 
capable  of  being  moved  laterally  within  the  screen-compressor  without  moving 
it,  so  that  stereoscopic  skiagrams  can  be  taken  without  moving  the  position  of  the 
patient  or  of  the  compressor. 

The  preparation  of  the  patient  for  the.  examination  is  of  great  importance, 
especially  in  one  of  heavy  build.  The  intestine  must  be  empty  in  order  to  get 
good  results,  and  the  patient  should,  if  possible,  be  kept  on  light  diet  for  some 
time  previously.  A  course  of  purgation  for  three  or  four  days,  followed  by  a 
long-tube  enema  on  the  morning  of  the  examination  before  the  patient  has  had 
any  food,  is  the  ideal  preparation. 

It  is  a  good  rule  to  follow  that  a  second  confirmatory  examination  should  be 
made  after  an  interval  of  two  or  three  days  in  all  cases  where  the  diagnosis  has 
not  been  established  beyond  all  shadow  of  doubt.  If  a  small  stone  has  been 
located  in  the  kidney,  and  operation  has  for  some  reason  or  other  been  deferred, 
it  is  always  advisable  that  a  confirmatory  skiagram  be  taken  immediately  before 
the  operation.  Cases  have  been  known  where  a  stone  had,  during  an  interval, 
shifted  its  position  from  the  kidney  to  within  an  inch  or  two  of  the  lower  end  of 
the  ureter  without  any  symptom  which  could  suggest  the  change  of  position. 

In  cases  where  operation  is  to  be  undertaken  for  a  small  single  stone,  or  for 
multiple  stones,  it  has  been  found  useful  to  have  the  apparatus  ready  at  the 
operation  so  as  to  examine  the  kidney  after  it  has  been  withdrawn  from  the  body 
with  a  sterilizable  cryptoscope.  A  small  calculus  can  then  be  located  before  the 
renal  incision  is  made,  and  it  is  possible  to  extract  it  with  less  damage  to  the 
kidney  substance  ;  it  is  also  valuable  in  multiple  stones  to  determine  that  all 
have  been  removed. 

Treatment. — In  the  early  stages  treatment  is  directed  to  the  cure 
of  lithiasis  (see  p.  1229).  The  patient's  diet  and  general  habits  of 
life  must  be  suitably  regulated,  and  he  is  instructed  to  make  use  of 
alkaline  waters,  such  as  those  derived  from  Contrexeville  or  Vichy, 
or  citrate  of  lithia  and  sulphate  of  soda  may  be  administered  in  a 
mixture.  Plenty  of  bland  fluid  should  be  ordered,  such  as  boiled  or 
distilled  water,  in  the  hope  of  softening  the  stone  or  assisting  its 
onward  passage  to  the  bladder.  Sometimes  it  may  become  encysted, 
if  the  patient  is  kept  absolutely  at  rest ;  the  symptoms  will  then 
gradually  ameliorate,  and  finally  disappear. 

Attacks  of  renal  colic  are  treated  by  the  use  of  hot  hip-baths, 
warm  drinks,  and  hypodermic  injections  of  morphia ;  in  the  more 
severe  cases  chloroform  must  be  administered. 

In  former  days,  when  the  presence  of  a  calculus  could  only  be  sus- 
pected from  the  history  or  symptoms,  the  question  of  operation  and 
when  to  undertake  it  was  a  subject  of  much  discussion.  Even  at 
that  time  Sir  Henry  Morris  wrote  that  an  '  unsuspected  renal 
calculus  is  a  source  of  very  real  danger  ;  and  when  its  presence  is 


I204  A  MANUAL  OF  SURGERY 

disclosed,  whether  by  accident  or  by  the  systematic  examination  of 
the  urine,  we  should  recommend  its  immediate  removal,  regardless 
of  the  fact  that  it  is  not  causing  pain,  unless  the  general  condition 
of  the  patient  contra-indicates  an  operation.'  At  the  present  day, 
when  radiography  has  placed  in  our  hands  a  means  of  almost  certain 
diagnosis,  the  same  advice  holds  good — whenever  a  stone  is  found, 
remove  it,  unless  special  contra-indications  exist.  Especially  is  this 
the  case  when  a  considerable  amount  of  blood  or  pus  is  being  passed 
in  the  urine,  and  the  patient's  temperature  is  raised.  Pain  in  both 
kidneys  is  no  contra-indication  to  operation,  since  there  is  no  objec- 
tion to  exposing  and  even  removing  calculi  from  both  organs.  The 
constant  passage  of  gravel,  moreover,  need  not  deter  one  from 
operating,  since  when  once  the  kidney  has  been  relieved  by  removal 
of  the  larger  masses,  the  tendency  to  recurrence  may  be  checked  by 
suitable  diet  or  drugs. 

Nephro- lithotomy  is  always  undertaken  through  the  loin.  When 
exposed,  the  kidney  is  carefully  freed  from  its  connections,  and  drawn 
up  into  the  wound  ;  in  the  majority  of  patients  it  can  be  brought  out 
on  the  loin,  and  this  is  certainly  a  desirable  manoeuvre.  The  whole 
gland  is  then  carefully  palpated,  as  also  the  pelvis  and  upper  part  of 
the  ureter,  so  as  to  locate,  if  possible,  the  stone.  X-rays  may  assist 
in  this  location,  as  already  indicated.  Should  it  be  distinctly  felt 
within  the  kidney  substance,  an  incision  is  made  over  it  through 
the  renal  parenchyma  ;  free  haemorrhage  follows,  but  this  is  readily 
controlled  by  inserting  the  finger  into  the  wound,  or  by  grasping  the 
vessels  in  the  hilum.  Should  the  stone  not  be  palpable,  an  incision 
is  made  through  the  convex  border  of  the  kidney  substance,  a  little 
posterior  to  the  mesial  plane  of  the  organ  and  at  the  junction  of  its 
inferior  and  middle  thirds.  One  of  the  lower  calyces  is  opened  by 
this  means,  and  the  interior  of  the  pelvis  is  carefully  and  fully  ex- 
plored by  finger  and  probe.  Sometimes  the  incision  in  the  kidney 
has  to  be  considerably  enlarged  and  the  discovery  of  a  small  calculus 
may  be  a  task  of  some  difficulty.  When  the  pelvis  is  much  dis- 
tended and  the  patient  has  previously  passed  a  good  deal  of  pus, 
extra  precautions  must  oe  taken  to  protect  the  surrounding  tissues 
from  infection.  Sterile  gauze  is  packed  into  the  angles  of  the  wound, 
and  the  assistant  must  press  up  the  abdominal  wall.  The  incision 
is  usually  made  through  the  cortex  in  preference  to  opening  directly 
into  the  pelvis ;  but  the  objection  often  stated  that  a  pelvic  incision 
heals  with  difficulty,  and  is  liable  to  leave  a  fistula,  is  not  true,  and 
some  surgeons  deliberately  open  the  pelvis  in  order  to  extract  stones. 
Careful  suturing  with  catgut  is  generally  successful  in  securing 
immediate  healing.  Stones  are  removed  by  dressing- forceps  or 
scoop,  and  care  must  be  exercised  to  prevent  any  from  falling  back- 
wards into  the  ureter.  Large  branched  calculi  are  often  held  very 
tightly,  and  require  an  extensive  incision  and  careful  peeling  off  of 
the  kidney  substance.  The  pelvic  cavity  need  not  be  irrigated . 
under  ordinary  circumstances,  but  when  dilated  and  suppurating  it 
is  well  to  do  so  with  a  hot  solution  of  sublimate  or  of  Condy's  fluid. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1205 

Before  closing  the  wound  in  the  kidney  the  ureter  should  be  care- 
fully examined  ;  it  is  sometimes  possible  to  introduce  a  ureteral 
sound  through  the  open  wound,  but  this  is  by  no  means  easy,  and  it 
is  often  wiser  to  make  a  tiny  opening  through  the  pelvic  infundib- 
ulum,  through  which  the  sound  is  passed,  and  which  is  subse- 
quently closed  by  a  Lembert's  suture.  Bleeding  is  usually  controlled 
without  difficulty  by  stitches  passed  through  the  kidney  substance, 
to  which  in  bad  cases  may  be  superadded  pressure  by  sponge  or 
a  gauze  plug  in  the  wound.  It  is  useless  to  attempt  to  place  a 
ligature  on  a  vessel  divided  in  the  renal  parenchyma.  Should 
bleeding  persist,  sutures  of  the  mattress  type  should  be  introduced 
and  tied  firmly.  It  is  often  wise  to  insert  a  drainage-tube  down  to 
the  sutured  wound  in  the  kidney,  after  it  has  been  replaced.  The 
abdominal  parietes  may  then  be  closed  in  the  usual  way. 

A  ureteral  calculus  may  be  reached  by  prolonging  the  lumbar 
incision  downwards  and  forwards  in  a  direction  parallel  with  Pou- 
part's  ligament  towards  the  inguinal  canal  (the  lumbo-ilio-inguinal 
incision  of  Sir  Henry  Morris).  The  peritoneum  and  its  contents  are 
pushed  bodily  inwards,  and  the  ureter  attached  to  the  posterior 
peritoneal  wall  can  be  followed  down  to  within  a  few  inches  of  the 
bladder.  A  stone  is  removed  through  a  longitudinal  incision,  which 
is  subsequently  closed  by  Lembert's  stitches.  When  there  is  much 
pus  behind  the  stone  in  the  dilated  ureter  and  pelvis  of  the  kidney, 
it  may  be  wise  to  pass  a  drainage-tube  up  the  ureter,  and  make  a 
urinary  fistula  for  a  time  ;  healing  usually  occurs  without  much  diffi- 
culty after  a  few  weeks.  A  calculus  impacted  close  to  the  bladder 
has  been  removed  through  the  rectum  or  vagina,  or  by  a  trans-sacral 
operation. 

When  the  kidney  is  totally  disorganized,  nephrectomy  may  be  re- 
quired, but  such  treatment  is  not  always  advisable,  especially  when 
sinuses  have  resulted  from  a  suppurative  perinephritis.  In  such 
cases  the  renal  tissue  has  often  entirely  disappeared,  and  disintegrating 
calculous  material  may  occupy  the  pelvis,  which  is  surrounded  by  a 
mass  of  dense  fibro-cicatricial  tissue,  the  removal  of  which  is  imprac- 
ticable and  even  dangerous.  All  that  should  be  attempted  locally  is 
the  extraction  of  the  stone  and  the  purification  of  the  cavity.  If  the 
inconvenience  arising  from  the  discharge  of  pus  and  perhaps  urine 
in  the  loin  is  too  great,  it  may  be  possible  to  check  it  in  large  mea- 
sure by  the  plan  suggested  and  practised  by  Major  Holt,  D.S.O., 
viz.,  ligature  of  the  renal  artery.* 

Tumours  of  the  Kidney. — The  different  forms  of  tumour  which 
originate  in  the  kidney  may  be  classified  as  the  simple  and  the  malig- 
nant. Several  cystic  conditions  also  occur.  The  general  features 
of  an  enlarged  kidney  have  been  already  described  (p.  11 77). 

The  Simple  tumours  of  the  kidney  are  : 

I.  Diffuse  Cystic  Disease  (or,  as  it  has  been  termed,  adenoma  of  the 
kidney),  which  may  be  congenital  or  acquired.  It  is  not  unfre- 
quently  bilateral,  especially  when  congenital.  The  kidney  is  enlarged 
*  Trans.  Royal  Med.-Chir.  Soc,  1907. 


1206 


A  MANUAL  OF  SURGERY 


and  occupied  by  cysts,  varying  in  size,  but  rarely  exceeding  that  of  a 
cherry ;  they  are  hned  with  epithehum,  which  is  generally  flattened, 
and  filled  with  a  limpid  fluid  containing  urea  and  perhaps  cholesterine. 
The  cysts  are  often  very  numerous,  and  may  project  from  the  surface 
of  the  kidney  as  nodular  elastic  outgrowths. 

The  pelvis  remains  unaffected  until  the  later  stages  of  the 
disease  (Fig.  514).  Generally  the  whole  kidney  is  involved,  and 
may  attain  enormous  dimensions,  constituting  large  swellings  which 
can  be  easily  felt,  and  with  a  distinctly  nodulated  surface  ;  occasion- 
ally the  growth  is  limited  to  one  portion  of  the  organ.  The  origin  of 
this  condition  is  uncertain,  but  it  is  supposed  to  be  due  to  the 
persistence  of  the  mesonephros  (or  Wolffian  body)  in  the  substance 
of  the  true  kidney  (or  metanephros),  and  its  development  into  cysts. 

In  the  early  stages  no  symptoms 
are  produced,  except,  perhaps, 
a  sense  of  dragging  weight  in 
the  loins  from  the  size  of  the 
tumours  ;  but  later  on  the  secre- 
tion of  urine  is  interfered  with 
to  such  an  extent  as  to  produce 
uraemia.  The  tendency  of  this 
affection  to  affect  both  kidneys 
prevents  any  hope  of  benefit 
from  operation. 

2.  Papilloma  of  the  renal  pelvis 
is  a  rare  condition,  characterized 
by  the  development  within  its 
cavity  of  a  villous  mass,  identical 
in  structure  with  that  met  with 
in  the  bladder.  It  has  usually 
been  observed  in  elderly  people, 
and  the  chief,  if  not  the  only, 
symptom  is  excessive  haema- 
turia.  It  cannot  be  diagnosed 
with  certainty,  but  if  discovered  in  an  exploratory  operation,  it  can  be 
removed  with  success. 

Malignant  tumours  of  the  kidney  may  be  divided  into : 
I.  The  Sarcomata  of  Infants,  which  are  often  congenital,  but  may 
be  acquired  within  the  first  few  years  of  life.  They  are  encapsuled, 
the  kidney  substance  being  spread  over  them,  and  consist  of  round 
or  spindle  cells,  the  latter  often  showing  a  cross-striation,  resembling 
that  of  muscular  fibres  (myo-sarcomata).  They  grow  to  a  great  size, 
and  may  affect  both  organs,  but  pain  and  hsematuria  are  absent. 
Death  results  from  general  dissemination  or  from  exhaustion,  or  may 
follow  mechanical  obstruction  to  the  circulation,  as  by  the  detachment 
of  a  sarcomatous  embolus,  which  travels  upwards  and  blocks  the 
pulmonary  vessels.  Treatment  by  nephrectomy  has  given  most 
unsatisfactory  results,  the  operative  mortality  having  been  high  and 
recurrence  almost  invariable  within  a  short  period.     The  operation 


Fig.  514.  — Cystic  Disease  of  Kidney. 
(King's  College  Hospital  Museum.) 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS  1207 

itself  is  not  particularly  difficult,  but  a  large  incision  is  required,  and 
care  must  be  taken  to  avoid  displaced  structures,  such  as  the  inferior 
vena  cava.    When  both  kidneys  are  affected,  nothing  can  be  done. 

2.  The  Sarcomata  of  Adults  occur  between  the  thirtieth  and  fiftieth 
years  of  life,  and  are  of  the  spindle-celled  variety,  often  originating 
from  the  capsule.  Only  one  kidney  is  generally  involved,  giving  rise 
to  a  rapidly-growing  swelling,  associated  with  pain  and  haematuria. 
Calculi  are  often  found  in  the  pelvis  of  such  organs,  and  may  be 
causative  or  consecutive.  Secondary  deposits  form  in  the  viscera ; 
extension  through  and  beyond  the  capsule  is  not  uncommon,  and 
death  is  usually  due  to  exhaustion.  The  results  of  nephrectomy 
have  not  been  very  encouraging. 

3.  Carcinoma  is  an  uncommon  form  of  tumour  in  the  kidney,  and 
may  be  primary  or  secondary.  It  presents  the  same  clinical  features 
as  a  sarcoma,  and  can  only  be  recognised  on  microscopic  examina- 
tion. One  symptom,  however,  requires  special  mention,  since  it  is 
extremely  suggestive  of  the  presence  of  cancer,  viz.,  the  development 
of  a  varicocele.  It  is  due  to  the  pressure  of  enlarged  and  cancerous 
lymphatic  glands  upon  the  root  of  the  spermatic  vein,  and  hence, 
whenever  an  elderly  person  develops  a  varicocele,  a  careful  examina- 
tion of  the  kidney  on  the  affected  side  should  always  be  instituted. 

4.  Occasionally  tumours  of  a  considerable  size  are  found  growing 
from  the  kidney,  under  the  liver,  or  on  the  spermatic  cord,  similar  in 
structure  to  the  zona  fasciculata  of  the  adrenal  bodies.  They  are 
looked  on  as  adenomata  growing  from  accessory  and  misplaced 
adrenals  (adrenal  rests) ;  the  renal  parenchyma  is  normal  in  texture, 
though  it  may  be  stretched  over  the  new  growth.  Sometimes  they 
take  on  malignant  characters,  and  develop  as  sarcomata  or  carcinomata, 
and  are  then  known  as  hypernephfomata.  They  grow  rapidly,  and 
at  times  it  is  difficult  to  determine  their  site  of  origin. 

Various  Cystic  Conditions  of  the  kidney  must  be  noted  in  addition 
to  the  general  cystic  disease,  already  described. 

{a)  Hydatid  Disease  affects  the  kidney,  as  it  may  involve  any  other 
organ  in  the  body.  It  starts  either  beneath  the  capsule  or  in  the 
glandular  substance ;  in  the  former  case  it  is  likely  to  form  a  rounded 
projection,  which  may  be  detected  on  palpation  of  the  loin  ;  in  the 
latter  it  expands,  or  even  destroys,  the  whole  of  the  glandular  tissue, 
and  may  burst  into  the  renal  pelvis,  the  cysts  being  passed  along  the 
ureter,  accompanied  by  more  or  less  colic.  Suppuration  may  com- 
plicate matters,  but,  unless  the  cyst  has  ruptured  into  the  renal 
pelvis,  diagnosis  is  scarcely  feasible  apart  from  an  exploratory 
incision. 

Treatment  consists  in  cutting  down  on  the  kidney,  and  enucleating 
the  mass,  if  possible.  Failing  this,  drainage  may  be  undertaken,  but 
in  bad  cases  nephrectomy  is  necessary. 

(h)  Dermoid  Cysts  have  also  been  found. 

{c)  Serous  Cysts  are  occasionally  met  wdth,  arising  possibly  as  a 
result  of  obstruction  to  some  of  the  ducts,  or  due  to  lymphatic 
obstruction.     Rounded  swellings,  simple  or  multiple,  are  produced, 


i2o8  A  MANUAL  OF  SURGERY 

growing  outwards  from  the  cortex,  and  containing  a  thin  fluid  with 
a  small  amount  of  albumen  and  saline  substances  in  solution. 
They  give  rise  to  no  symptoms  except  from  their  size,  and  rarely 
require  treatment  other  than  simple  aspiration  or  drainage.  If  dis- 
covered at  an  operation,  and  of  considerable  size,  they  should  be 
incised,  and  either  dissected  out,  or  the  outer  wall  cut  away,  and  the 
inner  left  continuous  with  the  renal  capsule. 

(d)  Not  unfrequently  a  number  of  small  cysts  develop  in  con- 
nection with  chronic  granular  nephritis,  but  they  are  of  no  clinical 
importance. 

Nephrectomy,  or  total  removal  of  the  kidney,  is  performed  for  the 
following  conditions :  (a)  For  tuberculous  disease,  when  conservative 
measures  have  failed  or  are  impracticable,  or  when  the  pelvis  and 
ureter  are  extensively  involved ;  (b)  for  calculous  pyonephrosis,  when 
the  renal  parenchyma  is  disintegrated  ;  (c)  for  hydronephrosis,  when 
palliative  measures  or  drainage  have  failed  to  give  relief;  (d)  for 
malignant  disease  ;  (e)  for  traumatic  lesions,  such  as  disintegration 
or  rupture,  especially  if  complicated  by  laceration  of  the  peritoneum  ; 
and  (/)  for  some  cases  of  ruptured  ureter. 

Before  undertaking  the  excision  of  any  kidney,  however  diseased, 
it  is  essential  that  the  surgeon  should  satisfy  himself  as  to  the  exist- 
ence of  another,  and  also,  if  possible,  ascertain  that  it  is  capable  of 
undertaking  the  increased  duties  which  will  subsequently  fall  upon 
it.  Many  different  plans  of  doing  this  have  been  already  alluded  to 
(p.  1 1 77). 

Nephrectomy  may  be  undertaken  through  the  abdomen  or  through 
the  loin ;  but  sundry  combinations  or  modifications  of  these  opera- 
tions have  been  recommended  by  various  authorities. 

The  Abdominal  Operation  is  chiefly  utilized  when  the  organ  is  much 
enlarged,  on  account  of  the  readier  access  obtained,  especially  to  the 
pedicle.  The  peritoneum  is  likely  to  be  opened,  and  may  be  exposed 
to  septic  contamination,  when  the  pelvis  and  the  upper  part  of  the 
ureter  are  distended  with  decomposing  pus,  as  is  frequently  the  case  ; 
but  this  is  easily  prevented.  Drainage  is  obtained  for  the  cavity  left 
after  the  removal  of  the  organ  by  a  counter-opening  made  through  the 
loin.  One  great  advantage,  as  before  stated,  is  that  the  other  kidney 
can  be  first  examined,  if  required,  and  its  condition  ascertained. 
As  to  the  technique  :  there  is  frequently  no  necessity  to  open  the  peri- 
toneal cavity,  since  the  kidney  is  almost  always  enlarged,  but  an 
opening  is  often  made,  intentionally  or  accidentally.  The  colon  and 
peritoneum  are  peeled  ofT  the  organ  and  displaced  inwards ;  it  is  then 
freed  from  its  adhesion  to  surrounding  tissues,  the  surgeon  endeavour- 
ing to  keep  outside  its  true  capsule,  but  inside  the  layer  of  condensed 
perinephric  tissue.  Special  precautions  must  be  adopted  in  dealing 
with  the  deep  aspect  of  the  tumour,  particularly  on  the  right  side, 
where  it  is  occasionally  adherent  to  the  inferior  vena  cava.  The 
mass  is  now  lifted  from  its  bed,  and  its  pedicle,  consisting  of  the 
ureter  and  renal  vessels,  isolated.  These  latter  are  secured  separately 
by  ligature  and  divided,  a  clamp  being  applied  to  the  distal  ends. 


^Vrgical  affections  of  the  kidneys  1209 

The  ureter  is  dealt  with  in  the  same  way,  small  pieces  of  gauze 
being  packed  round  so  as  to  receive  any  secretion  which  may  escape ; 
the  exposed  mucous  membrane  in  the  portion  which  is  left  is  care- 
fully touched  over  with  pure  carbolic  acid.  The  kidney  thus  freed  is 
removed,  and  the  wound  in  the  abdominal  parietes  closed  in  the  usual 
way,  provision  for  drainage  having  been  previously  made  either 
through  the  loin  or  from  the  front.  Considerable  shock  is  often  ex- 
perienced from  this  operation,  and  the  death-rate  is  somewhat  high. 

Occasionally  the  perinephric  adhesions  are  so  firm  and  extensive 
that  the  only  practicable  plan  of  removing  the  organ  is  to  enucleate 
it  from  within  the  capsule  as  far  as  the  hilum ;  the  capsule  is  then 
torn  or  cut  through  so  as  to  expose  the  pelvis  and  renal  vessels, 
which  are  secured. 

The  Lumbar  Method  can  be  employed  when  the  kidney  is  not  too 
greatly  enlarged.  The  organ  is  exposed  by  the  incision  already 
described,  enucleated  from  its  surroundings,  and  the  pedicle  dealt 
with  as  in  the  abdominal  operation.  If  the  condition  of  the  opposite 
organ  has  not  previously  been  ascertained,  the  peritoneum  should  be 
incised  at  the  outer  margin  of  the  wound,  so  as  to  enable  the  hand  to 
be  inserted  across  the  middle  line,  and  thus  allow  an  exploration 
of  the  opposite  loin. 

Should  it  be  desirable  to  include  the  ureter  in  the  scope  of  the 
operation,  the  incision  may  be  prolonged  into  the  groin  in  the 
direction  of  the  fibres  of  the  external  oblique,  and  the  peritoneum 
and  its  contents  pushed  forwards ;  by  this  means  it  can  be  traced 
down  almost  to  the  bladder. 


CHAPTER  XXXIX. 
BLADDER  AND  PROSTATE. 

Methods  of  Examining  tlie  Bladder. 

When  a  patient  presents  himself  complaining  of  increased  fre- 
quency of  micturition  and  other  evidences  suggestive  of  chronic 
disease  of  the  bladder,  a  systematic  examination  of  the  individual 
and  his  urinary  passages  must  always  be  instituted.  The  history  of 
the  case,  the  character  of  the  symptoms,  and  the  condition  of  the 
urine,  are  carefully  gone  into.  An  examination  of  the  bladder  should 
then  be  made,  (i)  The  patient  is  laid  on  a  couch,  and  the  lower 
part  of  the  abdomen  uncovered.  The  hypogastrium  is  then  examined 
by  inspection,  palpation,  and  percussion,  so  as  to  ascertain  whether 
or  not  the  bladder  is  distended,  or  if  any  abnormal  resistance  can  be 
felt,  either  from  thickening  of  the  wall  or  the  presence  of  a  tumour. 
(2)  A  sound  is  then  passed  according  to  the  method  described  at 
p.  1239,  and  the  interior  of  the  viscus  explored;  by  this  means  a 
calculus  may  be  detected,  and  even  sometimes  a  tumour,  as  also  a 
rough  and  irregular  condition  of  the  mucous  membrane.  (3)  The 
finger  is  inserted  into  the  rectum,  or,  in  the  female,  into  the  vagina, 
before  the  sound  is  withdrawn,  so  as  to  enable  the  condition  of  the 
posterior  vesical  wall  to  be  investigated  between  the  point  of  the 
finger  and  the  sound.  Enlargement  of  the  prostate  or  of  the  vesiculae 
seminales  can  also  be  detected  in  this  way.  (4)  The  patient  may 
then  be  asked  to  void  urine,  after  which  a  rubber  catheter  may  be 
introduced,  and  the  amount,  if  any,  of  residual  urine  estimated. 
(5)  As  mentioned  elsewhere,  Bigelow's  evacuator  is  useful,  not  only 
to  wash  out  the  bladder,  but  also  to  detect  the  presence  of  very  small 
calculi  which  the  sound  may  have  missed.  (6)  Of  recent  years  a 
new  means  of  examining  the  interior  of  the  bladder  has  been  intro- 
duced in  the  shape  of  the  cystoscopy  (Fig.  515).  This  consists  of  a 
straight  tube  with  a  short  end  bent  at  an  angle,  in  which  an  electric 
lamp  is  placed,  the  wires  leading  to  it  being  carried  within  the  tube. 
A  small  window  covered  with  glass  is  situated  close  to  the  angle, 
and  a  prism  is  here  inserted  in  such  a  manner  that,  when  the  surgeon 
looks  through  an  eyepiece  placed  at  the  end  of  the  instrument,  he  is 
able  to  see  the  portion  of  the  vesical  wall  illuminated  by  the  electric 
lamp.  To  use  it  the  bladder  must  be  previously  washed  out,  if 
necessary,  and  the  patient  anaesthetized.     About  six  ounces  of  boric 


BLADDER  AND  PROSTATE  T211 

acid  lotion  should  be  present  in  the  bladder,  so  as  to  prevent  the 
vesical  wall  from  being  injured  by  the  instrument,  which  always 
becomes  hot  after  the  lamp  has  been  used  for  some  time.  Different 
ends  are  supplied  to  enable  the  anterior  and  posterior  walls  to  be 
examined.  Considerable  practice  is  needed  for  any  useful  informa- 
tion to  be  gained  by  the  aid  of  this  instrument,  but  in  skilled  hands 
much  may  be  learnt  as  to  the  condition  of  the  mucous  membrane. 
(7)  Finally,  in  cases  where  great  irritability  of  the  bladder  exists 
in  spite  of  treatment,  and  its  presence  cannot  be  explained,  an 
exploratory  cystotomy,  either  suprapubic  or  perineal,  is  justifiable. 

A  distended  bladder  constitutes  a  rounded  swelling,  which  projects 
above  the  symphysis  pubis,  and  may  even  reach  to  the  umbilicus  in 
some  cases.  The  swelling  may  be  visible  to  the  naked  eye,  and  is 
dull  on  percussion,  the  dulness  rising  directly  above  the  symphysis ; 


Fig.  515. — Leiter's  Electric  Cystoscope.     (Tillmanns  ) 

a.  Electric  lamp  in  beak  ;  b,  glass  window  for  illumination  purposes  ; 
c  d,  switch  for  opening  or  closing  current. 

it  is  quite  immoveable,  and  therein  differs  from  many  ovarian  and 
uterine  tumours.  Bimanual  examination  per  vaginam  or  per  rectum 
should  at  once  indicate  its  nature  ;  and  when  at  all  doubtful,  a  catheter 
should  be  introduced. 

Congenital  Affections  of  the  Bladder. — i.  Ectopia  Vesicse,  or  Extroversion  of  the 
Bladder,  is  the  term  employed  to  denote  total  absence  of  the  anterior  wall  of  the 
bladder  and  of  the  lower  portion  of  the  abdominal  parietes,  as  a  result  of  which 
the  mucous  membrane  of  the  posterior  vesical  wall  is  exposed  and  rendered 
somewhat  prominent  by  the  pressure  from  behind  of  the  abdominal  con- 
tents (Fig.  516,  i).  This  surface  is  usually  not  much  more  than  an  inch 
in  diameter  in  an  infant,  and  is  often  irregular,  and  covered  with  papilliform 
processes  ;  the  orifices  of  the  ureters  are  easily  recognised  below,  urine  being 
occasionally  emitted  from  them  in  forcible  jets.  The  condition  is  necessarily 
one  of  the  greatest  discomfort,  not  only  from  the  constant  dribbling  of  urine 
causing  excoriation  and  eczema  of  the  thighs  and  surrounding  parts,  but  also 
from  the  pain  and  irritation  due  to  friction  of  the  clothes  against  the  exposed 
mucous  membrane.  The  symphysis  pubis  is  alvvays  absent,  and  the  horizontal 
ramus  of  the  pubic  arch  terminates  on  either  side  in  the  inguinal  region  (4). 
The  innominate  bones  are  usually  rotated  outwards,  and  the  sacrum  is  convex 
anteriorly  from  side  to  side  instead  of  being  concave.  In  consequence  of  this 
pelvic  malformation,  the  patient's  gait  and  powers  of  progression  are  con- 
siderably impaired.  The  penis  (2)  is  cleft,  and  in  a  condition  of  complete  epi- 
spadias ;  it  is  drawn  upwards  and  backwards  over  the  trigone,  so  that  it  requires 
pulling  down  to  expose  the  ureteral  orifices.  The  testes  are  often  found  in  the 
inguinal  canal,  or,  if  in  the  scrotum,  are  accompanied  by  congenital  hernias. 
No  umbilicus  is  present.  The  condition  is  due  to  impaired  development  of 
the  anterior  wall  of   the   allantois  and    the   lower   segment  of  the   abdominal 


taii  A  MANUAL  OF  SURGERY 

parietes.  At  birth  the  lower  portion  of  the  umbilical  cord  is  expanded  over 
the  raw  surface,  constituting  the  anterior  vesical  wall.  When  the  cord  separates, 
the  posterior  vesical  wall  is  necessarily  exposed. 

The  Treatment  of  this  distressing  malformation  is  most  unsatisfactory,  and 
hence  in  the  majority  of  the  cases  the  application  of  a  urinal  has  been  recom- 
mended, although  the  instruments  hitherto  devised  are  not  particularly  efficient. 
Various  operative  measures  have  also  been  practised,  [a)  Trendelenburg's  operation 
consists  in  division  of  the  sacro-iliac  ligaments  from  behind  so  as  to  enable  the 
lateral  halves  of  the  pelvis  to  be  compressed  together.  By  this  means  the 
posterior  vesical  wall  is  thrown  backwards  and  its  tendency  to  protrude  lessened. 
The  wounds  are  allowed  to  granulate,  and,  if  successful,  the  bladder  wall  finally 
lies  at  the  bottom  of  the  sulcus,  which  can  usually  be  covered  over  by  a  plastic 
operation  without  much  difficulty.  The  main  objections  to  this  method  are  that 
it  involves  a  very  severe  operation,  and  also  leads  to  a  further  weakening  of  the 
pelvic  arch,  the  integrity  of  which  is  already  much  impaired  by  the  absence 


Fig.  516. — Ectopia  Vesica. 

I.  Exposed  mucous  membrane  of  posterior  wall  of  bladder  ;  2,  glans  penis  drawn 
up  to  cover  lower  part  of  vesical  mucosa  and  orifices  of  the  ureters ;  3,  scrotum  ; 
4,  projection  of  pubic  ramus. 

of  the  pubic  symphysis,  {b)  Plastic  operations  without  interfering  with  the 
pelvis  were  introduced  and  practised  by  the  late  Professor  John  Wood,  Thiersch, 
and  others.  For  full  details,  we  must  refer  to  larger  text-books.  Suffice  it  here 
to  state  that  a  skin  flap  is  turned  down  from  the  anterior  abdominal  wall  above 
the  breach  of  surface,  and  sutured  on  either  side  to  the  margins  of  the  defect. 
The  cutaneous  surface  of  this  flap  constitutes  the  anterior  wall  of  the  newly- 
formed  bladder,  if  such  it  can  be  called,  whilst  its  raw  outer  surface  is  covered  in 
either  by  flaps  derived  from  either  side,  or  by  undercutting  the  neighbouring 
skin  and  sliding  it  upwards  to  the  middle  line,  where  it  is  united  by  sutures, 
as  suggested  and  successfully  carried  out  by  Mr.  Boyce  Barrow.  The  after- 
treatment  is  always  prolonged  and  tedious,  and  the  patients  are  likely  to  ex- 
perience much  subsequent  inconvenience  owing  to  the  growth  from  the  under 
surface  of  the  abdominal  iiap  of  hairs,  which  become  encrusted  with  phosphates. 
{c)  More  recently  various  methods  of  implanting  the  ureters  into  the  rectum 
have  been  practised,  and  it  is  claimed  that  the  urine  is  easily  retained  for  some 


BLADDER  AND  PROSTATE  1213 

hours,  and  voided  independently  of  the  faeces.     This  is  much  the  best  procedure, 
although  the  patient  runs  the  risk  of  an  ascending  infection  of  his  urinary  track^ 

2.  An  Umbilical  Urinary  Fistula  is  sometimes  met  with  as  a  result  of  imperfect 
closure  of  the  urachus. 

3.  Occasionally  in  cases  of  malformation  of  the  rectum  the  Primitive  Cloacal 
Condition  may  in  part  persist  (see  p.  1147). 

Traumatic  Affections  of  the  Bladder. — Rupture  may  be  produced 
in  several  ways:  (i)  It  may  be  due  to  direct  violence  applied  to  the 
lower  part  of  the  abdomen,  especially  when  the  viscus  is  distended. 
(2)  It  may  complicate  a  fracture  of  the  pelvis,  either  as  a  direct 
result  of  the  violence,  or  from  penetration  of  a  spicule  of  bone  from 
the  OS  pubis.  (3)  The  bladder  may  be  opened  by  a  penetrating 
wound.  (4)  Apart  from  traumatic  lesions,  rupture  may  occur  from 
simple  over-distension,  especially  if  destructive  ulceration  of  its  walls 
is  present ;  or  it  may  follow  ulceration  of  a  saccule  if  it  contains  a 
phosphatic  concretion. 

Rupture  of  the  bladder  is  divided  into  two  main  classes,  according 
to  whether  or  not  the  peritoneal  cavity  is  opened.  The  peritoneum 
covers  the  upper  and  back  part  of  the  viscus,  being  reflected 
anteriorly  along  the  urachus,  laterally  along  the  obliterated  hypo- 
gastric arteries,  and  posteriorly  on  to  the  rectum. 

Intraperitoneal  Rupture  involves  the  posterior  or  superior  portions 
of  the  viscus,  and  is  the  variety  most  frequently  met  with.  The 
symptoms  produced  are  severe  shock,  associated  with  hypogastric 
pain  of  a  burning  nature.  The  patient  experiences  a  constant 
desire  to  micturate,  but,  as  a  rule,  nothing  is  passed,  except  perhaps 
a  little  blood.  Peritonitis  soon  follows,  running  a  rapidly  fatal 
course,  especially  if  efficient  treatment  is  not  adopted.  On  passing 
a  catheter  the  bladder  is  usually  found  empty,  or  possibly  a  little 
blood-stained  urine  may  be  withdrawn ;  if,  however,  the  instrument 
happens  to  be  insinuated  through  the  rupture  into  the  peritoneal 
cavity,  a  considerable  quantity  of  blood-stained  urine  can  be  drawn 
off,  and  the  point  of  the  catheter  may  be  felt  under  the  anterior 
abdominal  wall.  A  useful  diagnostic  sign  consists  in  injecting  a 
measured  amount  of  boric  acid  lotion  into  the  bladder,  and  noting 
how  much  of  it  returns;  when  a  rupture  exists,  some  considerable 
discrepancy  will  probably  be  noted  between  the  two  quantities ;  this 
test  cannot,  however,  always  be  relied  on. 

The  Treatment  of  these  cases  consists  in  immediate  laparotomy ; 
the  fluid  within  the  peritoneal  sac  is  removed  by  swabs,  and  the 
wound  in  the  bladder  clearly  demonstrated,  preferably  with  the 
patient  in  the  Trendelenburg  position  (p.  970),  which  must  not, 
however,  be  adopted  until  the  urine  and  inflammatory  effusion  have 
been  removed.  The  rent  is  carefully  closed  by  means  of  a  row  of 
Lembert  sutures,  not  involving  the  mucous  membrane,  which  should 
always  extend  a  little  beyond  each  extremity  of  the  wound.  Possibly 
a  drainage-wick  or  a  Keith's  tube  may  need  to  be  inserted  for  a  few 
hours,  so  as  to  remove  any  exudation.  The  abdominal  wall  is  then 
closed  in  the  usual  way,  and  the  patient  put  back  to  bed.     The 


1 214  A  MANUAL  OF  SURGERY 

urine  is  either  drawn  off  at  regular  intervals,  or  a  catheter  may  be 
tied  in  the  bladder,  the  urine  being  syphoned  by  an  attached  rubber 
tube  into  a  vessel  placed  beneath  the  bed. 

Extraperitoneal  Rupture  of  the  bladder  involves  its  anterior  wall 
or  base.  The  urine  finds  its  way  into  the  pelvic  cellular  tissue,  and 
if  unhealthy  at  once  gives  rise  to  a  most  virulent  form  of  suppurative 
pelvic  cellulitis,  which  is  usually  fatal  from  toxaemia  or  pyaemia. 
Abscesses  generally  point  either  above  the  pelvic  brim  or  in  the 
perineum.  The  treatment  consists  in  free  incisions  through  the 
perineum,  or  above  the  brim  of  the  pehds.  In  the  latter  case  it  may 
be  possible  to  reach  the  rent  in  the  bladder  and  suture  it ;  otherwise 
it  may  be  possible  to  introduce  into  the  bladder  a  large  tube,  through 
which  the  urine  can  escape  freely  for  a  time.  As  soon  as  the  tissues 
are  sealed  off  by  the  development  of  granulations,  the  tube  may  be 
withdrawn.  The  prognosis  largely  depends  on  the  condition  of  the 
urine,  whether  healthy  or  contaminated  with  bacteria,  and  on  the 
length  of  time  it  was  allowed  to  remain  in  contact  with  the  tissues. 

Foreign  Bodies  introduced  into  the  bladder  from  without  are  of 
various  natures,  such  as  portions  of  catheters  or  bougies,  pins,  etc. 
They  give  rise  to  symptoms  of  chronic  cystitis,  and  usually  become 
encased  with  phosphatic  deposit.  They  should  be  removed  as  early 
as  possible  with  a  lithotrite,  but  if  of  large  size  or  thickly  covered 
with  phosphates,  must  be  treated  by  perineal  or  suprapubic  cysto- 
tom5^  In  the  female,  digital  dilatation  of  the  urethra  is  the  best 
means  of  gaining  access  to  the  interior  of  the  viscus. 

Cystitis  may  be  due  to  a  great  variety  of  causes,  but  is  always  in 
essence  of  bacterial  origin.  Many  different  forms  of  bacteria  may 
be  found,  but  those  most  usually  present  are  the  ordinary  pyogenic 
cocci,  especially  the  Staphylococcus  aureus,  which,  together  with  the 
Diplococcus  urece  liquefaciens,  has  the  power  of  decomposing  urea  and 
setting  free  ammonia,  whilst  the  B.  coli  is  also  commonly  found 
in  these  cases.  This  latter  organism  has  no  power  of  rendering  the 
urine  alkaline,  and,  indeed,  develops  badly  in  alkaline  media,  and 
hence  if  present  in  a  pure  infection  the  urine  remains  acid,  though 
stale  and  offensive  to  the  smell.  The  methods  of  invasion  of  the 
bladder  are  diverse  :  (i)  Bacteria  may  reach  the  viscus  from  above, 
either  owing  to  a  suppurative  lesion  of  the  kidney  or  its  pelvis,  or 
escaping  into  the  urine  from  the  blood.  (2)  They  may  travel  up 
the  urethra.  This  is  a  matter  of  no  difficulty  in  the  short  and 
comparatively  large  urethra  of  a  woman,  and  hence  cystitis  is 
frequently  associated  with  vulvitis  or  is  seen  after  labour.  In  girls 
a  pure  bacillary  cystitis  with  acid  urine  is  not  uncommon,  and  is 
probably  secondary  to  a  vulvo-vaginitis,  which  arises  from  con- 
tamination of  the  vulva  with  the  faeces  where  cleanliness  is  neglected. 
In  the  male  sex,  infection  from  the  urethra  is  unusual  unless  urethritis 
has  previously  existed  or  some  irritation,  due  to  the  passage  of 
instruments.  Even  if  they  are  carefully  sterilized,  mucus  is  liable 
to  form  and  cling  about  the  urethral  wall,  and  along  this  bacteria 
can   find  their  way.     Naturally  the   introduction  of  an  unsterilized, 


BLADDER  AND  PROSTATE  1215 

dirty  instrument  may  suffice  to  cause  cystitis.  (3)  Bacteria  can 
invade  the  bladder  from  surrounding  organs,  being  transmitted  by 
lymphatic  dissemination.  Thus  an  injury  of  the  rectum  may  easily 
lead  to  cystitis. 

The  mere  presence  of  bacteria  in  the  bladder  is,  however,  not 
sufficient  as  a  rule  to  determine  an  attack  of  cystitis.  Large  quanti- 
ties of  pus  are  frequently  discharged  from  the  kidney  through  the 
bladder,  and  that  over  lengthy  periods,  and  yet  no  inflammatory 
reaction  follows.  Some  local  predisposing  factor  must  be  added  in 
order  to  excite  their  activity,  and  amongst  the  most  favourable  are 
the  following :  (i.)  Congestion  of  the  mucous  membrane,  determined 
by  exposure  to  cold ;  this  is  peculiarly  liable  to  occur  in  gouty 
individuals,  and,  indeed,  there  are  people  who  *  take  cold '  in  their 
bladders  instead  of  developing  a  nasal  or  bronchial  catarrh, 
(ii.)  Injury,  as  by  the  presence  of  a  foreign  body,  a  calculus,  or 
rough  handling  during  an  operation,  may  serve  to  render  bacteria 
active  and  virulent,  (iii.)  One  of  the  most  important  causes  is 
retention  of  urine,  from  whatever  cause  it  is  due — e.g.,  enlarged 
prostate,  stricture,  etc.  The  bacteria  develop  and  decompose  the 
urine,  rendering  it  offensive  and  ammoniacal,  and  the  toxins  and 
irritating  bodies  thereby  produced  affect  the  vesical  mucosa, 
(iv.)  The  presence  of  irritants  in  the  urine  may  determine  cystitis,  as 
also  pyelitis — e.g.,  after  the  absorption  of  cantharides.  Other  drugs 
may  light  up  bacterial  activity  in  some  predisposed  individuals — e.g., 
copaiba  or  cubebs.  (v.)  Loss  of  nervous  control  is  a  most  important 
predisposing  factor,  and  comes  prominently  into  play  in  spinal 
injuries.  The  greatest  difficulty  is  experienced  in  protecting  such 
patients,  and  even  effective  purification  of  penis,  hands,  and  catheter, 
and  the  application  of  a  sterilized  dressing  to  the  organ  after  the 
catheter  has  been  used,  may  not  suffice  to  prevent  an  outbreak  of 
cystitis,  which  is  due  to  infection  from  the  kidney  or  rectum.  In 
these  patients  the  disease  always  runs  a  virulent  course,  and  is  likely 
to  kill  the  patient  by  extension  up  the  ureter. 

Pathological  Anatomy. — In  acute  cases  the  mucous  membrane  of 
the  bladder  becomes  congested  and  thickened  ;  the  epithelium  is 
shed ;  mucus  is  excreted,  and  is  soon  transformed  into  muco-pus, 
which  may  be  extremely  viscid,  and  develops  in  large  quantities. 
Ulceration  of  the  bladder  wall  may  occur,  or  even  sloughing ;  in  the 
worst  cases  the  whole  of  the  mucous  lining  may  necrose,  and  be 
cast  off  as  a  slough.  Sometimes  a  membranous  form  of  inflamma- 
tion occurs,  the  patient  frequently  passing  flakes  of  some  size,  which 
on  examination  are  found  to  be  chiefly  composed  of  fibrin. 

In  chronic  cases  the  mucous  membrane  is  thickened  and  con- 
gested, the  superficial  veins  dilated  and  even  varicose,  whilst 
ulceration  is  not  uncommon.  The  continued  repetition  of  the  acts 
of  micturition  leads  to  hypertrophy  of  the  bladder  wall,  which 
becomes  thickened  and  fasciculated ;  this  effect  is  of  course  most 
marked  when  the  cystitis  is  associated  with  obstruction  to  the  out- 
flow of   urine.      The    mucous    membrane   may  protrude   outwards 


I2i6  A  MANUAL  OF  SURGERY 

between  the  muscular  fasciculi,  giving  rise  to  pouch-like  saccules,  in 
which  phosphatic  concretions  are  sometimes  formed,  and  the  re- 
tained urine  undergoes  decomposition.  Perforative  ulceration  occa- 
sionally follows,  originating  a  fatal  peritonitis  or  pelvic  cellulitis 
from  extravasation  of  urine.  The  contracted  state  of  the  bladder 
and  the  overgrowth  of  its  muscular  substance  lead  to  compression  of 
the  openings  of  the  ureters,  hydronephrosis  being  thus  induced. 
A  plug  of  viscid  mucus  often  finds  its  way  into  the  ureteral  orifice, 
and  by  becoming  infected  with  bacteria  causes  an  extension  of  the 
infective  mischief  to  the  kidney. 

The  Symptoms  of  Acute  Cystitis  consist  in  pain  referred  to  the 
perineum  and  hypogastrium,  together  with  tenderness  on  pressure 
over  the  symphysis  pubis.  This  is  accompanied  by  extreme  irrita- 
bility of  the  bladder,  frequent  efforts  of  a  painful  and  spasmodic 
nature  being  made  to  pass  water  (strangury)  ;  but  little  urine  is 
voided  at  a  time,  for  as  soon  as  any  amount  has  collected  it  is 
ejected  forcibly.  It  generally  contains  blood  and  pus,  soon  becoming 
alkaline,  and  teeming  with  bacteria.  Some  amount  of  fever  is 
generally  noted,  as  also  vomiting,  whilst  tenesmus  may  be  induced 
as  a  result  of  the  proximity  of  the  rectum  to  the  inflamed  bladder. 
The  usual  termination  of  the  case  is  in  resolution,  but  sometimes 
chronic  irritability  may  persist.  In  rare  instances  the  inflammation 
is  of  such  a  virulent  nature  as  to  cause  death.  The  urine  in  these 
cases  is  often  exceedingly  foul,  and  the  fatal  issue  is  due  to  ex- 
haustion, peritonitis,  suppurative  pyonephrosis,  or  even  acute 
toxaemia.  In  some  patients,  however,  when  the  inflammation  is 
concentrated  at  the  neck  of  the  bladder,  retention,  distension,  and 
atony  may  ensue. 

Treatment. — The  patient  should  be  kept  in  a  warm  atmosphere, 
and  preferably  in  bed,  and  fomentations  applied  to  the  lower  part  of 
the  abdomen  ;  hot  hip-baths  twice  daily,  maintained  for  some  time, 
are  very  advantageous.  The  diet  should  be  restricted  to  fluid,  and 
the  patient  encouraged  to  partake  freely  of  barley-water  and  other 
bland  liquids.  Alkalies  and  henbane  may  be  administered,  and 
morphia  and  belladonna  suppositories  are  useful  to  allay  the  pain  and 
irritability.  As  a  rule,  no  instrument  should  be  passed  during  the 
acute  stage,  unless  retention  is  present;  but  if  the  urine  becomes 
very  foul,  the  bladder  may  be  gently  w^ashed  out,  or  even  drainage  of 
the  bladder  through  the  perineum  may  be  necessary  (see  Perineal 
Cystotomy,  p.  12 18).  Urinary  antiseptics,  such  as  urotropine 
(5  to  ID  grains  three  or  four  times  a  day),  salol  (10  to  20  grains),  and 
boric  acid  (15  to  20  grains),  administered  by  the  mouth,  may  do  good. 

Chronic  Cystitis  is  much  more  common  than  the  acute  variety,  and 
is  usually  associated  with  some  irritation  of  the  walls  of  the  viscus, 
as  from  calculi,  tumours,  foreign  bodies,  tuberculous  ulceration,  or 
retention  and  decomposition  of  urine,  especially  if  associated  with 
obstruction  to  the  outflow,  as  by  a  stricture  or  enlarged  prostate.  It 
may  also  follow  acute  cystitis. 

The  Symptoms  are  those  of  irritability  of  the  bladder,  the  patient 


BLADDER  AND  PROSTATE  1217 

constantly  desiring  to  pass  water,  and  having  to  rise  at  night,  perhaps 
several  times,  for  this  purpose.  The  urine  becomes  turbid,  and,  on 
standing,  deposits  a  variable  amount  of  mucus  or  muco-pus,  mixed 
with  epithelial  cells,  crystals  of  triple  phosphate,  and  a  granular 
sediment  of  phosphate  of  lime.  It  is  usually  alkaline  (unless  due  to 
a  pure  infection  with  the  B.  coli),  perhaps  foul-smelling  and  am- 
moniacal,  containing  an  abundance  of  micro-organisms.  There  is 
often  but  little  pain,  though  when  a  calculus  exists,  or  the  neck 
of  the  bladder  is  ulcerated,  this  may  become  a  prominent  symptom. 
The  patient's  general  health  is  not  at  first  affected ;  but  if  the 
symptoms  persist  it  soon  becomes  impaired — -partly  from  the 
absorption  of  septic  products  from  the  bladder,  and  partly  from  the 
want  of  rest  and  sleep  arising  from  nocturnal  disturbance — and  this 
may  be  so  marked  as  to  lead  to  fatal  exhaustion.  In  other  cases  the 
inflammation  may  spread  from  the  bladder  along  the  ureters  to 
the  kidneys,  and  the  phenomena  of  septic  pyelonephritis  manifest 
themselves  (p.  1189). 

The  Diagnosis  of  chronic  cystitis  is  readily  made  from  the  charac- 
teristic symptoms  of  irritation  of  the  bladder  and  the  condition  of  the 
urine ;  but  considerable  difficulty  may  be  experienced  in  determining 
its  cause.  In  investigating  a  case,  not  only  must  the  character  of 
its  onset  be  considered  but  also  the  general  history  of  the  patient ; 
whilst  a  thorough  examination  of  the  lower  urinary  passages  must 
be  instituted,  and  the  urine  examined  microscopically  and  bacterio- 
logically.  The  passage  of  a  catheter  or  sound  will  generally  detect 
any  obstruction  located  in  the  urethra,  whilst  the  bladder  is  also 
examined  by  the  cystoscope  and  other  methods  described  at  p.  12 10. 

The  Treatment  of  chronic  cystitis  is  naturally  directed  towards  its 
cause,  if  such  can  be  discovered  ;  thus,  calculi  or  foreign  bodies 
should  be  removed,  and  strictures  dilated.  In  most  cases,  even 
where  the  cause  is  not  apparent,  great  benefit  will  be  derived  from 
washing  out  the  bladder. 

The  bladder  is  best  irrigated  by  passing  a  soft  rubber  instrument 
to  the  end  of  which  is  attached  a  portion  of  drainage-tube  about 
3  feet  long,  and  beyond  this  a  glass  funnel,  into  which  the  material 
employed  is  poured.  By  raising  the  funnel  the  fluid  runs  into  the 
bladder,  whilst  on  depressing  it  below  the  bed  or  couch  the  fluid 
returns  on  the  syphon  principle.  The  patient's  sensations  must  guide 
the  surgeon  as  to  how  much  fluid  can  be  borne  in  any  particular 
case.  Various  solutions  are  employed  for  this  purpose,  but  perhaps 
the  most  useful  are  weak  Condy's  fluid,  sanitas  (i  in  10),  boric  acid 
(20  grains  to  i  ounce),  perchloride  of  mercury  (i  in  5,000),  a  neutral 
solution  of  quinine  (2  grains  to  i  ounce),  or  nitrate  of  silver  (^  grain 
to  I  ounce),  and  they  may  be  used  alternately  with  advantage. 
The  frequency  with  which  the  injections  are  made  must  vary  with 
the  severity  of  the  symptoms ;  it  is  not  often  necessary  to  perform 
the  operation  more  than  once  or  twice  a  day.  Of  course  the  most 
stringent  precautions  must  be  taken  as  to  sterilization  of  the  patient's 
penis,  of  the  surgeon's  hands,  and  of  the  instruments  employed. 

77 


I2l8 


A  MANUAL  OF  SURGERY 


At  the  same  time  that  this  local  treatment  is  being  adopted,  the 
patient's  general  habits  of  life  must  be  regulated.  The  diet  should 
be  bland  and  unstimulating ;  alcohol  is  better  avoided,  but  if  essential 
for  other  reasons,  well-diluted  gin  or  whisky  may  be  given.  Tea  and 
coffee  should  be  prohibited,  whilst  milk  should  be  given  freely, 
together  with  barley-water  and  some  mild  alkaline  water — such  as 
that  derived  from  Contrexeville.  As  to  medicines,  there  are  none 
which  can  alter  the  reaction  of  the  urine  from  alkaline  to  acid,  but 
perhaps  salol,  boric  acid,  or  benzoic  acid  may  be  of  some  assistance. 
Urotropine  is  useful,  acting  by  setting  free  formalin  in  the  bladder. 
Hot  infusions  of  buchu,  uva  ursi,  and  triticum  repens  act  as  mild 
diuretics,  and  as  alteratives  to  the  vesical  mucous  membrane ;  full 
doses,  however,  such  as  a  pint  or  a  pint  and  a  half  in  the  course  of 
the  day,  are  needed.     Where  much  muco-pus  is  excreted,  copaiba, 


Fig.  517. — Perineal  Cystotomy.     (Fergusson.) 

cubebs,  turpentine,  or  sandal-wood  oil  may  be  given,  whilst  injec- 
tions of  dilute  astringents  have  been  advised,  but  must  be  used  with 
caution. 

Vaccine  treatment  should  be  employed  if  the  B.  coli  is  the  active 
organism  ;  but  in  such  cases  the  results  are  often  very  disappointing, 
possibly  because  the  vaccine  is  in  the  blood  and  the  bacteria  in  the 
urine.  The  patient  may  remain  apparently  well,  and  yet  the  urine 
teems  with  bacteria,  and  occasional  bouts  of  cystitis  occur,  which 
must  be  treated  by  alkaline  drugs  and  by  washing  out  the  bladder 
either  with  Condy's  fluid  or  with  a  very  dilute  solution  of  nitrate  of 
silver. 

In  cases  which  do  not  improve,  and  if  the  patient  is  becoming 
exhausted  from  the  constant  interference  with  his  rest,  etc.,  the  only 
means  of  treatment  left  is  that  of  opening  the  bladder  through  a 
perineal  incision,     Perineal  Cystotomy  is  undertaken  not  only  for 


BLADDER  AND  PROSTATE  1219 

draining  a  chronically  inflamed  bladder,  but  also  to  explore  th^ 
mucous  lining  of  the  viscus  to  remove  growths  and  foreign  bodies,' 
as  also  sometimes  to  deal  with  prostatic  enlargements  and  calculi. 
The  bladder  is  first  thoroughly  washed  out,  a  few  ounces  of  antiseptic 
solution  being  left  within  it.  After  anaesthesia  has  been  induced, 
a  staff  with  a  median  groove  is  passed  into  the  bladder,  and  then  the 
patient  is  placed  in  the  lithotomy  position,  and  the  perineum  shaved.. 
An  incision  is  made  in  the  middle  line  of  the  perineum,  from  a  point 
2^  inches  in  front  of  the  anus  to  about  i  inch  from  that  opening. 
The  knife  divides  the  deeper  structures  of  the  perineum,  and,  guided 
by  the  left  index  finger  in  the  wound  (Fig.  517),  is  made  to  enter  the 
groove  in  the  staff  at  a  point  corresponding  to  the  membranous 
portion  of  the  urethra.  It  is  then  carried  upwards  and  backwards 
along  the  groove,  incising  the  prostate  and  entering  the  bladder. 
The  knife  is  carefully  withdrawn,  the  finger  gently  inserted  into  the 
cavity,  and  the  staff  removed.  After  digital  exploration  of  the 
bladder,  a  full-sized  gum-elastic  catheter  (No.  16  or  18)  is  passed  in 
through  the  wound  and  fixed,  a  long  piece  of  rubber  tubing  being 
attached  to  allow  of  the  constant  escape  of  the  urine,  as  well  as  to 
permit  of  occasional  irrigation.  The  catheter  is  removed  and 
changed  at  the  end  of  forty-eight  hours,  and  in  favourable  cases  may 
be  discontinued  altogether  at  the  end  of  a  week ;  in  severer  cases 
a  permanent  opening  may  have  to  be  maintained. 

Complications  and  Dangers  of  Perineal  Cystotomy. — (i)  Hcemorrhage  may  arise 
from  the  superficial  arteries  of  the  perineum,  the  deep  branches  of  the  pudic 
(especially  that  which  passes  to  the  bulb),  and  the  veins  of  the  prostatic  plexus. 
The  first  of  these  are  divided  in  the  Superficial  incision,  and  may  be  readily 
secured  by  forceps.  If  the  artery  to  the  bulb  or  its  branches  in  the  bulb  are  cut, 
free  haemorrhage  follows,  which  is  usually  stopped  without  difficulty  by  opening 
up  the  wound  and  seizing  the  bleeding-points  with  forceps,  or  by  packing  around 
a  catheter.  Venous  haemorrhage  from  the  prostate  is  more  serious,  and  is 
especially  prone  to  occur  in  elderly  persons.  Venous  blood  wells  up  from  the 
depths  of  the  wound,  or  passes  back  into  the  bladder,  which  becomes  distended 
with  clot,  considerable  pain  being  thereby  induced.  It  is  treated  by  syringing 
out  the  wound  with  iced  lotion,  and  the  insertion  of  an  air  tampon  or  a  petticoated 
tube.  The  former  contrivance  consists  of  a  gum-elastic  catheter,  the  deep  portion 
of  which  is  surrounded  by  an  indiarubber  bag,  which  can  be  inflated  with  air 
through  a  small  tube  fitted  with  a  stop-cock,  to  which  a  force-pump  can  be 
attached.  The  petticoated  tube  is  used  when  the  former  is  not  obtainable  or 
fails  to  act  ;  it  is  made  by  tying  a  petticoat  of  lint  or  gauze  around  the  distal  end 
of  a  vaginal  tube  ;  this  is  then  passed  into  the  bladder,  and  the  space  between  the 
petticoat  and  the  tube  packed  with  gauze.  If  the  bladder  becomes  filled  with 
blood-clot,  this  must  be  broken  up  and  removed  by  syringing  with  hot  water 
through  a  large-eyed  catheter,  and  the  wound  subsequently  plugged  around  a 
catheter.  (2)  A  Wound  of  the  Rectum  may  be  caused  by  carrying  the  incision  too 
far  backwards,  or  by  not  maintaining  the  point  of  the  knife  strictly  in  the  groove ; 
it  is  more  liable  to  happen,  however,  whilst  withdrawing  the  knife,  the  point 
being  swept  backwards,  thus  opening  the  bowel.  It  is  often  not  recognised  until 
flatus  and  faeces  are  passed  through  the  wound  at  a  later  date.  If  of  small  size 
and  situated  low  down,  it  will  probably  close  by  cicatrization  without  special 
treatment ;  but  when  high  up  and  more  extensive,  a  recto-vesical  fistula  is  likely 
to  follow.  The  treatment  usually  recommended  in  such  a  case  is  to  divide  the 
sphincter,  and  thus  lay  the  lower  end  of  the  rectum  and  the  cystotomy  wound 
into  one  cavity,  the  communication  being  sometimes  closed  by  the  contractioo 


I220  A  MANUAL  OF  SURGERY 

of  the  granulation  tissue  which  fills  up  the  wound.  In  suitable  cases  it  may 
be  possible  to  stitch  up  the  opening  from  the  rectum  after  paring  its  edges. 
(3)  Pelvic  Cellulitis  is  caused  by  cutting  beyond  the  limits  of  the  prostate,  and 
thus  opening  up  the  recto-vesical  fascia,  or  by  bruising  and  over-distension  of 
the  neck  of  the  bladder  by  dragging  through  it  too  large  a  stone.  In  either 
case  urinary  extravasation  and  diffuse  septic  inflammation  are  likely  to  follow, 
resulting  in  grave  constitutional  disturbance  of  a  septic  nature,  and  possibly  in 
the  death  of  the  patient.  The  treatment  suggested  is  to  support  the  general 
health  by  suitable  diet  and  stimulants,  whilst  local  tension  is  relieved  by  ex- 
tending the  wound  backwards  even  into  the  rectum.  (4)  An  acute  ascending 
pyelonephritis  is  occasionally  lighted  up,  in  spite  of  all  precautions,  and  cannot 
be  prevented.     For  symptoms,  etc.,  see  p.  1189. 

Tuberculous  Disease  of  the  Bladder  may  be  primary  or  secondary : 
the  latter  being  the  more  usual,  and  extending  from  the  kidney, 
prostate,  or  testicle.  It  is  much  more  common  in  men  than  in 
women,  and  is  most  frequently  seen  in  young  adults.  It  commences 
in  the  submucous  tissue  as  a  deposit  of  miliary  tubercle,  which 
caseates  and  suppurates,  breaking  down,  and  giving  rise  to  ulcers 
with  undermined  edges ;  these  are  rarely  of  large  size  at  first,  are 
usually  multiple,  and  situated  in  or  near  the  trigone.  The  Symptoms 
are  those  of  chronic  cystitis  and  haematuria,  the  irritability  of  the 
viscus  being  very  marked.  The  diagnosis  is  made  by  demonstrating 
the  bacillus  of  tubercle  in  the  urine,  and  by  the  cystoscope.  The 
course  of  the  case  is  unfavourable,  the  ulcers  increasing  in  size,  and 
death  resulting  from  exhaustion,  general  infection,  phthisis,  or  exten- 
sion to  the  kidneys. 

Treatment. — The  case  is  usually  treated  for  some  time  as  one  of 
chronic  cystitis  before  its  nature  as  a  tuberculous  affection  is  ascer- 
tained. In  the  milder  cases  it  will  suffice  to  attend  to  the  general 
health  and  hygiene  of  the  individual,  and  to  wash  out  the  bladder 
with  some  antiseptic  two  or  three  times  a  week,  leaving  a  drachm  or 
two  of  a  10  per  cent,  solution  of  iodoform  in  olive  oil  or  glycerine 
within  the  viscus.  Injections  of  tuberculin  (TR)  have  been 
found  decidedly  valuable  in  this  condition.  In  more  advanced  cases 
cystotomy  has  been  undertaken  by  the  suprapubic  method,  and  the 
ulcerated  surfaces  scraped  and  disinfected  by  applying  the  galvano- 
cautery  or  pure  carbolic  acid.  To  effect  this  the  patient  should  be 
placed  in  the  Trendelenburg  position,  and  a  suitable  speculum  used  as 
a  caisson  through  which  to  work.  It  is  doubtful,  however,  whether 
such  practice  is  of  much  ultimate  value.  When  the  primary  lesion 
in  kidney  or  testis  is  efficiently  treated,  a  secondary  bladder  trouble 
often  improves. 

Very  similar  Symptoms  may  be  induced  by  the  presence  of  a 
Simple  Ulcer  of  the  Bladder,  which,  according  to  Fenwick,  occurs  not 
unfrequently.  It  is  usually  single,  and  situated  near  the  neck  or 
trigone,  giving  rise  to  great  irritability  of  the  viscus  and  haematuria, 
although  the  urine  remains  clear.  The  diagnosis  is  best  made  by 
the  cystoscope.  Phosphatic  deposits  sometimes  form  over  the 
ulcerated  surface,  and  may  suggest  the  existence  of  a  stone.  Treat- 
ment consists  in  washing  out  the  bladder  with  lactic  acid  (^  to  3  per 


BLADDER  AND  PROSTATE  **« 

cent.),  or  in  scraping  and  cauterizing  the  base  of  the  sore  through  a 
suprapubic  incision. 

Tumours  of  the  Bladder. — New  growths  from  the  vesical  wall  are 
not  very  uncommon ;  they  may  be  simple  or  malignant. 

Simple  Tumours  occur  in  the  form  of  fibroma  and  myxoma;  but 
that  most  often  seen  is  the  Papillomatous  or  Villous  Tumour,  which 
appears  as  a  soft  flocculent  mass,  usually  situated  near  the  trigone, 
and  close  to  the  opening  of  one  of  the  ureters  (Fig.  518).  The 
floating  tufts  or  villous  processes  consist  of   an  extremely  delicate 


Fig.  51J 


-Villous  Tumour  of  the  Bladder. 
Hospital  Museum.) 


(From  King's  College 


connective  tissue,  covered  with  a  layer  or  two  of  epithelium  similar 
to  that  lining  the  bladder,  and  traversed  by  bloodvessels.  Occasion- 
ally the  growths  have  a  narrow  base,  and  are  pedunculated,  but  more 
frequently  are  sessile.  They  may  be  single,  or  may  multiply  rapidly, 
and  spread  all  over  the  bladder  by  infection  from  the  primary  growth. 
The  Symptoms  are  those  of  recurrent  haemorrhage,  the  blood  being 
of  a  bright  red  colour,  followed  later  on  by  irritability  of  the  bladder. 
At  first  the  haemorrhage  is  intermittent,  considerable  intervals  oc- 
curring between  the  attacks ;    but   subsequently  it   becomes   more 


i222  A  MANUAL  OF  SURGERY 

continuous.  The  irritability  of  the  bladder  is  generally  induced  by 
chronic  cystitis,  and  when  the  urine  has  undergone  alkaline  changes, 
there  is  a  copious  exudation  of  ropy  mucus,  which,  mixing  with  the 
urine,  causes  considerable  difficulty  in  micturition,  leading  in  some 
cases  to  strangury.  On  standing,  this  deposit  becomes  so  tenacious 
and  jelly-like  as  to  be  poured  with  difficulty  from  one  vessel  to 
another.  The  urine  may  also  contain  portions  of  the  tumour  which 
have  been  set  free,  and  occasionally,  if  situated  near  the  neck  of  the 
bladder,  some  of  the  fimbriated  ends  may  be  swept  into  the  urethral 
orifice,  and  interfere  with  micturition.  In  the  same  way  the  opening 
of  one  or  both  ureters  may  be  encroached  upon,  leading  to  hydro- 
nephrosis. On  examination  of  the  bladder  with  a  sound,  nothing 
definite  can  be  detected,  unless  the  surface  of  the  growth  becomes 
encrusted  with  phosphates,  and  no  abnormality  is  noticed  on  rectal 
examination.  Occasionally  a  small  portion  of  the  growth  may  be 
caught  in  the  eye  of  a  catheter. 

The  Prognosis  of  the  case  is  unsatisfactory  in  the  absence  of 
effective  operative  treatment,  since,  although  the  growth  is  not  at 
first  malignant,  it  may  become  so,  and  lead  to  a  fatal  termination 
through  exhaustion,  haemorrhage,  or  septic  complications.  The 
growths  may  also  become  multiple  by  tissue  implantation,  and  then 
their  removal  is  almost  an  impossibility,  and  the  patients  are  likely 
to  bleed  to  death.  The  after-result  of  operations  for  a  single  mass 
is  usually  satisfactory. 

Sarcoma  of  the  bladder  is  an  uncommon  disease,  more  often  seen  in 
children  than  in  adults.  In  the  former  it  gives  rise  to  multiple 
polypoid  growths ;  in  the  latter  it  is  often  single  and  sessile.  The 
tumour  grows  rapidly  and  may  attain  considerable  dimensions, 
spreading  outside  the  bladder,  and  even  invading  the  pelvic  bones. 
Lymphatic  glands  may  be  implicated  at  an  early  date. 

Cancer  of  the  bladder  may  originate  in  that  viscus,  or  may  spread 
to  it  from  the  rectum  or  neighbouring  organs.  In  the  former  case, 
the  growth  is  generally  a  squamous  epithelioma;  in  the  latter,  its 
nature  is,  of  course,  similar  to  that  of  the  primary  disease ;  thus, 
when  secondary  to  rectal  cancer,  the  tumour  is  of  a  columnar  type. 
Most  frequently  the  affection  commences  in  the  posterior  wall 
above  the  trigone,  extending  forwards  to  the  neck  of  the  bladder. 
The  growth  is  sometimes  superficial,  projecting  into  the  vesical 
cavity  as  a  soft  spongy  mass,  which  does  not  ulcerate  early,  or  invade 
the  muscular  walls  till  late ;  but  more  frequently  the  neoplasm  ex- 
tends into  and  infiltrates  the  walls,  whilst  marked  ulceration  is  also 
present  (Fig.  519),  the  raw  surface  often  becoming  coated  in  places 
with  a  phosphatic  deposit.  A  cancerous  growth  in  the  bladder  is 
always  more  or  less  likely  to  become  papillated.  The  disease  is 
much  more  common  in  men  than  in  women. 

The  Symptoms  vary  somewhat  in  these  two  forms,  although  the 
conspicuous  features  of  each  are  baematuria  and  irritability  of  the 
bladder.  In  the  slowly-growing  superficial  variety,  the  tumour  often 
attains    a    considerable    size    before    causing   any   trouble,    beyond 


BLADDER  AND  PROSTATE  1223 

possibly  some  slight  irritability  of  the  bladder.  A  severe  attack  of 
haematuria,  unaccompanied  by  pain,  is  usually  the  first  symptom  of 
importance,  and  may  be  induced  by  some  injury  which  causes  a 
crack  or  fissure  in  the  growth.  This  painless  haematuria  closely 
simulates  the  early  symptoms  of  a  simple  villous  tumour,  but  is  more 
persistent,  and  yields  less  readily  to  treatment.  After  one  or  more  of 
such  prolonged  attacks,  cystitis  follows,  and  the  subsequent  history 
resembles  that  of  the  harder  and  more  rapidly  growing  infiltrating 
tumours.  In  such,  the  symptoms  of  vesical  irritability  precede  those 
of  haematuria.  Dysuria  and  severe  pain  referred  to  the  bladder  and 
perineum  are  complained  of,  and  the  urine  early  becomes  alkaline 


Fig.  519. — Cancer  of  the  Bladder.     (From  Royal  College  of 

Surgeons'  Museum.) 

and  putrescent ;  shreds  of  the  growth  may  also  be  found  in  the  urine 
on  microscopic  examination.  If  the  tumour  involves  the  internal 
meatus,  micturition  may  be  considerably  impaired ;  whilst  if  the 
orifices  of  the  ureters  are  obstructed,  hydronephrosis  results.  On 
passing  a  sound,  the  tumour  can  be  detected  as  an  irregular  mass 
projecting  into  the  bladder,  whilst  the  posterior  vesical  wall  may  be 
felt  per  rectum  to  be  hard  and  resistant ;  its  ulcerated  surface  may 
also  be  seen  with  the  cystoscope. 

The  course  of  the  case  is  similar  to  that  of  a  somewhat  rapidly 
growing  carcinoma,  leading  to  early  and  marked  cachexia,  increased 
by  the  sleeplessness  resulting  from  the  vesical  irritation ;  secondary 


1224  A  MANUAL  OF  SURGERY 

deposits  are  found  in  the  viscera  and  lumbar  glands,  whilst  per- 
foration of  the  wall  may  occasionally  follow,  causing  urinary  ex- 
travasation, septic  cellulitis,  and  death.  Another  most  distressing 
complication  is  the  establishment  of  a  recto- vesical  fistula,  through 
which  the  urine  makes  its  way  into  the  rectum,  thus  intensifying 
the  sufferings  of  the  patient. 

The  Diagnosis  of  a  vesical  tumour  can  only  be  made  with  certainty 
by  the  cystoscope,  or  by  discovering  fragments  of  its  substance  in 
the  urine,  though  in  the, female  it  is  easy  to  dilate  the  urethra,  and 
explore  the  bladder  with  the  finger.  Whenever  haemorrhage  is 
associated  with  marked  vesical  irritability,  and  cannot  otherwise  be 
explained,  a  tumour  of  the  bladder  may  be  suspected,  and  cystoscopy 
must  be  undertaken.  In  this  viscus,  as  in  others,  the  only  hope  of 
curing  malignant  disease  lies  in  early  operation,  and  if  the  prac- 
titioner waits  until  the  diagnosis  is  assured  by  the  symptoms,  the 
patient's  case  is  probably  hopeless.  Early  cystoscopy  is  all- 
important. 

In  simple  papilloma  and  the  superficial  type  of  epithelioma, 
haemorrhage  precedes  the  irritability ;  but  whilst  it  is  usually  im- 
possible to  detect  the  villous  growth  either  by  examination  with  the 
sound,  or  from  the  rectum,  a  fungating  malignant  growth  may  some- 
times be  recognised  by  the  sound.  In  the  infiltrating  type  of  malig- 
nant disease,  on  the  other  hand,  pain  and  dysuria  always  precede  the 
bleeding  for  a  considerable  interval ;  whilst  definite  evidence  of  the 
existence  of  the  growth  can  usually  be  made  out,  both  by  the  sound 
and  on  rectal  examination.  A  worn  and  exhausted  appearance  must 
not  be  looked  on  as  necessarily  the  outcome  of  advanced  cancerous 
cachexia,  since  the  loss  of  rest  and  sleep  due  to  chronic  vesical 
irritability  can  of  itself  lead  to  a  somewhat  similar  condition. 

Treatment  of  Tumours  of  the  Bladder. — In  the  early  stages,  when 
the  diagnosis  of  a  tumour  has  not  been  confirmed,  the  haematuria 
may  be  treated  with  ordinary  haemostatic  remedies,  such  as  a  mixture 
containing  dilute  sulphuric  acid  and  ergot,  or  turpentine  administered 
in  capsules  (lo  minims  three  times  a  day). 

When  once  a  diagnosis  has  been  established,  removal  by  operation 
is  the  only  plan  which  holds  out  any  hope  to  the  patient,  and  such 
can  only  be  undertaken  with  any  prospect  of  success  in  benign 
growths,  or  in  the  very  earliest  stages  of  malignant  disease.  The 
suprapubic  operation  is  always  employed.  The  bladder  is  first 
worked  out,  and  the  patient  placed  in  the  Trendelenburg  position. 
After  opening  the  bladder  and  exploring  it  with  the  finger,  a  speculum 
is  introduced  and  its  interior  illuminated  by  an  electric  lamp  fitted 
to  the  surgeon's  head.  If  more  room  is  required,  one  of  the  rectus 
muscles  may  be  cut  across  about  i^  inches  above  its  insertion,  and 
the  viscus  can  then  be  freely  opened. 

Papillomata  and  other  simple  tumours  are  removed,  together  with 
the  mucous  membrane  from  which  they  grow,  by  cutting  round  them 
with  the  knife  or  scissors.  Bleeding  is  stopped  by  pressure  of 
sponges  or  of  strips  of  gauze  soaked  in  adrenalin.     The  fingers  of 


BLADDER  AND  PROSTATE  1225 

an  assistant  in  the  rectum  will  suffice  to  press  up  the  posterior  wall 
and  to  give  support.  If  possible,  the  incision  in  the  mucous  mem- 
brane should  be  closed  by  catgut  stitches.  Where  the  papillomata 
are  large  or  multiple,  this  rhay  involve  an  extensive  operation,  but 
with  careful  after-treatment  there  is  a  good  prospect  of  recovery. 

For  malignant  disease  of  the  bladder,  partial  or  complete  cystectomy 
may  be  possible.  Partial  Cystectomy  consists  in  removal  of  the 
whole  thickness  of  the  vesical  wall  involved  by  the  growth,  and 
according  to  its  location  this  may  involve  opening  the  peritoneal 
cavity  or  not.  The  bladder  is  exposed  as  described  above,  and  the 
peritoneum  is  detached  up  to  and  beyond  the  growth,  which  is  cut 
away,  the  solution  of  continuity  in  the  wall  being  made  good  by 
careful  suturing  with  catgut.  Complete  Cystectomy  has  been  under- 
taken for  extensive  malignant  disease,  and  may  include  removal  of 
the  prostate  and  seminal  vesicles,  the  scope  of  the  operation  extending 
nearly  to  the  membranous  urethra.  Necessarily,  preliminary  arrange- 
ments have  to  be  made  as  to  the  ureters.  Three  plans  are  feasible  : 
(i)  They  are  implanted  into  the  rectum,  and  the  patient  must  run 
the  chance  of  an  ascending  pyelonephritis ;  (2)  the  ureters  are 
brought  out  of  incisions  in  the  loin  and  drained  ;  or  (3)  a  double 
nephrostomy  is  performed,  and  the  pelvis  drained  on  either  side,  the 
patient  then  experiencing  the  discomfort  of  a  double  urinary  fistula. 
The  subsequent  operation  of  removing  the  bladder  is  not  one  of 
extreme  difficulty,  but  requires  care  to  protect  the  patient  from 
haemorrhage  and  from  infection  of  the  peritoneal  cavity. 

When  removal  is  impracticable,  it  only  remains  to  ease  the 
patient's  sufferings  by  means  of  morphia,  the  bladder  also  being 
occasionally  washed  out ;  but  if  the  irritability  is  very  great,  a 
permanent  suprapubic  or  perineal  opening  may  be  established. 

Functional  Derangements  of  the  Bladder. 

The  act  of  micturition  is  a  complicated  proceeding,  which  for  its 
effective  performance  requires  the  due  co-ordination  of  several 
factors.  When  urine  collects  in  the  bladder,  it  is  prevented  from 
escaping  at  once  by  the  tonic  contraction  of  the  sphincter  vesicse ; 
in  infants  this  is  but  little  developed,  and  hence  is  readily  overcome 
by  the  relatively  strong  detrusor  in  response  to  but  slight  intravesical 
pressure.  As  the  child  grows,  the  sphincter  becomes  better  developed, 
and  is  under  more  effective  control;  whilst  at  puberty  the  growth  of 
the  phosphate  adds  to  this,  and  therefore  micturition  loses  its  reflex 
character,  and  becomes  entirely  voluntary.  Three  chief  elements 
enter  into  the  act  of  urination — viz.,  (i)  an  appreciation  of  the 
stimuli  set  up  in  the  bladder  by  its  increasing  distension,  which 
depends  on  the  sensory  nerves  having  a  free  communication  with 
the  sensorium  ;  (2)  as  a  result  of  this  stimulus,  the  sphincter  vesicae 
is  voluntarily  inhibited  ;  and  (3)  the  detrusor  muscle  is  contracted, 
expulsion  of  the  urine  necessarily  following.  A  voluntary  contrac- 
tion of  the  abdominal  muscles  is  often  employed  to  assist  in  this 
expulsive    effort.      Each  of   these  muscular  elements  has  its  own 


1226  A  MANUAL  OF  SURGERY 

centre  in  the  lumbar  enlargement  of  the  spinal  cord,  and  it  is  possible 
for  one  or  both  of  them  to  be  destroyed  or  weakened.  Should  the 
sphincteric  control  become  weak,  the  activity  of  the  detrusor  may  be 
relatively  increased,  and  the  bladder  contents  are  expelled  too 
frequently  (active  incontinence).  Should  the  sphincteric  control  be 
relatively  increased,  the  expulsive  efforts  of  the  detrusor  will  be 
hindered,  and  retention  results.  Necessarily  other  causes,  because 
nervous,  enter  into  the  production  of  these  two  conditions,  and  hence 
they  must  be  considered  separately. 

Incontinence  of  Urine. — A  patient  is  said  to  be  suffering  from 
incontinence  when  the  urine  escapes  involuntarily,  dribbling  away 
either  constantly  or  intermittently  from  the  urethra. 

1.  Active  Incontinence  (Enuresis)  is  often  present  in  young 
children,  mostly  boys,  in  whom,  as  already  indicated,  sphincteric 
control  is  not  too  well  developed.  It  results  from  some  condition 
of  increased  excitability  of  the  urinary  apparatus,  and  is  looked  on 
by  some  as  of  a  choreic  nature.  The  chief  sources  of  irritation  are 
phimosis,  ascarides  in  the  rectum,  a  rectal  polypus,  or  urine  of  high 
specific  gravity,  containing  uric  acid  crystals  in  suspension.  The 
affection  is  most  obvious  at  night,  and,  indeed,  may  only  occur 
during  sleep ;  it  usually  disappears  when  adult  life  is  reached,  if  not 
cured  before,  but  has  been  known  to  persist  later.  Treatment  of  the 
nocturnal  incontinence  consists  in  the  removal  of  all  sources  of 
irritation — such  as  a  tight  foreskin ;  whilst  the  child  is  waked  from 
sleep  at  regular  intervals  in  order  to  pass  water,  so  as  to  break  him 
from  the  bad  habit.  Tonics — e.g.,  iron,  arsenic,  and  quinine — may  be 
administered,  and  tincture  of  belladonna  should  also  be  given  in  full 
doses.  He  must  not  be  allowed  to  lie  on  his  back,  or  to  eat  or  drink 
late  at  night,  but  must  be  kept  warm.  All  excitement  of  the  sexual 
senses  must  also  be  avoided. 

2.  Passive  Incontinence  is  said  to  be  present  when  the  neck  of  the 
bladder  is  relaxed,  so  that  as  soon  as  any  urine  is  secreted,  it  flows 
out  of  the  urethra — the  bladder  in  this  way  never  becoming  dis- 
tended. It  arises  mainly  from  two  causes :  (a)  Paralysis  of  the 
sphincter  vesicae,  as  a  result  of  some  injury  or  disease  of  the  spinal 
cord,  which  may  impair  its  function  either  temporarily  or  perma- 
nently. Thus,  in  severe  shock,  the  bladder  is  unconsciously  evacuated 
from  relaxation  of  the  sphincter ;  but  if  the  lumbar  cord  is  not  com- 
pressed or  destroyed,  the  function  is  soon  regained.  Any  lesion 
involving  the  centre  for  the  sphincter  necessarily  destroys  its  future 
utility,  and  results  in  permanent  incontinence.  It  is  quite  possible 
for  the  detrusor  centre  to  be  damaged  without  injury  to  the  sphincter, 
and  in  such  a  case  distension  of  the  bladder  with  subsequent  over- 
flow supervenes.  Paralytic  incontinence  occasionally  follows  over-dis- 
tension of  the  female  urethra  for  the  removal  of  a  calculus.  Nothing 
can  be  done  for  either  of  these  conditions,  if  permanent,  beyond  the 
application  of  a  suitable  urinal,  (b)  Mechanical  Incontinence  sometimes 
results  from  the  impaction  of  a  calculus  in  the  internal  meatus,  or 
from  its  dilatation  by  a  pedunculated  growth  from  the  prostate. 


BLADDER  AND  PROSTATE  122^ 

3.  False  Incontinence,  or  Distension  witli  Overflow,  may  be  the 
outcome  of  an  attack  of  retention,  naturally  relieved,  or  is  due  to  any 
condition  in  which  the  outflow  of  urine  is  impeded  to  such  an  extent 
as  to  lead  to  a  certain  quantity  being  left  in  the  bladder  after  every 
act  of  micturition,  although  the  patient  imagines  that  the  organ  has 
been  completely  emptied.  This  so-called  residual  urine  gradually 
increases  in  amount  until  the  bladder  becomes  filled,  and  then  some 
of  it  dribbles  away  involuntarily  so  as  to  wet  the  patient's  clothes. 
In  old-standing  cases  the  bladder  can  be  detected  as  a  tense,  rounded 
swelling  in  the  hypogastrium.  This  condition  is  usually  met  with 
in  patients  with  neglected  stricture  or  enlargement  of  the  prostate, 
and  in  the  latter  case  the  bladder  may  be  so  distended  as  to  contain 
several  pints  of  urine.  Very  much  the  same  state  of  things  obtains 
in  paralysis  due  to  spinal  mischief.  Treatment  must  be  directed  to 
keeping  the  bladder  emptied  by  the  regular  use  of  a  catheter,  but  it 
often  remains  in  an  atonic  state  for  some  time. 

Retention  of  Urine. — When  a  person  is  unable  to  expel  the  con- 
tents of  his  bladder,  so  that  it  becomes  distended,  retention  is  said  to 
be  present.  It  results  from  a  variety  of  conditions,  which  may  be 
classified  as  follows : 

1 .  Mechanical  ohstniction  which  may  involve  any  part  of  the  urethra 
or  the  neck  of  the  bladder,  the  actual  cause  varying  somewhat  with 
the  age  and  condition  of  the  patient.  Thus,  in  infants  the  commonest 
cause  of  retention  is  the  narrowed  orifice  of  a  tight  phimosis  ;  in 
children,  an  impacted  calculus  in  the  urethra  or  a  ligature  tied  round 
the  penis  ;  in  young  men,  gonorrhoea  or  one  of  its  complications ;  in 
young  women,  foreign  bodies  in  the  urethra  or  bladder  ;  in  adult 
men,  stricture  ;  in  adult  women,  uterine  fibroids  or  some  uterine 
condition  compressing  the  bladder  or  urethra ;  and  in  old  men, 
hypertrophy  of  the  prostate. 

2.  Nervous  lesions  may  be  responsible  for  some  cases.  Anything 
that  excites  the  sphincteric  energy  or  diminishes  the  activity  of  the 
detrusor  muscle  may  determine  retention,  and  thus  it  may  be  brought 
about  in  many  ways  :  {a)  Spasm  of  the  sphincter  may  result  from 
mental  perturbation  or  excitement,  a  person  being  unable  to  micturate 
in  the  presence  of  others ;  possibly  this  is  more  evident  in  those  who 
have  been  guilty  of  masturbation,  {h)  Neurosis  is  a  common  cause, 
as  in  hysteria  or  shock  ;  whilst  a  reflex  neurosis  is  responsible  for 
retention  after  injuries  or  operations,  especially  when  the  latter  are 
somewhere  in  the  neighbourhood  of  the  genital  organs,  as  for  piles, 
hernia,  varicocele,  etc.  (c)  Organic  disease  of  the  nervous  system 
produces  retention,  as  in  tabes,  disseminated  sclerosis,  traumatic  and 
neoplastic  conditions  of  the  cord,  etc. 

3.  Inflammatory  diseases  of  the  bladder  may  be  followed  by 
difficulty  in  micturition  or  even  retention,  probably  as  the  result 
of  an  interstitial  fibrosis  of  the  vesical  wall,  and  may,  perhaps, 
occur  most  frequently  after  gonorrhceal  cystitis,  or  that  due  to  the 
B.  coli. 

4.  Retention  is  sometimes  the  outcome  of  habit  or  circumstances, 


1228  A  MANUAL  OF  SURGERY 

as  in  clerks  or  school  teachers,  and  then  when  the  opportunity  to 
micturate  occurs  the  act  cannot  be  completed. 

If  left  unrelieved,  the  urine  accumulates  and  the  bladder  becomes 
distended,  as  described  at  p.  121 1,  giving  rise  to  much  pain  and  dis- 
comfort. One  of  two  conditions  is  certain  to  follow  :  (a)  In  case3  of 
retention  from  stricture,  or  when  a  calculus  is  impacted  in  the 
urethra,  the  dilated  urethra  behind  the  seat  of  obstruction  gives  way, 
resulting  in  perineal  extravasation  of  urine.  If,  however,  the  vesical 
bladder  wall  has  been  weakened  as  the  result  of  ulceration,  or  if  it  be 
sacculated,  rupture  of  that  viscus  may  occur,  and  pelvic  extravasation 
may  follow,  (b)  When  the  retention  is  not  due  to  complete  obstruc- 
tion of  the  passages,  the  distention  is  in  time  followed  by  unconscious 
overflow,  and  relief  is  thereby  obtained,  although  the  bladder  wall 
passes  into  a  condition  of  atony. 

The  treatment  of  retention  necessarily  varies  with  the  cause,  as  it 
is  but  a  symptom. 

Atony  of  the  Bladder  is  the  term  applied  to  a  condition  in  which 
the  patient  is  unable  to  expel  the  contents,  not  on  account  of  any 
true  paralysis  but  simply  from  loss  of  tone  of  the  muscular  wall. 
The  causes  are  as  for  retention,  and  the  condition  may  be  determined 
by  a  single  act  of  over-distension,  or  be  the  outcome  of  a  more 
chronic  type  of  retention.  Thus,  owing  to  the  oversight  of  a  house- 
surgeon,  it  occurred  in  a  patient  who  had  been  operated  on  for 
varicocele,  and  left  unrelieved  for  twenty-four  hours.  More  com- 
monly, however,  it  is  met  with  in  old  people  who  are  suffering  from 
retention  due  to  enlargement  of  the  prostate,  or  in  men  who  are  the 
subjects  of  stricture  of  the  urethra 

In  the  slighter  cases  all  that  is  noticed  is  some  hesitation  or  diffi- 
culty in  commencing  the  act  of  micturition,  whilst  the  flow  itself 
is  weak,  the  urine  escaping  with  no  force,  and  often  dribbling  away 
after  the  act  is  apparently  completed.  In  bad  cases  a  considerable 
amount  of  residual  urine  may  be  left  in  the  bladder,  which  its  decom- 
position may  lead  to  chronic  cystitis.  The  Treatment  should  be 
directed  to  removing  any  source  of  obstruction  which  exists,  whilst 
regular  catheterism  two  or  three  times  a  day  will  prevent  any  disten- 
sion of  the  bladder,  and  the  administration  of  strychnine,  phosphoric 
acid,  and  other  tonics,  will  improve  the  expulsive  power  of  the  viscus. 
The  passage  of  a  constant  current  of  electricity  may  also  be  employed 
two  or  three  times  a  week,  to  stimulate  the  muscular  fibres  ;  one 
electrode  is  inserted  into  the  bladder,  and  the  other  placed  over  the 
hypogastrium. 

Abnormal  Conditions  of  the  Urine. 

I.  Urinary  Deposits. — Uric  or  lithic  acid  is  eliminated  in  the  form 
of  '  cayenne -pepper  '  granules,  usually  kno^\'Ti  as  gravel.  On  micro- 
scopic examination,  the  granules  are  found  to  consist  of  flat  rhom- 
boidal,  lozenge  -  shaped  plates,  or  masses  of  acicular  crystals 
(Fig.  520).  They  are  of  a  dusky  brownish-red  colour,  due  to  the 
absorption  of  urobilin,  the  normal  pigment  of  the  urine.     The  secre- 


BLADDER  AND  PROSTATE 


1229 


tion  in  these  cases  is  always  acid,  and  usually  of  high  specific 
gravity.  The  deposit  is  not  soluble  in  boiling  water,  but  readily  so  in 
alkaline  fluids ;  and  on  re-acidulating  such  a  solution,  the  uric  acid 
is  precipitated  in  the  shape  of  white  needle-shaped  crystals. 

Urates  or  lithates  of  potassium,  sodium,  or  ammonium  are  of  fre- 
quent occurrence  in  the  urine,  appearing  as  a  deposit  of  amorphous 
granules  of  variable  colour,  according  to  the  amount  of  urinary  pig- 
ment present,  and  this  is  often  known  as  a  'lateritious,'  or  brick-dust 
sediment.  The  ammonium  salt  is  sometimes  found  in  the  shape  of 
spiculated  globular  bodies  (Fig.  521).  Urates  always  occur  in  acid 
urine  of  high  specific  gravity,  and  are  freely  soluble  in  boiling  water ; 
on  the  addition  of  dilute  hydrochloric  acid  the  uric  acid  is  precipi- 
tated. The  muvexide  test  may  be  applied  for  either  uric  acid  or  its 
salts ;  it  consists  in  mixing  the  substance  to  be  tested  with  a  little 
nitric  acid,  and  evaporating  to  dryness,  when  an  orange-red  dis- 
coloration is  produced,  which  on  the  addition  of  liquor  ammoniae 
changes  to  a  deep  purple-red. 


Fig.  520. — Uric  Acid  Crystals, 


Fig.  521.— Urate  of  Ammonium 
IN  Amorphous  Granules  and 
Hedgehog-shaped  Bodies. 


A  deposit  of  uric  acid  or  urates  is  either  a  temporary  condition 
dependent  on  some  trivial  derangement  of  the  system,  or  a  pheno- 
menon constantly  recurring  and  due  to  too  great  an  indulgence  in 
nitrogenous  food,  too  little  fresh  air  and  exercise,  or  imperfect  diges- 
tion, the  result  of  some  hepatic  disturbance.  It  is  also  noted  in  con- 
ditions where  great  tissue  change  is  occurring,  as  after  violent  exercise 
or  in  fevers.  Under  these  circumstances  the  materials  which  should 
be  changed  into  urea  are  transformed  into  uric  acid  or  its  salts. 
When  such  a  tendency  is  continually  present,  the  patient  is  said  to  be 
suffering  from  LitMasis  or  Lithaemia.  Should  the  material  thus 
formed  not  be  eliminated,  an  attack  of  gout  is  likely  to  supervene, 
whilst  it  must  always  be  borne  in  mind  that  the  formation  of  a  uric 
acid  calculus  is  merely  a  manifestation  of  the  same  diathesis,  which 
needs  careful  treatment  after  the  removal  of  the  stone,  if  a  recurrence 
is  to  be  prevented. 

The  Treatment  of  lithaemia  or  lithiasis  consists  mainly  in  attention 
to  the  personal  hygiene.     The  patient's  diet  is  regulated,  all  sweets, 


1230 


A  MANUAL.  OF  SURGERY 


pastry,  and  alcoholic  stimulants  (with  the  exception,  perhaps,  of  a 
little  whisky  well  diluted  with  lithia  or  potash  water)  being  avoided. 
Fish  and  poultry  are  permitted,  but  butcher's  meat  is  forbidden. 
Regular  habits  are  enforced,  and  plenty  of  outdoor  exercise  recom- 
mended. The  hepatic  secretion  is  stimulated,  and  the  bowels  regu- 
lated by  the  administration  of  saline  purgatives,  especially  natural 
mineral  waters  {e.g.,  Friedrichshall,  Carlsbad,  or  Hunyadi  Janos), 
whilst  an  occasional  dose  of  blue  pill  or  podophyllin  is  advisable. 
Lithia  salts  and  piperazine  have  also  been  employed  with  advantage. 
A  course  of  treatment  at  a  recognised  spa  is  most  useful  in  these 
cases. 

Oxalate  of  lime  usually  occurs  in  the  urine  of  dyspeptic  and  hypo- 
chondriacal patients,  who  are  pale,  nervous,  and  irritable.  It  is  sup- 
posed to  arise  from  the  incomplete  oxidation  of  carbohydrate  foods. 
The  urine  is  of  low  specific  gravity,  pale  and  abundant  in  quantity, 
and  slightly  acid  in  reaction ;  an  excess  of  mucus  is  usually  present, 
causing  the  crystals  to  adhere  to  any  irregularities  in  a  test-glass. 
On  microscopic  examination  they  are  found  to  be  regular  octahedra. 


Fig.  522. — Oxalate  of  Lime  in 
Octahedral  Crystals  and 
Dumb-bell-shaped  Masses. 


Fig.  523.- 


-Crystals  of  Triple  Phosphate 
IN  Urine. 


or  in  the  shape  of  dumb-bells  (Fig.  522).  The  treatment  of  oxaluria 
consists  in  regulation  of  the  diet,  which  must  be  light  and  nourishing, 
all  heavy  food  being  avoided,  as  also  rhubarb,  which  contains  large 
quantities  of  oxalates,  and  the  patient  is  directed  to  drink  only  boiled 
or  distilled  water.  Tonics,  such  as  mineral  acids,  iron,  and  quinine, 
may  be  ordered,  but  the  best  treatment  consists  in  change  of  air  and 
removal,  if  possible,  from  causes  of  anxiety  and  worry. 

Phosphatic  deposits  in  the  urine  occur  in  three  forms  :  (i).  The  triple 
phosphate,  or  ammonio-magnesic,  is  found  in  alkaline  or  decom- 
posing urine,  and  is  always  vesical,  in  origin.  It  exists  in  the  form 
of  hexagonal  prisms,  three  of  the  sides,  however,  being  very  narrow ; 
the  ends  also  are  bevelled  off,  so  that  the  appearance  of  a  '  knife-rest ' 
is  produced  (Fig.  523).  (ii.)  The  amorphous  phosphate  of  lime  is 
exceedingly  common,  forming  the  main  mass  of  any  phosphatic 
sediment.  It  is  always  present  in  chronic  cystitis,  and  is  not  unfre- 
quently  met  with  a  few  hours  after  a  meal,  constituting  what  is 
known  as  the  '  alkaline  tide.'  This  condition  is  often  observed  about 
twelve  o'clock  in  the  morning,  especially  if  an  alkaline  saline  purga- 
tive has  been  taken   before  breakfast.     The  phosphatic  material 


BLADDER  AND  PROSTATE  1231 

is  voided  at  the  end  of  the  act  of  micturition,  and  may  give  rise  to 
considerable  anxiety  on  the  part  of  the  patient,  who  mistakes  it  for 
seminal  fluid,  (iii.)  The  most  usual  condition  in  which  phosphates 
are  met  with  in  urine  is  a  mixture  of  the  two  varieties  described 
above.  Whichever  form  is  present,  the  deposit  becomes  more 
evident  on  boiling,  disappearing,  however,  on  the  addition  of  a  few 
drops  of  acetic  acid.  The  treatment  of  phosphaturia  is  always 
directed  to  the  vesical  condition,  except  in  those  unusual  cases  where 
it  is  due  to  some  constitutional  error. 

2.  Haematuria,  or  the  admixture  of  blood  with  the  urine,  is  best 
described  according  to  the  source  from  which  the  blood  is  derived. 

ia)  Renal  haematuria  results  from  acute  inflammation,  congestion, 
calculus,  tumours,  or  injuries  of  the  kidney.  The  urine  is  sometimes 
deeply  coloured  with  the  blood,  and  may  be  as  dark  as  porter. 
Blood-casts  of  the  renal  tubules  are  often  observed,  and  even  long 
sinuous  clots,  corresponding  to  the  shape  of  the  ureter. 

(b)  Vesical  haematuria  is  due  to  injury,  calculus,  tumours,  ulcera- 
tion, simple  congestion  of  the  bladder  with  varicosity  of  the  vesical 
veins,  or  the  presence  of  the  BiUiarzia  hamatobia.  The  blood  is 
intimately  mixed  with  the  urine,  but  is  more  abundant  at  the  end  of 
micturition,  and  clots  are  often  present. 

The  Bilharzia  is  a  parasite  which  inhabits  some  of  the  rivers  and 
pools  of  South  Africa.  It  is  taken  into  the  system  by  the  mouth, 
and  may  develop  either  in  the  urinary  track,  or  sometimes  in  the 
lower  bowel  (p.  1150).  The  adult  worms  are  found  in  the  body 
inhabiting  the  radicals  of  the  portal  and  vesical  veins,  and  discharge 
their  ova  through  the  mucous  membrane  of  the  bowel  or  bladder, 
giving  rise  to  haemorrhage.  By  an  extension  to  the  kidney,  pyone- 
phrosis may  be  induced.  No  specific  treatment  has  at  present  been 
discovered,  but  in  most  cases  the  disease  after  a  time  disappears 
spontaneously. 

(c)  Prostatic  haematuria  may  be  caused  by  congestion,  calculus, 
ulceration,  or  malignant  disease,  or  especially  by  the  passage  of  a 
catheter  or  bougie  used  in  the  diagnosis  or  treatment  of  any  of  these 
conditions.  The  blood  may  pass  back  into  the  bladder,  and  hence 
the  phenomena  simulate  the  vesical  condition,  but  frequently  it 
escapes  from  the  urethra,  particularly  if  due  to  traumatism.  Ex- 
amination of  the  prostate  from  the  rectum  may,  however,  give  a 
clue  to  the  source  of  the  mischief. 

(d)  Urethral  haematuria  arises  from  acute  gonorrhoea,  laceration, 
or  instrumentation.  The  blood  often  flows  from  the  urethra  in- 
dependently of  micturition,  whilst  the  first  few  drops  of  the  stream 
are  also  coloured. 

(e)  Haematuria  is  occasionally  of  constitutional  origin,  arising  from 
purpura,  scurvy,  or  haemophilia ;  other  manifestations  of  these 
diseases  will  be  observed,  and  render  the  diagnosis  evident. 

Microscopical  examination  of  the  urine  should  always  be  made  to 
ascertain  whether  or  not  blood-corpuscles  are  present,  since  the 
condition  may  be  simulated  by  that  known  as  '  paroxysmal  ha^mo- 


1232  A  MANUAL  OF  SURGERY 

globinuria,'  in  which  corpuscles  are  absent-  The  latter  condition 
is  supposed  to  be  due  to  vaso-motor  spasm  of  the  renal  arterioles, 
and  is  not  uncommonly  associated  with  Raynaud's  disease. 

The  only  certain  test  for  the  presence  of  blood  is  by  spectrum 
analysis  ,  but  that  most  usually  relied  on  consists  in  mixing  together 
equal  parts  of  tincture  of  guaiacum  and  ozonic  ether.  The  sus- 
pected urine  is  subsequently  added,  and  sinks  to  the  bottom  of  the 
test-glass ;  a  copious  precipitate  forms  at  the  line  of  junction  of  the 
two  fluids,  which  on  standing  becomes  a  bright  blue  colour  if  blood 
is  present. 

The  investigation  of  a  case  of  haematuria  in  order  to  ascertain  its 
origin  should  be  conducted  in  the  following  way  •  (a)  The  history  of 
the  patient  and  of  his  urinary  trouble  should  be  taken,  (b)  The 
character  of  the  urine  should  be  investigated,  noting  its  colour,  and 
whether  or  not  the  blood  is  intimately  mixed  with  it.  (c)  The  relation 
of  the  passage  of  the  blood  to  the  act  of  micturition  should  be  noted 
by  making  the  patient  pass  the  first  and  last  portions  of  the  urine 
into  separate  vessels  from  that  in  which  he  passes  the  bulk ;  if  the 
urine  in  all  three  vessels  is  equally  discoloured,  the  haemorrhage 
usually  comes  from  the  kidneys ;  if  most  of  the  blood  is  in  the  first 
vessel,  it  comes  from  the  urethra  or  prostate,  whilst  if  the  bulk  of  it 
is  contained  in  the  last  vessel,  it  is  probably  derived  from  the  bladder. 
(d)  Microscopical  examination  of  the  urine  may  lead  to  the  discovery 
of  shreds  of  tumour,  epithelial  cells,  or  blood-casts,  which  could  be 
alone  derived  from  some  special  part  of  the  urinary  track.  By  these 
means  the  source  of  the  haemorrhage,  whether  from  kidney,  bladder, 
prostate,  or  urethra,  may  be  detected,  and  an  opinion  formed  as  to 
the  nature  of  the  disease. 

3.  Pyuria  is  the  term  applied  to  the  admixture  of  pus  or  muco-pus 
with  the  urine.  It  always  results  from  inflammatory  affections  of 
the  mucous  membrane  lining  the  urinary  passages,  and  may  be  renal, 
vesical,  prostatic,  or  urethral  in  origin ;  the  methods  of  investigation, 
in  order  to  ascertain  its  exact  source,  are  the  same  as  for  haematuria. 

Pus  in  urine  is  mainly  recognised  by  the  microscope,  whilst  on  the 
addition  of  liquor  potassae  it  becomes  ropy. 

4.  Chyluria  arises  from  distension  or  rupture  of  the  lymphatic 
vessels  in  the  vesical  mucous  membrane,  and  is  usually  due  to  the 
presence  of  the  Filavia  sanguinis  hominis  (p.  363).  The  urine  is 
milky  in  colour,  and  on  microscopical  examination  this  is  found  to  be 
due  to  the  presence  of  an  emulsion  of  fat. 

5.  Albuminuria,  or  the  escape  of  some  of  the  albuminous  contents 
of  the  blood  with  the  urine,  is  a  condition  of  such  frequent  occurrence, 
and  so  important  in  its  results,  that  the  precaution  should  always  be 
adopted  of  testing  the  urine  of  every  patient  before  undertaking  any 
operative  proceedings  ;  and  this  is  the  more  essential  because  it  is 
well  known  that  this  condition  often  exists  quite  unexpectedly  and 
entirely  apart  from  symptoms. 

Tests. — Many  different  methods  have  been  adopted  for  detecting 
the  presence  of  albummuria.     The  following  are,  however,  the  chief : 


BLADDER  AND  PROSTATE  1233 

(i)  On  simply  boiling  the  urine  a  milky  white  deposit  forms  similar 
to  that  which  is  caused  by  an  excess  of  phosphates ;  the  latter,  how- 
ever, disappears  entirely  on  the  addition  of  a  single  drop  of  dilute 
acetic  acid,  whilst  the  former  persists  or  increases.  (2)  Nitric"  acid 
gives  a  white  cloud  or  light  brown  flocculent  precipitate.  The  urine 
should  first  be  boiled  and  the  acid  added,  but  not  in  excess,  as  the 
deposit  may  be  re-dissolved.  A  more  delicate  test  consists  in  pouring 
the  cold  urine  into  a  test-tube,  and  carefully  adding  the  acid,  so  as  to 
form  a  stratum  below  the  urine ;  at  the  line  of  junction  of  the  two,  a 
white  film  is  formed,  if  albumen  is  present.  (3)  With  picric  acid 
a  yellowish-white  precipitate  is  thrown  down,  increased  by  boiling. 
If  the  urine  is  neutral  or  alkaline,  it  must  first  be  rendered  slightly 
acid  by  the  addition  of  a  few  drops  of  acetic  acid. 

When  once  the  existence  of  albumen  in  the  urine  has  been  ascer- 
tained, its  source  and  its  significance  must  be  investigated.  A 
careful  microscopical  examination  of  the  sediment  is  made,  so  as  to 
determine  whether  casts  or  pus  cells  are  present.  The  condition  of 
the  peripheral  bloodvessels  in  the  limbs  and  the  character  of  the 
pulse  should  be  noted,  as  also  the  previous  history  of  the  patient. 

Albuminuria  arises  from  a  variety  of  sources,  and  its  significance 
necessarily  turns  on  the  origin  of  the  affection,  (i)  When  it  is 
associated  with  long-standing  suppuration,  as  in  diseases  of  bones 
or  joints,  it  is  probably  due  to  lardaceous  change  in  the  kidneys. 
If  the  urine  is  of  low  specific  gravity  and  light  in  colour,  and  with 
but  few  casts,  only  an  early  stage  of  the  condition  is  present,  and 
conservative  measures  directed  to  the  treatment  of  the  primary  lesion 
will  probably  suffice ;  if,  however,  the  urine  is  scanty  and  of  high 
specific  gravity  with  much  albumen  and  many  casts,  the  affection 
has  probably  progressed  some  way,  and  radical  treatment,  such  as 
amputation,  should  be  undertaken  to  save  the  patient's  life.  The 
surgeon  must  be  careful  to  prevent  any  undue  absorption  of  carbolic 
acid  in  the  operation,  as  thereby  acute  nephritis  may  be  lighted  up, 
and  even  a  fatal  issue  determined.  (2)  Albuminuria  may  be  inter- 
mittent (cyclical),  and  is  then  due  to  some  temporary  functional 
disturbance ;  this  can  only  be  ascertained  by  testing  the  urine  from 
time  to  time.  In  such  cases  operation  is  not  contra-indicated,  the 
albumen  usually  disappearing  with  rest  and  careful  diet.  (3)  When 
caused  by  chronic  Bright's  disease,  the  concurrent  phenomena  of 
that  affections  will  also  be  present  in  the  shape  of  thickened  arteries 
and  high  pulse  tension,  w^hilst  possibly  a  certain  amount  of  anasarca 
may  be  noted,  or  the  history  of  such  at  an  earlier  date.  If  there  is 
but  little  albumen,  and  a  fair  amount  of  urea  is  being  passed,  it  is 
possible  by  rest  and  suitable  diet  so  to  diminish  it  as  to  warrant  the 
performance  of  slight  operations ;  but  where  the  condition  is  at  all 
advanced,  all  operations  de  complaisance  are  absolutely  contra-indicated, 
and  only  the  chief  surgical  emergencies  should  be  knowingly  dealt 
with,  viz.,  haemorrhage,  asphyxia,  grave  intraperitoneal  lesions,  and 
retention  of  urine.  In  severe  injuries,  amputation  is  generally  indi- 
cated under  circumstances  where  in  a  healthy  individual  conservative 

78 


i234  ^  MANUAL  OF  SURGERY 

measures  would  be  adopted.  Operation  for  malignant  disease  may 
be  undertaken  at  the  request  of  the  patient  if  the  increased  risks 
have  been  explained  to  him.  The  risk  depends  on  the  facts  that 
such  patients  tolerate  an  anaesthetic  badly,  that  the  tissues  are  in 
a  condition  of  lowered  vitality,  and  hence  the  process  of  repair  is 
hindered,  infective  iniiammations  and  erysipelas  are  very  prone  to 
develop,  whilst  secondary  haemorrhage  is  predisposed  to  by  the  high 
pulse  tension.  Again,  boils  and  carbuncles  are  very  common  in  these 
patients,  and  where  such  conditions  are  met  with,  and  especially  if 
they  recur,  the  urine  should  always  be  examined.  (4)  Albuminuria 
may  arise  by  extension  of  inflammation  to  the  kidneys  from  surgical 
affections  of  the  lower  urinary  organs,  and  a  fatal  result  from  shock  or 
suppression  of  urine  may  follow  an  operation  under  these  conditions. 
(5)  It  is  sometimes  the  result  of  cardiac  disease,  owing  to  valvular 
incompetence  and  regurgitation  into  the  systemic  veins,  and  it  is 
then  advisable  to  delay  all  operative  measures  until  suitable  treatment 
has  relieved  the  urgent  symptoms. 

6.  Grlycosuria  and  Diabetes  are  alike  characterized  by  the  presence 
in  the  urine  of  sugar  (glucose),  but  whilst  the  former  may  be  tem- 
porary and  of  comparatively  little  significance,  the  latter  is  generally 
permanent  and  due  to  disease  of  the  pancreas.  The  mere  existence 
of  sugar  in  the  urine  is  not  nowadays  looked  on  as  an  absolute  contra- 
indication to  operative  treatment,  as  was  the  case  formerly,  and  yet 
the  urine  of  all  patients  requiring  operation  should  always  be  examined 
as  a  routine  preliminary  in  order  to  ascertain  whether  or  not  it  is 
present.  The  chief  tests  employed  are  as  follows :  (i)  Equal  parts 
of  liquor  potassae  and  solution  of  copper  sulphate  are  boiled  together, 
and  then  a  few  drops  of  the  suspected  urine  added ;  if  sugar  is 
present,  a  yellowish-red  precipitate  forms  by  the  reduction  of  the 
cupric  salt  to  cuprous  oxide.  (2)  The  same  result  follows  the  use 
of  Fehling's  solution.  It  is  better  to  keep  the  copper  solution 
separate  from  the  potash ;  equal  parts  of  them  are  boiled  together, 
and  a  few  drops  of  the  urine  added ;  if  sugar  is  present,  a  red  deposit 
occurs.  (3)  Picric  acid  and  liquor  potassae  are  mixed  and  boiled,  and 
the  urine  added;  the  presence  of  sugar  is  indicated  by  the  solution 
turning  to  a  dark,  blackish-red  colour.  The  admixture  of  2  grains 
of  sugar  to  the  ounce  is  sufficient  to  determine  this  discoloration  to 
such  an  extent  as  to  render  the  fluid  quite  opaque. 

Simple  Glycosuria  arises  from  many  different  conditions,  included 
amongst  which  may  be  mentioned  an  excess  of  carbohydrates  and 
of  fatty  or  sweet  things  in  the  dietary,  the  liver  being  unable  to  store 
them  away,  hepatic  disturbances  of  various  types,  and  injuries  or 
diseases  of  the  medulla  or  upper  part  of  the  cord.  An  interesting 
form  of  glycosuria  occurs  in  some  infective  conditions  of  the  type 
of  cellulitis  (boils,  carbuncles,  etc.),  where  the  presence  of  glucose  in 
the  urine  appears  to  be  secondary,  and  disappearance  quickly  follows 
effective  operative  treatment.  The  explanation  of  this  condition  is 
not  at  all  obvious. 

True  diabetes  is  now  generally  considered  to  be  due  to  lesions  of 


BLADDER  AND  PROSTATE  1235 

the  pancreas.  Experimentally  total  removal  of  the  gland  in  animals 
is  followed  by  diabetes,  and  in  man  clinical  research  has  demonstrated 
that  certain  types  of  chronic  pancreatitis,  in  which  degeneration  or 
destruction  occurs  of  the  curious  cellular  bodies  known  as  the  Islands 
of  Langerhans,  are  associated  with  diabetic  phenomena.  These  islands 
are  supposed  to  form  the  internal  secretion  of  the  gland,  a  ferment 
upon  the  activity  of  which  the  glycogenic  function  of  the  liver  depends. 
In  the  vast  majority  of  the  accredited  cases  of  diabetes  lesions  of  the 
pancreas  are  demonstrable,  and  the  condition  is  often  improved  by 
hydrotherapy  and  measures  directed  to  relieving  hepatic  engorgement. 
It  is  quite  reasonable  to  consider  seriously,  in  all  cases  of  diabetes, 
the  question  of  exploring  the  biliary  and  pancreatic  passages  with  a 
view  to  remove  calculi,  or  relieve  congestion  by  temporary  drainage. 
Although  the  condition  may  not  be  absolutely  cured,  yet  great  benefit 
has  frequently  resulted. 

In  simple  glycosuria  limitation  of  diet  for  a  few  days  and  rest  in 
bed,  with  some  attention  to  the  activity  of  the  liver  and  of  the  bowels, 
will  frequently  cause  a  diminution  in  the  excretion  of  sugar,  and 
under  such  circumstances  a  surgeon  need  not  hesitate  to  perform 
ordinary  operations.  But  if  the  sugar  persists  in  spite  of  such 
treatment,  and  there  is  reason  to  suspect  that  the  case  is  one  of  true 
pancreatic  diabetes,  operations  must  be  undertaken  very  cautiously. 
The  tissues  are  always  in  a  condition  of  lowered  vitality,  so  that 
infection  readily  occurs,  as  indicated  by  the  frequency  of  such  con- 
ditions as  boils,  carbuncles,  and  infective  gangrene  of  the  extremities. 
In  old-standing  cases,  peripheral  neuritis  and  sclerosis  of  the  smaller 
vessels  are  induced,  and  gangrene  is  not  an  uncommon  sequela 
(p.  108).  It  is  therefore  obvious  that  operative  proceedings  should 
not  be  resorted  to  unless  they  are  absolutely  necessary ;  but,  unless 
the  case  has  progressed  very  far,  there  is  no  reason  why  necessary 
operations  should  not  be  performed,  granted  that  the  most  rigid  care 
is  taken  as  to  the  maintenance  of  asepsis.  Thus  several  cases  have 
been  reported  in  which  such  serious  proceedings  as  total  removal  of 
the  breast  and  axillary  contents  for  scirrhus,  or  appendicectomy,  have 
been  safely  undertaken  in  confirmed  diabetes. 

One  of  the  chief  dangers  of  neglected  or  serious  diabetes  is  the 
supervention  of  Diabetic  Coma,  which  may  develop  without  apparent 
reason,  or  be  lighted  up  by  some  septic  complication,  or  the  operative 
treatment  required  for  the  same,  especially  if  a  general  anaesthetic  is 
given.  The  patient  becomes  apathetic,  and  finally  dies  in  a  condition 
of  coma ;  his  breath  smells  of  acetone,  and  the  blood  is  defective 
in  its  alkalinity.  The  explanation  of  this  is  as  follows :  in  diabetes 
there  is  always  an  excessive  production  of  acid  in  the  body — mainly 
/S-oxybutyric  acid — which  in  health  is  either  not  formed,  or  is 
oxidized  to  CO2  and  HgO.  In  this  disease  it  is  excreted  in  com- 
bination with  alkalies,  mainly  with  the  ammonium  which  is  normally 
formed  into  and  removed  from  the  body  as  urea.  The  sodium  and 
potassium  of  the  blood  are  also  called  on  to  neutralize  it,  and  even 
calcium  or  magnesium  may  be  dissolved  from  the  bones.     The  blood 


1236  A  MANUALOF  SURGERY 

therefore  suffers  in  its  alkalinity ;  the  carbonic  acid  is  no  longer 
carried  to  the  lungs,  and  consequently  dyspncea,  with  or  without 
cyanosis,  may  result.  Diacetic  acid  is  also  formed,  especially  just 
before  coma  occurs.  It  arises  by  oxidation  of  the  /S-oxybutyric 
acid,  and  breaks  up  in  its  turn  into  acetone  and  carbolic  acid.  Its 
presence  can  be  demonstrated  in  the  urine  by  the  addition  of  ferric 
chloride,  when  a  claret  colour  appears  ;  if  the  urine  is  subsequently 
boiled,  this  discoloration  disappears.  Naturally  the  presence  of  this 
acid  in  the  urine  of  a  diabetic  patient  is  a  danger  signal,  warning 
the  surgeon  that  coma  is  not  far  distant,  and  that  general  ansesthetics 
must  be  avoided.  Large  doses  of  sodium  bicarbonate  given  by 
mouth  or  rectum,  or  even  by  intravenous  infusion,  may  be  of  use 
in  checking  the  progress  of  this  condition. 

For  the  influence  of  diabetes  and  albuminuria  in  the  choice  of  an 
anaesthetic,  see  pp.  1349  and  1355. 

Stone  in  the  Bladder. 

Varieties. — A  vesical  calculus  may  be  formed  of  almost  any  of  the 
urinary  deposits  commonly  met  with,  and  each  has  its  own  special 
characteristics. 

(a)  The  uric  acid  calculus  (Plate  XL,  Figs,  i  and  2)  is  usually  an 
oval,  flattened  body  of  considerable  density,  with  a  smooth  or  slightly 
nodular  surface,  and  of  a  nut-brown  colour.  On  section  it  is  dis- 
tinctly laminated,  and  it  may  be  surrounded  by  a  crust  of  phosphatic 
material. 

(b)  The  uraie  of  ammonium  calculus  is  of  very  similar  structure,  but 
of  a  lighter  colour,  and  the  lamination  is  less  distinct. 

(c)  The  oxalate  of  lime  or  mulberry  calculus  (Plate  XL,  Figs.  3  and  4) 
is  a  rough,  irregular  body,  sometimes  evenly  nodular,  but  not  unfre- 
quently  tuberculated,  or  even  spiculated.  It  is  extremely  hard  and 
dense,  laminated,  and  of  a  dark  red-brown  colour,  or  sometimes 
black,  owing  to  admixture  with  blood.  It  is  rarely  of  great  size,  on 
account  of  the  irritation  caused  by  its  presence,  and  its  slowness  of 
growth. 

(d)  A  pure  phosphatic  calculus  (Plate  XII.)  is  very  uncommon,  but 
any  stone  or  foreign  body  is  certain  to  become  coated  with  a  phos- 
phatic deposit  when  chronic  cystitis  has  resulted  in  alkaline  decom- 
position of  the  urine.  Occasionally  concretions  of  a  similar  nature 
form  spontaneously  in  saccules  of  the  bladder ;  such  bodies  are  white 
and  chalky  in  appearance,  friable  in  consistency,  with  no  evidence,  or 
but  little,  of  lamination,  and  on  removal  are  exceedingly  offensive. 
These  concretions  consist  of  a  mixture  of  the  triple  phosphate  and 
phosphate  of  lime.  Less  commonly  an  excess  of  the  triple  phosphate 
is  present ;  if  in  the  proportion  of  two  parts  of  the  latter  to  one 
of  phosphate  of  lime,  a  laminated  and  somewhat  denser  calculus 
is  produced,  which  is  sometimes  termed  a  fusible  calculus,  owing  to  the 
fact  that  it  fuses  to  a  bead  under  the  blowpipe  flame.  Occasionally 
a  phosphate  of  lime  calculus  occurs  in  the  upper  urinary  passages 


PLATE  XI. 


Stones  from  the  Bladder. 

Figs.  1  aw(/2.— Uric  acid  Calculus— on  section  and  outer  surface.  Fig.  3.— Encysted 
Calculus  of  uric  acid.  The  lower  segment  was  held  firmly  in  a  saccule  near  the 
tisgone ;  the  larger  portion  projected  into  the  bladder.  A  certain  amount  of 
phosphatic  deposit  covers  the  exterior.  It  was  successfully  removed  by  a  suprapulic 
operation.     Figs.  4  and  5. — Phosphatic  Calculus. 

\_To  face  page  1236. 


PLATE   XII. 


Oxalate  of  Lime  Calculus. 

Fig.  I. -On  section.  Fig.  2. -From  the  exterior. 

\To  face  page  1236. 


BLADDER  AND  PROSTATE  1237 

{e.g.,  the  pelvis  of  the  kidney),  and  has  a  crystaUine  appearance  on 
drying. 

(e)  Cystine  forms  the  basis  of  a  rare  calculus  which  is  of  a  yellowish- 
green  colour  and  waxy  appearance. 

(/)  Xanthine,  or  xanthic  oxide,  occurs  very  exceptionally  as  a 
calculus  of  a  reddish  colour. 

An  encysted  calculus  is  one  which  develops  in  a  pocket  or  pouch 
connected  with  the  bladder  wall.  It  may  consist  of  any  of  the  above 
substances,  and  is  due  to  a  small  stone  finding  its  way  into  a 
saccule  and  being  arrested  there.  It  grows  by  gradual  accretion  of 
new  calculus  material,  and  after  a  time  projects  into  the  vesical 
cavity.  A  typical  illustration  is  shown  in  Plate  XII.,  where  the 
large  intravesical  portion  is  separated  from  the  encysted  part  by  a 
narrow  neck.  Occasionally  this  condition  is  due  to  the  decomposition 
of  stagnant  urine  in  a  pouch,  and  the  calculus  is  then  phosphatic  in 
composition  ;  it  is  not  unlikely  to  lead  to  ulceration  of  the  sac  wall 
and  extravasation  of  urine. 

Structure  of  a  Calculus. — A  calculus  usually  consists  of  the  follow- 
ing parts  :  i.  The  nucleus,  which  may  be  formed  by  a  portion  of  blood- 
clot,  inspissated  mucus,  a  renal  calculus,  or  some  foreign  substance 
introduced  from  without.  2.  The  body,  which  consists  of  superposed 
layers  of  uric  acid  or  oxalate  of  lime,  or  of  whatever  substance  the 
stone  is  composed;  not  unfrequently  the  composition  of  adjacent 
laminae  differs,  leading  to  what  is  known  as  an  alternating  calculus. 
Each  lamina  consists  of  myriads  of  minute  crystals,  held  together  by 
vesical  mucus,  with  which  a  certain  amount  of  phosphatic  material 
is  often  mixed,  whilst  layers  of  pure  phosphatic  deposit  may  be  inter- 
posed. 3.  The  cviist  consists  of  a  variable  amount  of  soft,  friable 
phosphatic  material,  the  quantity  of  which  is  the  measure  of  the 
degree  of  chronic  cystitis  originated  by  the  calculus ;  in  some  cases  it 
is  entirely  absent. 

The  Number  of  calculi  present  in  a  bladder  varies  greatly.  Some- 
times there  is  only  one  ;  occasionally  a  considerable  number,  counted 
perhaps  by  hundreds,  may  exist ;  in  such  circumstances  they  are 
never  of  great  size.  Multiple  calculi  are  not  unfrequently  faceted  as 
a  result  of  mutual  friction. 

The  Causes  of  vesical  calculus  must  be  looked  for  in  some  of  those 
constitutional  conditions  already  described  as  predisposing  to  lithiasis 
or  oxaluria.  They  are  very  common  in  children  during  the  first 
decade  of  life,  especially  amongst  the  lower  classes,  the  children  of 
the  rich  rarely  suffering  from  stone.  It  diminishes  in  frequency  from 
childhood  to  the  age  of  twenty-five,  and  then  gradually  increases  until 
it  is  relatively  common  in  elderly  men.  The  condition  is  compara- 
tively rare  in  women,  owing  to  the  fact  that  the  shortness  and  large 
size  of  the  urethra  allow  small  calculi  to  be  much  more  readily 
passed.  Possibly  the  character  of  the  drinking-water,  or  the  amount 
imbibed,  is  a  matter  of  importance,  as  indicated  by  the  fact  that  the 
occurrence  of  calculus  is  very  unequally  distributed  in  different  parts 
of  the  country  ;  thus,  it  is  most  frequently  met  with  in  the  Eastern 


1238  A  MANUAL  OF  SURGERY 

Counties.  It  is  also  very  common  in  India  and  Arabia,  a  fact  which 
may  possibly  be  explained  by  the  large  amount  of  fluid  withdrawn  from 
the  body  by  perspiration. 

Symptoms. — The  effects  produced  by  vesical  calculi  vary  in 
different  individuals,  according  to  the  shape  of  the  stone,  and  the 
tolerance  of  the  mucous  membrane.  In  children  and  young  adults, 
where  the  parts  are  very  sensitive,  even  a  smooth  calculus  gives  rise 
to  severe  symptoms,  whilst  old  men  often  tolerate  a  large  stone 
without  much  inconvenience ;  ccstevis  paribus,  an  oxalate  of  lime 
calculus  is  always  more  irritating  than  one  composed  of  uric  acid. 
The  classical  symptoms  of  a  vesical  calculus  may  be  preceded  by  a 
history  of  the  patient  having  passed  '  gravel '  for  a  long  time,  or  by 
an  attack  of  renal  colic,  on  the  cessation  of  which  the  calculous 
symptoms  commenced.  Sometimes  the  vesical  symptoms  do  not 
appear  for  some  time  after  the  passage  of  a  stone  into  the  bladder, 
presumably  in  consequence  of  its  small  size.  They  consist  of  pain 
in  the  perineum  and  neck  of  the  bladder,  which  radiates  to  the 
back  and  down  the  thighs,  but  is  especially  noticed  at  the  end  of 
the  penis  immediately  after  micturition.  The  stone  is  then  pressed 
down  against  the  sensitive  neck  of  the  bladder  by  the  contraction 
of  its  muscular  walls.  Increased  frequency  of  micturition  is  also 
present,  and  perhaps  haematuria  of  a  vesical  type,  though  this  is  not 
a  prominent  feature.  All  these  phenomena  are  increased  in  severity 
by  jolting,  jumping,  or  any  form  of  exercise,  and  hence  are  more 
m^arked  during  the  day  than  at  night.  Occasionally  the  patient 
complains  that  the  flow  of  urine  suddenly  ceases  before  the  bladder 
has  been  completely  emptied,  and  that  some  change  in  the  position 
of  the  body  is  needed  in  order  to  allow  him  to  complete  the  act. 
In  addition  to  these  characteristic  symptoms,  he  may  suffer  from 
various  phenomena  secondary  to  the  irritability  of  the  bladder,  and 
dependent  on  the  straining  induced  by  the  calculus.  Thus,  tenesmus, 
followed  by  piles  or  prolapsus  ani,  may  be  produced  by  sympathetic 
irritability  of  the  rectum,  especially  in  children  ;  whilst  a  hernia 
may  also  be  caused,  and  not  unfrequently  priapism. 

The  symptoms  are  somewhat  modified  in  children,  leading  to  irrita- 
bility of  the  bladder,  as  evidenced  by  wetting  of  their  clothes  and  of 
their  beds  at  night,  and  pulling  at  the  prepuce  and  penis.  These 
manifestations  are  very  similar  to  those  caused  by  a  tight  foreskin, 
with  which  condition,  indeed,  a  stone  is  often  associated ;  hence,  it  is 
important  always  to  sound  the  bladder  of  a  child  after  circumcision 
for  phimosis. 

The  actual  Diagnosis  of  vesical  calculus  can  be  made  by  radio- 
graphy or  sounding.  X-ray  examination  is  conducted  in  the  usual 
fashion,  care  being  taken  to  see  that  the  rectum  is  empty.  The 
lamp  is  placed  over  the  patient's  abdomen,  with  the  rays  directed 
downwards  and  backwards,  and  the  plate  is  behind.  The  calculus 
usually  appears  as  a  shadow  immediately  above  the  pubic  rami 
(Fig.  524).  In  order  to  examine  a  patient  by  sounding,  he  is  laid  on 
a  couch  with  the  head  low,  and  the  buttocks  raised  on  a  pillow 


BLADDER  AND  PROSTATE  1239 

placed  beneath  them.  The  bladder  should  always  contain  a  few 
ounces  of  fluid,  so  as  to  obliterate  any  folds  produced  by  laxity  of 
the  mucous  membrane,  as  well  as  to  facilitate  the  introduction  of 
the  instrument ;  the  usual  antiseptic  precautions  as  to  surgeon's 
hands,  patient's  penis,  instrument,  and  lubricating  material,  are  of 
course  rigidly  enforced.  A  sterilized  sound  of  suitable  size,  warmed 
and  lubricated  by  some  antiseptic  preparation,  is  then  gently 
passed  along  the  urethra,  and  the  handle  depressed  between  the 
separated  legs  so  as  to  enable  the  point  to  enter  the  bladder.  The 
handle,  which  should  be  cylindrical  in  shape  and  fluted,  with  the 


Fig.  524. — Skiagram  of  Vesical  Calculus  in  a  Boy. 

maker's  name  or  some  mark  to  indicate  the  direction  of  the  beak,  is 
then  lightly  grasped  between  the  index  finger  and  thumb,  and 
rotated  from  side  to  side,  whilst  at  the  same  time  the  whole  instru- 
ment is  drawn  forwards  or  backwards  in  the  urethra.  Each  side  of 
the  bladder  is  thus  carefully  investigated,  and,  finally,  if  no  stone  is 
detected,  the  beak  is  turned  directly  downwards,  so  as  to  examine 
the  pouch  which  often  forms  behind  a  slightly  enlarged  prostate. 
The  presence  of  a  stone  is  recognised  by  a  metallic  click,  which  can 
be  felt  and  even  heard,  when  the  end  of  the  instrument  taps  it.  The 
character  of  the  click  is  some  guide:  to  the  size  and  density  of  the 


1240 


A  MANUAL  OF  SURGERY 


stone.  The  presence  of  two  or  more  calculi  is  indicated  by  the 
surgeon  being  able  to  touch  them  on  rotating  the  instrument  alter- 
nately to  each  side  of  the  middle  line,  or  by  seizing  one  stone  with  a 
lithotrite,  and  using  it  as  a  sound  for  the  other.  In  doubtful  cases, 
a  still  more  delicate  test  than  the  sound  is  obtained  by  passing  a 
medium-sized  tube  of  a  Bigelow's  evacuator,  and  washing  out  the 
bladder.  The  calculi  may  by  this  means  be  sucked  out  even  from 
sacculi,  and  be  felt  to  rattle  against  the  end  of  the  instrument  when 
the  pressure  upon  the  indiarubber  bulb  is  relaxed.  When  the  calculi 
are  multiple  and  of  small  size,  they  may  be  even  removed  in  this 
way  by  an  examination  which  was  only  intended  to  be  diagnostic  in 
character.  The  surgeon  must  not  forget  that  a  hypertrophied  bladder 
with  projecting  fasciculi-  may  somewhat  resemble  a  calculus,  espe- 
cially when  coated  with  phosphatic  material.  In  some  rare  instances 
a  calculus  may  be  so  completely  hidden  in  one  of  the  saccules  as  to 
render  its  detection  impossible  by  these  means.  An  encysted  calculus 
which  projects  into  the  bladder  is  recognised  by  being  always  found 
at  the  same  place. 

Course  of  the  Case. — A  patient  suffering  from  vesical  calculus  is 
certain,  sooner  or  later,  to  develop  symptoms  of  chronic  cystitis,  and 
septic  changes  in  the  urine  are  equally  sure  to  follow — possibly  as  a 
natural  sequence,  but  often  as  the  result  of  the  introduction  of  septic 
instruments.  The  bladder  is  hypertrophied,  and  if  the  stone  is  not 
removed,  the  mucous  membrane  becomes  ulcerated,  and  the  inflam- 
mation extends  to  the  kidneys;  the  patient's  life  is  thus  destroyed, 
partly  by  exhaustion,  and  partly  by  septic  or  uraemic  poisoning. 

The  Treatment  of  vesical  calculus  is  a  matter  which  has  exercised 
the  judgment  and  manipulative  dexterity  of  surgeons  for  many 
centuries.  A  large  number  of  operations  have  been  made  use  of, 
but  at  the  present  day  only  three  are  employed,  viz.,  lithotrity,  supra- 
pubic cystotomy,  and  very  uncommonly  perineal  cystotomy. 

Lithotrity  was  formerly  conducted  in  several  stages,  the  stone 
being  crushed,  and  the  patient  allowed  to  pass  the  debris  subse- 
quently ;  this  process  was  repeated  at  intervals  of  a  few  days,  until 
the  bladder  was  clear.  Such  a  proceeding  took  a  considerable  time, 
and  was  exceedingly  painful,  irksome,  and  dangerous  to  the  patient. 
The  introduction  of  Bigelow's  evacuator  completely  revolutionized 
this  operation,  and  enables  it  to  be  completed  at  one  sitting,  con- 
stituting the  proceeding  sometimes  termed  Litholapaxy. 

Operation. — The  patient  is  carefully  prepared  by  keeping  him 
under  observation  for  a  few  days,  regulating  the  bowels,  and,  if 
possible,  reducing  any  inflammation  of  the  bladder  by  suitable  diet 
and  drugs,  and  by  washing  it  out.  On  the  preceding  night  a  dose  of 
castor  oil  is  administered,  and  an  efficient  enema  a  few  hours  before 
the  operation.  The  patient  should  be  warmly  clad,  and  the  legs 
enclosed  in  thick  worsted  stockings  reaching  nearly  to  the  groins. 
After  anaesthesia  has  been  induced,  the  head  is  kept  low,  and  a 
pillow  placed  beneath  the  buttocks,  so  as  slightly  to  raise  the 
pelvis.     The   bladder    is    carefully   washed   out   with   some   bland 


BLADDER  AND  PROSTATE 


1241 


antiseptic,  such  as  a  solution  of  boric  acid,  and  about  6  ounces  of 
lotion  are  left  within  it,  in  order  not  only  to  obliterate  all  folds 
of  mucous  membrane,  but  also  to  facilitate  the  seizure  of  the  stone, 
and  to  prevent  injury  of  the  walls  during  the 
operation. 

The  lithotrite  is  then  introduced.  The  best  in- 
strument to  employ  is  Thompson's  modification  of 
Civiale's  (Fig.  525),  the  male  blade  of  which  is 
solid,  and  the  female  fenestrated.  Other  forms 
are  sometimes  used  in  which  the  female  blade  is 
solid,  and  is  either  the  same  size  or  larger  than 
the  male,  in  order  to  protect  the  walls  of  the 
bladder  from  injury.  The  male  blade  slides  easily 
up  and  down  a  groove  in  the  stem  of  the  female 
blade,  and  after  the  stone  has  been  seized  the 
blades  are  forcibly  pressed  together  by  a  screw 
action,  brought  into  play  by  the  mechanism  in  the 
handle,  which  can  be  put  in  and  out  of  gear  at 
will.  It  is  absolutely  essential  that  the  instru- 
ment should  be  made  of  well-tempered  steel,  so 
as  to  prevent  any  risk  of  breaking  during  the 
operation.  To  introduce  it  some  skill  is  needed, 
since  the  curved  end  is  short,  and  consequently 
the  handle  must  be  well  depressed  between  the 
legs,  in  order  that  the  beak  may  pass  under  the 
pubic  arch.  The  position  of  the  stone  is  next 
ascertained  by  rotating  the  instrument,  and  using 
it  as  a  sound ;  the  blades  are  opened,  and  the  stone 
caused  to  roll  between  them  by  a  slight  jerk  of  the 
handle.  This  is  better  than  attempting  to  pick  up 
the  calculus  by  inverting  the  blades,  and  is  less 
likely  to  injure  the  mucous  membrane.  If  fairly 
grasped,  the  blades  when  screwed  up  crush  it  into 
several  fragments,  each  of  which  is  subsequently 
dealt  with  in  a  similar  fashion.  If  only  the  margin 
of  the  stone  is  gripped,  the  application  of  screw 
pressure  may  cause  it  to  slip  away,  and  the 
manoeuvre  must  then  be  carefully  repeated. 
When  the  surgeon  is  satisfied  that  the  fragments 
are  sufiiciently  small,  the  largest  evacuator-tube 
that  can  be  safely  introduced  is  passed  into  the 
bladder.  To  effect  this,  it  is  sometimes  necessary 
to  incise  the  urethral  orifice  with  a  bistoury  in  a 
downward  direction.  The  evacuator  is  attached  to 
the  tube,  and  the  bladder  thoroughly  washed  out 
by  alternate  pressure  upon,  and  relaxation  of,  the 
rubber  bottle  (Fig.  526).  By  this  means  the  fragments  of  the  stone 
are  collected  in  the  glass  receptacle  which  forms  part  of  the  apparatus. 
The  washing  is  continued  until  no  more  fragments  are  heard  or  felt 


u 


1242 


A  MANUAL  OF  SURGERY 


to  rattle  against  the  end  of  the  tube.  It  is  often  necessary  to  re- 
introduce the  hthotrite  in  order  to  crush  some  larger  portions  of  the 
calculus  still  remaining ;  the  old  practice  of  withdrawing  small  frag- 
ments within  the  grasp  of  a  lithotrite  is  to  be  condemned.  It  is 
scarcely  necessary  to  re-sound  the  bladder  after  the  efficient  use 
of  the  evacuator.  A  certain  amount  of  bleeding  is  indispensable 
from  these  manipulations,  but  it  is  not  excessive  in  careful  hands. 
Should,  however,  considerable  bleeding  follow,  the  bladder  is  likely 
to  become  subsequently  distended  with  clots,  necessitating  the  use  of 
a  large-eyed  catheter  for  their  removal. 

After-Treatment. — -The  patient  is  placed  in  bed  as  soon  as  the 
operation  is  completed,  and  kept  warm  and  quiet,  and  suitable 
measures  must  be  taken  to  combat  shock.  The  diet  is  restricted  to 
fluids  for  a  few  days,  whilst  pain,  if  complained  of,  may  be  relieved 


Fig.  526  -Evacuator  in  Position  in  the  Bladder. 


by  a  little  morphia.     If  all  goes  well,  he  may  be  allowed  to  get  up  at 
the  end  of  the  week. 

Various  Sequelae  may  follow  this  operation.  Cystitis  results  partly 
from  mechanical  causes,  but  more  frequently  from  imperfect  asepsis. 
The  symptoms  are  usually  subacute  in  character,  and  may  pass  away 
after  a  few  days  ;  but  if  of  a  serious  type,  considerable  constitutional 
disturbance  arises,  and  a  large  amount  of  viscid  muco-pus  is  excreted, 
whilst  the  urine  becomes  alkaline  and  ammoniacal.  In  such  a  case 
it  is  absolutely  essential  to  wash  out  the  bladder  once  or  twice  a  day, 
as  if  left  to  itself  the  condition  is  very  liable  to  spread  up  to  the 
ureters,  and  may  destroy  the  patient's  life  by  suppurative  pyelone- 
phritis. Atony  of  the  bladder  is  occasionally  induced,  either  by  the 
operation  or  by  a  consequent  cystitis,  and  is  especially  common  in 
elderly  individuals.  It  must  be  treated  by  regular  and  aseptic 
catheterism.  When  the  patient's  kidneys  are  already  affected  prior 
to  the  operation,  an   acute  ascending  pyelonephritis  (p.  1189)  may 


BLADDER  AND  PROSTATE  1243 

be  originated  by  it,  perhaps  leading  to  suppression  of   urine  and 
death  from  uraemia. 

Suprapubic  Lithotomy  was  formerly  looked  on  as  a  serious  pro- 
cedure with  a  high  mortality  ;  at  the  present  time  increasing 
experience  has  shown  that  the  dangers  were  preventable,  and  that 
it  may  be  considered  a  very  successful  procedure.  The  bladder  is 
washed  out,  and  8  or  10  ounces  of  lotion  left  within  it ;  the  patient 
is  then  placed  in  the  Trendelenburg  position,  with  the  pelvis  raised 
well  above  the  head,  the  intestines  being  thus  allowed  to  gravitate 
to  the  postero-superior  part  of  the  abdomen  ;  as  soon  as  the 
abdominal  parietes  are  opened,  air  finds  its  way  into  the  connective 
tissue  behind  the  symphysis  (cavum  Retzii),  and  the  peritoneum  is 
thus  pressed  back. 

Operation. — The  pubes  having  been  previously  shaved,  and  the 
hypogastrium  purified,  an  incision  is  made  in  the  median  line 
reaching  from  the  top  of  the  symphysis  upwards  for  about  2  or 
3  inches  ;  the  lower  part  of  the  linea  alba  is  divided,  and  the  retro- 
pubic cellular  tissue  opened  up.  The  tense  rounded  outline  of  the 
bladder  can  now  be  readily  detected  with  the  finger,  and  a  couple  of 
lateral  silk  sutures  or  slings  are  passed  through  its  walls  so  as  to 
steady  it  and  prevent  its  subsequent  retraction.  An  opening  is  then 
made  into  it  in  the  middle  line  from  below  upwards,  through  which 
the  index  finger  is  passed  and  the  stone  examined.  Suitably  curved 
lithotomy  forceps  are  introduced,  and  the  stone  grasped  and  with- 
drawn. A  careful  examination  of  the  interior  of  the  bladder  is 
made,  to  ascertain  whether  any  further  calculi  are  present,  as  also 
to  investigate  the  condition  of  the  prostate,  which  may  sometimes  be 
advisably  removed  at  the  same  time.  The  after-treatment  of  the 
wound  differs  with  the  condition  of  the  bladder  ;  if  it  is  septic,  a  good 
sized  drainage-tube  is  introduced,  and  the  urine  syphoned  off,  healing 
occurring  by  granulation  in  three  to  six  weeks.  If  the  bladder  is 
healthy  and  free  from  sepsis,  it  may  be  closed  by  sutures,  which 
only  pass  through  the  muscular  and  submucous  coats,  and  thus 
when  tied  do  not  project  into  its  cavity.  The  external  wound  may 
then  be  left  open  or  closed,  except  at  the  spot  where  a  drainage-tube 
or  gauze  wick  is  passed  down  to  the  vesical  wound,  so  as  to  allow 
exit  to  any  urine  which  may  accidentally  leak  into  the  wound.  The 
urine  is  either  drawn  off  by  a  catheter  at  regular  intervals,  certainly 
not  less  than  three  or  four  times  daily,  or  the  bladder  is  drained  by 
tying  in  a  catheter. 

Perineal  Lithotomy  is  seldom  required  at  the  present  day  ;  the 
procedure  described  as  perineal  cystotomy  (p.  12 18)  would  be 
adopted.  The  finger  is  passed  into  the  bladder,  and  the  stone 
located.  It  is  removed  by  suitable  stone  forceps,  or  by  a  scoop  and 
the  finger.  Care  must  be  exercised  not  to  damage  the  structures  at 
the  neck  of  the  bladder,  or  pelvic  cellulitis  may  ensue ;  but  this 
danger  is  little  likely  to  arise,  as  the  operation  ought  never  to  be 
undertaken  when  the  stone  is  of  large  size. 

Formerly  much    importance   was   attached   to   the   operation   of 


1244  A  MANUAL  OF  SURGERY 

lateral  lithotomy,  in  which  the  stone  was  removed  through  a  perineal 
incision  which  included  the  left  lateral  lobe  of  the  prostate.  This 
procedure  is  now  entirely  superseded,  and  need  no  longer  be  de- 
scribed. 

Choice  of  Operation  for  Vesical  Calculus. — At  the  present  day 
lithotrity  has  been  brought  to  such  a  standard  of  excellence  that 
there  is  no  doubt  as  to  the  general  rule  which  should  be  followed, 
viz.,  that  unless  some  contva-indication  is  present,  all  cases  of  vesical  calculus 
should  he  treated  by  lithotrity. 

The  Contra-indications  to  Lithotrity  are  as  follow :  (i)  Conditions 
of  the  Stone.  If  the  calculus  exceeds  i^  inches  in  diameter,  it  is  not 
advisable  to  attempt  lithotrity,  on  account  of  the  damage  which  may 
be  inflicted  on  the  vesical  wall.  Moreover,  some  stones,  especially 
those  consisting  of  oxalate  of  lime,  are  so  hard  that  no  lithotrite  can 
crush  them.  Phosphatic  concretions,  on  the  other  hand,  are  so  soft 
that  a  lithotrite  becomes  clogged,  and  crushing  is  impracticable. 
An  encysted  stone  will  also  preclude  lithotrity  on  account  of  its 
fixed  position.  There  is  no  objection  to  dealing  with  multiple 
calculi  by  this  means,  but  if  only  of  small  size,  they  may  be  removed 
by  simply  using  the  evacuator.  (2)  Conditions  of  the  Urethra.  The 
existence  of  an  organic  stricture,  or  an  enlarged  prostate,  may  render 
lithotrity  impracticable  from  the  impossibility  of  passing  large  enough 
instruments,  whilst  false  passages  may  make  it  exceedingly  difficult. 
Excessive  irritability  of  the  urethra,  as  evidenced  by  the  occurrence 
of  severe  rigors  after  instrumentation,  may  also  render  the  operation 
unadvisable.  (3)  Conditions  of  the  Bladder.  The  existence  of  severe 
cystitis  or  the  presence  of  sacculi,  as  indicated  by  the  cystoscope, 
will  usually  suggest  the  performance  of  lithotomy;  whilst  a  con- 
tracted bladder,  which  will  only  hold  a  few  ounces  of  urine,  materially 
increases  the  dangers  and  difficulties  of  lithotrity. 

Suprapubic  Lithotomy  should  be  undertaken  under  the  following 
conditions :  (i)  Where  the  stone  is  too  large  to  be  dealt  with  by 
crushing ;  (2)  where  the  stone  is  encysted  ;  (3)  where  a  stricture  or 
enlarged  prostate  is  present,  and  it  is  often  feasible  to  remove  the 
prostate  at  the  same  time.  Suprapubic  cystotomy  is  only  absolutely 
contra-indicated  by  two  conditions,  viz.,  severe  septic  cystitis  and 
contraction  of  the  bladder. 

Indications  for  Perineal  Lithotomy. — (i)  When  serious  cystitis 
and  great  irritability  of  the  bladder  are  present,  the  incision 
facilitating  the  process  of  draining  and  washing  it  out ;  (2)  a  con- 
tracted and  hypertrophied  condition  of  the  bladder ;  (3)  when  a 
calculus  is  impacted  in  the  neck  of  the  bladder. 

Calculus  in  Boys  is  a  common  occurrence.  It  must  be  remembered 
that  the  bladder  is  rather  an  abdominal  than  a  pelvic  organ  in 
children,  and  hence  suprapubic  lithotomy  is  particularly  indicated, 
except  in  the  hands  of  skilled  lithotritists.  It  has  been  shown,  how- 
ever, that  lithotrity  can  be  safely  practised,  and  many  surgeons  in 
the  East,  where  stone  is  so  common,  employ  it  as  routine  procedure, 
granting  that  a  No.  6  catheter  can  be  passed,  and  that  the  stone 


BLADDER  AND  PROSTATE  1245 

is  not  too  large  for  a  lithotrite  to  grasp.     Special   lithotrites  and 
evacuators  are  constructed  for  the  purpose. 

Calculus  in  the  Female. — As  already  mentioned,  vesical  calculus  is 
very  rare  amongst  women,  owing  to  the  shortness  and  greater  size 
of  the  urethra,  so  that  small  stones  passing  downwards  from  the 
kidneys  are  easily  voided.  Phosphatic  concretions  are  not  un- 
common, and  are  then  formed  around  a  foreign  body  usually  intro- 
duced by  the  patient.  Many  of  the  symptoms  are  very  similar  to 
those  in  the  male.  Treatment. — If  the  calculus  does  not  exceed 
■|-  to  f  inch  in  diameter,  it  can  usually  be  extracted  by  dilating  the 
urethra  with  the  finger,  the  sphincter  being  also  nicked  in  two  or 
three  places  if  necessary.  It  is  never  wise  to  divide  the  sphincter 
totally,  as  incontinence  is  almost  certain  to  follow.  For  a  somewhat 
larger  stone  lithotrity  can  be  undertaken,  whilst  for  those  of  really 
large  size  suprapubic  cystotomy  is  the  best  procedure.  It  has  been 
recommended  to  open  the  bladder  through  the  anterior  vaginal  wall, 
and  thus  remove  a  stone ;  but  this  is  scarcely  desirable,  for  fear  of 
the  persistence  of  a  vesico-vaginal  fistula. 

Affections  of  the  Prostate. 

Acute  Prostatitis  arises  most  usually  as  a  sequela  of  gonorrhoea, 
either  in  its  acute  or  chronic  stage,  by  direct  extension  backwards 
of  the  inflammatory  process ;  it  is  also  occasionally  met  with  as  a 
result  of  stricture  arising  from  the  irritation  of  retained  and  decom- 
posing urine,  or  from  the  passage  of  instruments.  It  is  said  to 
be  induced  by  the  application  of  cold  or  damp  to  the  perineum,  as 
by  sitting  on  cold  stones  or  damp  grass,  but  probably  this  has  been 
preceded  by  bacterial  invasion  of  the  posterior  part  of  the  urethra. 
Suppuration  follows  in  not  a  few  cases,  being  due  to  the  infection  of 
the  prostatic  follicles  with  pyogenic  organisms.  Sometimes  merely 
one  or  two  superficial  follicles  are  affected,  causing  what  is  termed 
a  follicular  abscess ;  occasionally  the  mischief  extends  much  more 
widely,  involving  the  whole  of  one  lobe,  or  perhaps  the  whole  organ, 
and  constituting  a  parenchymatous  abscess. 

The  Symptoms  consist  of  deep-seated  pain  referred  to  the  neck  of 
the  bladder,  with  perhaps  a  sense  of  weight  and  fulness  about  the 
perineum,  and  pain  referred  to  the  end  of  the  penis.  Micturition 
becomes  frequent  and  painful,  and  defagcation  may  cause  consider- 
able distress.  As  the  organ  increases  in  size,  the  pain  becomes 
more  and  more  severe,  and  all  movements  of  the  body,  as  also  the 
act  of  sitting,  are  increasingly  difficult.  On  rectal  examination  the 
organ  can  be  felt  enlarged,  hot,  and  tender.  Suppuration  is  likely 
to  follow,  and  retention  of .  urine  may  be  thereby  induced.  A 
follicular  abscess  bursts  into  the  urethra  spontaneously,  or  is  ruptured 
by  the  passage  of  a  catheter  for  the  relief  of  retention ;  the  opening, 
however,  is  sometimes  of  a  valvular  nature,  and  only  a  small  portion 
of  the  pus  escapes.  The  process  may  then  continue  to  spread,  and 
the  pus  may  find  its  way  into  the  rectum,  or  come  to  the  surface 


1246  A  MANUAL  OF  SURGERY 

through  the  perineum.  In  either  of  the  latter  conditions  a  rectal  or 
perineal  fistula  is  liable  to  result.  Considerable  constitutional  dis- 
turbance, and  perhaps  a  good  deal  of  fever,  are  usually  associated 
with  this  affection,  whether  suppuration  occurs  or  not.  The  forma- 
tion of  a  parenchymatous  abscess  is  always  attended  with  much  more 
acute  symptoms,  both  general  and  local.  The  organ  is  larger  and 
produces  more  rectal  irritation ;  a  considerable  quantity  of  pus  may 
form,  and  suppuration  may  extend  beyond  the  capsule  into  sur- 
rounding parts. 

Treatment. — The  patient  should  be  kept  in  bed  on  a  restricted 
diet,  and  the  bowels  freely  opened  by  saline  purges,  combined  with 
small  doses  of  antimony,  and  perhaps  full  doses  of  hyoscyamus. 
Local  depletion  may  be  undertaken  by  cupping  the  perineum,  or  by 
applying  ten  or  twelve  leeches  to  it.  Hot  hip-baths  are  also  very 
valuable,  and  linseed-meal  poultices  may  be  placed  on  the  perineum 
after  the  leeches  have  been  removed.  Extreme  pain  should  be 
relieved  by  the  use  of  morphia  suppositories,  and  if  the  urine  needs 
to  be  drawn  off,  a  soft  rubber  catheter  of  small  size  should  be  used. 
If  an  abscess  forms  and  is  not  opened  by  the  passage  of  a  catheter, 
or  if  the  natural  opening  is  of  a  valvular  character,  so  that  the  cavity 
cannot  completely  empty  itself,  an  incision  must  be  made  into  it 
through  the  middle  line  of  the  perineum,  being  guided  by  a  finger 
placed  in  the  rectum ;  pus  may  not  be  reached  until  the  knife  has 
entered  to  a  depth  of  about  2  inches.  Urine  will  sometimes  escape 
from  this  opening,  and  may  continue  to  do  so  for  some  considerable 
time.  If  gonorrhoea  is  also  present,  suitable  treatment  must  be 
adopted  in  order  to  check  the  discharge.  When  the  abscess  is 
pointing  in  the  rectum,  it  may  be  wise  to  open  it  from  that  cavity ; 
but  every  effort  must  be  made  to  avoid  this  contingency,  as  a  recto- 
urethral  fistula  may  result. 

Chronic  Prostatitis  is  perhaps  one  of  the  most  common  causes  of 
chronic  gleet  after  gonorrhoea.  It  is  sometimes  left  as  a  sequela  of 
an  acute  attack,  or  may  arise  as  a  result  of  stricture. 

The  Symptoms  produced  by  it  are  a  sense  of  weight  and  fulness 
about  the  perineum,  combined  with  irritability  of  the  bladder,  and 
pain  referred  to  the  extremity  of  the  penis  at  the  end  of  micturition, 
owing  to  the  bladder  contracting  upon  the  hyperasmic  and  sensitive 
organ.  A  glairy  discharge  of  viscid  material,  similar  in  appearance 
to  uncooked  white  of  egg  (prostatorrhoea),  is  often  present,  whilst  fine 
threads  of  mucus  are  usually  seen  floating  in  the  urine,  being  due  to 
the  formation  of  mucous  casts  of  the  prostatic  ducts.  On  examina- 
tion through  the  rectum,  the  organ  can  be  felt  enlarged  and  tender, 
and  the  vesiculae  are  usually  in  the  same  condition.  Chronic  sup- 
puration may  follow,  the  abscess  bursting  into  the  urethra  or  rectum, 
or  pointing  in  the  perineum. 

The  Diagnosis  from  tuberculous  disease  can  usually  be  made  by 
careful  attention  to  the  history  and  physical  signs. 

Treatment  consists  in  counter-irritation  of  the  surface  of  the 
perineum,  as  by  blisters  or  iodine  paint,  care  being  taken  that  the 


BLADDER  AND  PROSTATE  1247 

reagent  employed  does  not  extend  either  to  the  anus  or  scrotum. 
Belladonna  suppositories  may  be  of  value,  whilst  the  occasional 
passage  of  a  cold  metal  bougie  may  do  good.  In  suitable  cases, 
where  a  long-standing  gleet  is  present  with  no  suspicion  of  suppura- 
tion, a  cure  may  occasionally  be  brought  about  by  the  administration 
of  iodide  of  potassium,  or  of  the  liq.  ferri  perchloridi  (TTl^xv.  or  more, 
t.d.s.),  combined  with  sulphate  of  magnesia.  The  local  application 
of  a  solution  of  nitrate  of  silver  by  a  porte-caustique  is  also  some- 
times recommended,  but  probably  the  best  treatment  consists  in 
forcible  dilatation  of  the  prostatic  urethra,  as  suggested  by  Ober- 
iander,  the  follicles  being  thereby  emptied  of  their  secretion  ;  massage 
of  the  prostate  per  rectum  against  a  sound  held  in  position  may 
also  be  useful.  Should  an  abscess  form,  it  is  incised  through  the 
perineum. 

Tuberculous  Disease  of  the  Prostate  is  usually  met  with  as  a  result 
of  extension  from  similar  disease  in  the  epididymus,  the  seminal 
vesicles  being  also  invaded ;  occasionally,  however,  it  may  arise  as  a 
primary  affection.  In  either  case,  it  rapidly  spreads  to  the  bladder, 
and  thence  to  the  ureters  and  kidneys.  The  prostate  is  found  to 
contain  caseous  masses  in  the  early  stages,  but  later  on  these  break 
down,  leading  to  extensive  ulceration,  and  sometimes  the  organ  is 
riddled  with  ragged  cavities.  The  symptoms  are  those  of  irritability 
of  the  neck  of  the  bladder,  combined  with  pain  referred,  perhaps,  to 
the  end  of  the  penis,  or  mainly  noticed  in  the  back  or  perineum. 
Haematuria  is  occasionally  produced,  whilst  pyuria  is  almost 
constant.  The  urine  is  feebly  acid  or  neutral,  and,  on  examination 
of  the  pus  which  is  deposited  on  standing,  the  tubercle  bacillus  may 
be  detected.  Rectal  examination  will  demonstrate  an  irregular 
enlargement  of  the  organ,  whilst  if  the  vesiculae  are  invaded  they 
can  also  be  felt. 

Treatment  consists  in  attending  to  the  general  health,  and  the 
administration  of  tonics ;  vaccination  with  tuberculin  (TR)  may 
prove  of  some  value.  Possibly,  if  the  disease  is  not  too  extensive, 
benefit  may  be  derived  from  scraping  away  the  tuberculous  tissue 
through  a  perineal  incision. 

Prostatic  Calculi  are  of  unfrequent  occurrence,  being  usually  met 
with  in  cases  of  chronic  prostatitis,  especially  that  resulting  from 
stricture  of  the  urethra  or  previous  attacks  of  gonorrhoea.  They 
are  generally  multiple,  and  of  small  size,  consisting  mainly  of 
carbonate  of  lime.  They  develop  primarily  in  the  glandular  crypts, 
and  may  remain  embedded  in  the  organ,  giving  rise  to  but  little 
inconvenience.  When  large  and  protruding  from  the  gland  into  the 
urethra,  symptoms  of  obstruction  to  the  flow  of  urine  are  produced, 
whilst  on  passing  a  catheter  or  sound  a  distinct  click  or  grating  may 
be  noticed.  In  the  latter  case,  great  irritability  of  the  neck  of  the 
bladder  is  induced.  Sometimes  a  number  of  them  are  found  in 
a  pouch  or  pocket,  formed  by  the  amalgamation  of  several  of  the 
crypts.  Diagnosis  can  be  effected  in  some  instances  by  skiagraphy, 
the  calculi  casting  shadows  usually  a  little  below  the  brim  of  the 


1248  A  MANUAL  OF  SURGERY 

pelvis.  It  is  in  some  instances  possible  to  remove  the  calculi 
through  the  urethra,  but  more  frequently  a  perineal  incision  is 
required. 

Enlargement  of  the  Prostate  (or,  as  it  used  to  be  termed,  senile 
hypertrophy)  is  a  condition  rarely  seen  under  fifty  years  of  age, 
characterized  by  a  chronic  persistent  overgrowth  of  the  organ,  which 
results  in  interference  with  the  act  of  micturition,  and  may  finally 
destroy  life  by  inducing  secondary  changes  in  the  bladder  and 
kidneys  by  prolonged  backward  pressure.  As  to  causation,  but  little 
is  known ;  it  is  not  apparently  attributable  to  excessive  sexual  indul- 
gence. It  may  attain  a  considerable  size,  perhaps  constituting  a 
tumour  as  large  as  one's  fist  and  weighing  200  grammes,  the  average 
normal  weight  of  the  prostate  being  about  18  grammes.  It  may  be 
of  hard  or  soft  consistence,  and  in  the  latter  case  is  extremely 
vascular.  The  vascularity  varies  from  time  to  time,  and  the  patient 
is  liable  to  sudden  attacks  of  congestion  which  aggravate  the 
symptoms.  On  section  the  organ  may  appear  to  be  homogeneous 
and  of  the  same  texture  throughout,  but  most  commonly  it  consists 
of  a  number  of  firm  rounded  masses,  sharply  defined,  and  held  to- 
gether by  a  certain  amount  of  connective  tissue.  Outside  these  is  an 
ill-defined  layer  of  stretched  (and  sometimes  atrophied)  muscular 
tissue,  containing  a  few  glandular  elements,  but  continuous  with  the 
stroma,  and  constituting  the  true  capsule  of  the  organ.  Still  further 
out  is  the  extrinsic  sheath,  derived  from  the  pelvic  fascia  (mainly 
recto-vesical) ;  it  consists  of  two  layers,  between  which  are  the  veins 
of  the  prostatic  plexus. 

Histologically,  an  enlarged  prostate  consists  of  an  overgrowth  of 
the  glandular  tissue,  sometimes  diffuse,  more  frequently  in  the  form 
of  multiple  adenomata,  set  in  a  connective-tissue  basis  developed 
from  the  prostatic  stroma  of  muscle  fibres.  Cystic  changes  are  not 
unusually  observed  in  these  adenomata.  Occasionally  a  few  fibro- 
myomata  may  develop,  but  they  are  decidedly  uncommon. 

The  changes  induced  in  connection  with  an  enlarged  prostate  are 
numerous  and  important.* 

1.  The  prostatic  sheath  of  pelvic  fascia  becomes  thickened  and 
condensed,  thereby  preventing  any  downward  expansion  of  the 
organ,  and  directing  its  enlargement  upwards. 

2.  The  close  connection  between  the  capsule  and  the  sheath, 
which  is  so  marked  a  feature  in  the  normal  anatomy  of  the  organ, 
is  profoundly  modified,  so  that  it  becomes  easy  to  enucleate  the  gland 
in  its  entirety  from  its  surroundings. 

3.  The  relations  to  the  bladder  wall  are  also  much  altered. 
Normally,  the  sphincter  (Fig.  527,  S.V.)  is  interposed  between  the 
prostate  and  the  vesical  mucosa.  As  the  gland  enlarges,  this  relation 
may  persist  (Fig.  528),  and  although  the  bladder  base  is  raised  up, 
the  growth  is  extravesical,  and  the  sphincter  muscle  covers  over 
the  enlargement.    More  frequently,  however,  the  gland,  as  it  enlarges, 

*  Vide  'The  Surgical  Anatomy  of  the  Normal  and  Enlarged  Prostate,'  by 
J.  W.  Thompson  Walker,  Med.-Chir.  Trans.,  vol.  Ixxxvii. 


BLADDER  AND  PROSTATE 


1249 


insinuates  itself  between  the  sphincter  and  internal  meatus,  con- 
stituting an  intravesical  enlargement  (Fig.  529).  This  is  generally 
most  marked  in  the  middle  line  behind,  constituting  the  so-called 
'  middle  lobe  '*  (Fig.  530) ;  but  it  may  involve  the  whole  gland,  which 
projects  into  the  bladder  as  a  collar-like  enlargement  around  the 
meatus,  whilst  sometimes  one  or  both  of  the  lateral  lobes  are  chiefly 
affected  in  this  manner.  The  gland  also  pushes  backwards  between 
the  seminal  vesicles,  which  in  time  ^re  displaced  from  their  connec- 
tion with  the  back  of  the  bladder,  and  constitute  a  posterior  relation 
with  the  enlarged  organ.  It  is  interesting  to  note  that  this  over- 
growth involves  mainly,  if  not  entirely,  the  upper  part  of  the  gland, 
and  that  the  portion  below  the  verumontanum  is  rarely  affected,  so 
that  the  openings  of  the  ejaculatory  ducts  are  not  displaced 
backwards. 


Fig.  527. 


Fig.  528. 


Fig.  529. 


Figs. 


527-529. — Diagrams  to  illustrate  Relation  of  the  Prostate  to 
THE  Sphincter  Vesica  (S.V.  ). 

In  Fig.  527  the  prostate  is  supposed  to  be  of  normal  size,  and  the  sphincter  lies 
above  it;  in  Fig.  528  the  prostate  is  enlarged,  but  has  no  intravesical  projec- 
tion or  '  middle  lobe,'  and  hence  the  sphincter  retains  its  normal  relation  ;  in 
Fig.  529,  the  most  common  type  of  prostatic  enlargement,  a  well-marked 
intravesical  projection  or  middle  lobe  exists,  the  sphincter  being  displaced 
backwards  by  this  development. 


4.  The  changes  produced  in  the  prostatic  urethra  and  neck  of  the 
bladder  vary  considerably  in  different  cases.  The,  length  of  the 
urethra  is  always  increased,  perhaps  by  2  or  3  inches,  or  even  more. 
Some  amount  of  obstruction  to  the  outflow  of  urine  is  universal.  In 
rare  instances  it  may  be  due  to  an  adenoma  becoming  pedunculated, 
and  projecting  downwards  into  the  urethra  as  a  polypus.  Occasion- 
ally the  base  of  the  middle  lobe  becomes  narrowed,  probably  as  the 
result  of  constriction  by  a  band  of  longitudinal  muscle  fibres  passing 
down  on  either  side  from  the  ureteral  orifice  to  the  meatus ;  the 
middle  lobe  thereby  becomes  more  or  less  pedunculated  and  may  be 
moveable,  constituting  a  ball-valve  which  determines  retention,  or 
else  wedging  open  the  internal  meatus  and  causing  incontinence;  As 
a  rule  the  outflow  of  urine  is  hindered  by  the  '  prostatic  bar,'  caused 

*  Students  must  remember  that  in  the  normal  prostate  there  is  no  middle  lobe, 
and  that  the  structure  thus  named  is  caused  by  an  abnormal  overgrowth  or  pro- 
jection from  one  of  the  lateral  lobes. 

79 


ISjO 


A  MANUAL  OF  SURGERY 


by  the  projection  of  the  middle  lobe,  which  also  hinders  the  entrance 
of  a  catheter.  When  both  lateral  lobes  are  enlarged  symmetrically, 
the  lumen  of  the  urethra  is  diminished  from  side  to  side,  being 
narrow  or  chink-like  instead  of  triangular,  but  its  vertical  measure- 
ments are  increased.  Asymmetrical  enlargement,  of  course,  dis- 
places the  urethra  to  one  or  other  side. 

5.  The  effect  of  an  enlarged  prostate  on  the  bladder  is  important. 
The  obstruction  to  the  outflow  of  urine  leads  to  increased  expulsive 
efforts  on  its  part,  and  consequently  the  wall  becomes  thickened  and 
hypertrophied.  This  involves  the  muscular  fibres,  which  stand  out 
prominently  as  rounded  fasciculi,  and  the  mucous  membrane  may 


Fig.  530. — Enlarged  Prostate  with  a  Large  Intravesical  Portion. 
(From  College  of  Surgeons'  Museum.) 

project  outwards  between  them  as  hernial  protrusions,  constituting 
saccules  in  which  urine  may  stagnate  and  decompose,  and  even 
phosphatic  concretions  form. 

In  almost  every  case  the  enlarged  prostate  projects  more  or  less 
into  the  vesical  cavity,  either  as  a  collar-like  mass  around  the  internal 
meatus,  or  as  one  or  more  rounded  outgrowths.  This  is  necessarily 
associated  with  a  pouching  backwards  of  the  lowest  part  of  the 
bladder  {prostatic  pouch),  which,  being  below  the  level  of  the  meatus, 
does  not  become  emptied  during  the  natural  process  of  micturition 
and  in  which  residual  urine  is  therefore  able  to  collect  and  remain. 

Cystitis  is  very  likely  to  follow,  either  by  infection  from  within  or 


BLADDER  AND  PROSTATE  1251 

from  the  use  of  unsterilized  instruments,  and  then  the  bladder  wall 
becomes  inflamed ;  ammoniacal  decomposition  of  the  urine  follows, 
and  renal  complications  may  ensue  (either  hydronephrosis  or  pyo- 
nephrosis), which  will  determine  a  fatal  issue. 

The  Symptoms  vary  somewhat  with  the  nature  and  position  of  the 
enlargement.  The  patient  at  first  finds  some  difficulty  in  micturition, 
especially  at  the  commencement  of  the  act ;  straining  often  hinders 
rather  than  assists.  The  stream  is  not  necessarily  smaller  than 
formerly,  but  is  projected  with  less  force.  Gradually  irritability  of 
the  bladder  ensues,  and  the  patient  has  to  pass  water  very  frequently, 
a  trouble  especially  noticed  during  the  night.     Some  degree  of  pain 


Fig.  531. — Enlarged  Prostate  after  Removal  by  Suprapubic  Operation. 

The  catheter  has  been  placed  in  the  urethra,  i,  The  so-called  middle  lobe,  or 
intravesical  projection  behind  the  internal  meatus ;  2  and  2a,  the  lateral  lobes  ; 
3,  indicates  the  nodular  adenomatous  masses  which  constitute  the  bulk  of  the 
swelling. 

and  a  sense  of  weight  and  fulness  about  the  perineum  are  also  ex- 
perienced, whilst  tenesmus,  and  even  hernia,  may  be  subsequently 
induced  by  the  straining.  Intermittent  attacks  of  increased  pain  and 
difficulty  in  micturition  occurs  from  time  to  time,  being  generally  in- 
duced by  exposure  to  cold  and  wet,  and  presumably  due  to  con- 
gestion of  the  prostate.  After  lasting  for  a  few  days  the  more  acute 
symptoms  slowly  disappear,  if  judiciously  treated. 

As  the  obstruction  increases,  a  certain  amount  of  residual  urine 
remains  within  the  bladder  after  each  act  of  micturition,  the  vesical 
muscles  in  time  losing  power  and  becoming  atonic.  Well-marked 
distension  and  atony  of  the  bladder  ensue  at  length  in  neglected 
cases,  the  urine  dribbling  away  and  wetting  the  clothes,  whilst  de- 


1252  A  MANUAL  OF  SURGERY 

composition  of  the  retained  fluid  follows,  and  causes  cystitis  with  in- 
creasing vesical  irritation  and  muscular  spasm.  The  urine  becomes 
alkaline  after  a  time,  containing  muco-pus  and  phosphates,  the  result 
of  chronic  cystitis.  This,  if  untreated,  is  certain  to  lead  to  hydro- 
nephrosis and  pyelonephritis.  The  general  health  of  the  patient  is 
slowly  undermined  by  the  constant  irritation  produced  by  this 
process,  as  also  by  toxic  absorption,  and  the  final  chapter  may  be 
ushered  in  by  symptoms  of  uraemia  from  the  mischief  inflicted  on  the 
kidneys. 

Occasionally  the  early  symptoms  may  pass  unnoticed  for  a  con- 
siderable time,  the  patient  imagining  that  the  frequent  calls  to  pass 
water  are  good  signs  rather  than  evidences  of  disease.  In  such  cases 
the  bladder  may  become  over-distended,  and  the  condition  unsus- 
pected until,  owing  possibly  to  some  exposure  to  cold  or  t)ver- 
indulgence  in  alcohol,  complete  retention  is  induced,  and  then,  to  the 
surprise  of  the  patient,  an  enormous  amount  of  urine  is  withdrawn  on 
the  passage  of  a  catheter.  Priapism  is  sometimes  a  troublesome  con- 
dition, and  the  effect  of  this  on  the  moral  sense  may  be  very  serious, 
and  leads  in  some  cases  to  acts  of  gross  indecency. 

The  Diagnosis  of  enlarged  prostate  is  made  partly  by  a  considera- 
tion of  the  symptoms  complained  of,  but  mainly  by  an  examination 
of  the  urethra  and  rectum.  The  age  of  the  patient,  the  increasing 
irritability  of  the  bladder  by  night  and  day,  the  fact  that  straining 
hinders  rather  than  helps  the  expulsive  act,  together  with  evidence 
of  vesical  distension— all  these  facts  indicate  that  the  seat  of  obstruc- 
tion lies  in  the  prostate.  A  rectal  examination  is  then  instituted,  and 
some  idea  gained  of  the  size  and  condition  of  the  organ  ;  it  must  not 
be  forgotten,  however,  that  the  size,  as  recognised  by  a  finger  in  the 
rectum,  cannot  measure  in  any  way  the  amount  of  obstruction  to  the 
passage  of  the  urine,  and,  in  fact,  it  often  happens  that  where  the 
gland  does  not  feel  especially  large  from  the  rectum,  the  obstruction 
is  the  greatest.  The  careful  introduction  of  a  catheter  will  assist  in 
making  the  diagnosis,  inasmuch  as  the  barrier  at  the  neck  of  the 
bladder  is  easily  detected,  and  sometimes  with  difficulty  passed. 
For  the  diagnosis  from  cancer  of  the  prostate,  see  p.  1256. 

Treatment. — All  that  is  required  at  first  is  regular  catheterism,  in 
order  to  prevent  the  bladder  from  becoming  over-distended,  and  this 
the  patient  may  often  be  taught  to  do  for  himself.  To  pass  a  catheter 
in  a  case  of  enlarged  prostate  is  not  always  easy,  owing  to  the  fact 
that  the  middle  lobe  (Fig.  529)  projects  across  the  urethra,  and  bars 
the  onward  progress  of  an  instrument  of  the  ordinary  shape.  The 
surgeon  should  therefore  use  a  catheter  coude  or  bicoude  (Fig.  532), 
which  consists  of  a  soft,  straight  instrument  of  the  usual  French  type, 
the  end  of  which  is  bent  or  doubly  bent  at  an  angle,  like  an  elbow,  so 
as  to  enable  it-  to  ride  over  the  obstruction ;  or  he  may  employ  an 
English  gum-elastic  catheter,  the  stilette  of  which  is  drawn  out  a 
little  so  as  to  increase  its  curve ;  or  he  may  utilize  the  silver  prostatic 
catheter,  which  is  longer  and  more  curved  than  usual,  depressing  it 
well  between  the  thighs  after  clearing  the  pubic  arch.     Whichever 


BLADDER  AND  PROSTATE  1253 

method  is  adopted,  no  force  is  required,  since  with  a  Httle  skill  the 
point  of  the  instrument  will  pass  round  the  obstruction  and  enter  the 
bladder.  Every  precaution  must  be  taken  to  ensure  the  efficient 
sterilization  of  all  instruments  employed,  and  it  should  be  remem- 
bered that  as  a  general  rule  large  rather  than  small  instruments  wil* 
pass  more  easily. 

During  the  first  fortnight  of  catheter  life  the  patient  must  be  care- 
fully guarded  from  cold  and  exposure,  to  avoid  the  occurrence  of 
constitutional  disturbance.  Not  unfrequently  a  certain  amount  of 
fever  (to  which  the  name  of  Catheter  Fever  was  given  by  the  late 
Sir  Andrew  Clark)  is  produced,  which  either  passes  off  in  the  course 
of  a  few  days,  or  may  increase,  together  with  symptoms  of  chronic 
cystitis,  running  on  to  a  fatal  issue  at  the  end  of  three  or  four 
weeks.  The  origin  of  this  condition  is  still  somewhat  doubtful ;  it 
probably  arises  from  the  absorption  of  micro-organisms  or  their 
products  from  the  urethra,  or  from  the  use  of  impure  instruments, 
but  possibly  reflex  nervous  disturbance  plays  some  part  in  its  pro- 
duction. The  only  treatment  required  in  the  simpler  cases  is  to  keep 
the  patient  warm  in  bed,  to  limit  his  diet,  to  administer  quinine  and 
perhaps  opium,  and  to  keep  the  bowels  well  open. 


Fig,  532.— Catheter  Coude  and  Bicoude. 

During  the  continuance  of  catheter  life,  the  patient  must  be 
warned  to  live  quietly,  and  abstain  from  all  excesses,  especially  as 
regards  eating  and  drinking;  sexual  excitement  should  be  avoided, 
and  horse-exercise  forbidden  ;  precautions  must  also  be  taken  to 
ensure  protection  from  cold  and  damp.  The  administration  of 
alkalies  is  desirable  if  the  urine  is  highly  acid,  so  as  to  diminish  the 
irritability  of  the  bladder. 

Under  such  a  regime,  it  is  possible  that  the  patient  may  live  in 
comparative  comfort  perhaps  for  years,  the  progress  of  the  affection 
being  entirely  checked  in  some  instances.  In  others,  the  patient 
suffers  from  intermittent  attacks  of  congestion  of  the  prostate,  with 
increased  pain  and  irritability  of  the  bladder,  and  augmented  diffi- 
culty in  micturition.  The  introduction  of  a  catheter  is  then  very 
likely  to  cause  bleeding,  but  a  few  days'  rest  in  bed,  hot  baths  and 
the  administration  of  ergot,  usually  bring  about  considerable 
improvement.  If  there  is  much  difficulty  in  passing  a  catheter,  it 
may  be  wise  to  tie  it  in  for  a  time,  or  even  suprapubic  aspiration  may 
be  required.  The  p]:ogress  of  the  case  depends,  to  a  large  extent, 
upon  the  bladder  remaining  free  from  septic  contamination,  and  the 
surgeon  must  realize  and  impress  upon  his  patient  that  such  is 
generally   due    to    infection    from   without,   and    hence    the    most 


1354 


A  MANUAL  OF  SURGERY 


scrupulous  care  must  be  taken  to  sterilize  all  instruments  before  and 
after  use.  In  cases"  where  the  relief  given  by  regular  catheterism  is 
but  temporary,  and  the  irritability  of  the  bladder  or  the  amount  of 
residual  urine  increases  seriously,  or  the  patient  wishes  to  be  freed 
from  the  wearisome  necessity  of  regular  and  perhaps  frequent 
catheterism,  operation  for  removal  of  the  enlarged  organ  may  be 
recommended. 

Prostatectomy  was  originally  practised  by  McGill  of  Leeds  many 
years  ago,  but  it  has  only  been  established  as  a  successful  and  emi- 
nently practicable  procedure  for  a  few  years,  and  that  mainly  by  the 
energy  of  Mr.  P.  J.  Freyer.  There  has  been  much  discussion  as  to 
whether  the  whole  prostate  is  removed  from  its  fascial  sheath  in  this 
procedure,  or  merely  an  intraglandular  enucleation  performed. 
This  probably  depends  largely  on  the  technique ;  either  procedure  is 
possible,  and  in  the  more  exaggerated  cases  there  is  not  much  to 
choose  between  the  two,  as  the  enlarged  organ  is  entirely  adeno- 
matous, and  the  intrinsic  capsule  is  thinned  and  atrophic.  The 
surgeon's  aim,  however,  should  be  directed  towards  the  complete 
removal  of  the  organ,  the  line  of  cleavage  being  placed  between  what 
we  have  described  as  the  capsule  and  the  fascial  sheath.  Two 
methods  of  approach  are  possible,  viz.,  from  the  perineum  or  by  the 
suprapubic  route.  Personally,  we  are  at  one  with  the  majority  of 
surgeons  in  preferring  the  latter. 

Suprapubic  Prostatectomy. — If  there  is  much  cystitis,  the  bladder 
must  be  carefully  prepared  for  a  few  days  by  keeping  the  patient  in 
bed  and  washing  it  out  with  a  mild  antiseptic,  or  even  possibly  by 
draining  it.  At  the  time  of  operation  it  is  again  irrigated,  and  some 
6  ounces  or  so  of  boric  acid  lotion  left  in  it.  The  patient  is  placed  in 
the  Trendelenburg  position,  and  the  usual  suprapubic  incision  made 
into  the  bladder.  The  vesical  wall  is  by  some  anchored  to  the 
abdominal  parietes  by  a  deep  silkworm  gut  stitch  on  either  side,  so 
that  it  shall  not  be  unduly  torn  or  displaced  in  the  subsequent 
manipulations  ;  this  step  is  not  essential,  although  the  introduction  of 
a  silk  sling  through  the  bladder  wall  on  either  side  is  desirable.  The 
portion  of  the  prostate  projecting  into  the  bladder  is  now  carefully 
examined  and  its  removal  commenced.  The  mdex  and  middle  fingers 
of  the  left  hand  (which  is  covered  with  a  sterilized  indiarubber  glove) 
are  introduced  into  the  rectum  so  as  to  steady  and  push  forwards  the 
prostate.  The  right  index  finger  tears  through  the  mucous  mem- 
brane behind  the  projecting  median  lobe  or  collar,  thus  passing 
between  it  and  the  displaced  sphincter  vesicae.  It  will  often  be 
found  aji  easy  matter  to  pass  the  finger  round  the  enlarged  organ  and 
enucleate  it ;  the  larger  the  prostate,  the  more  easily  this  is  effected ; 
but  when  it  is  comparatively  small  and  hard,  enucleation  may  be 
difficult.  In  this  procedure  the  ejaculatory  ducts  are  torn  across,  as 
also  the  vessels  which  enter  and  leave  the  gland  on  either  side.  The 
urethra  is  either  removed  entirely,  or  the  lower  portion  of  it  is 
detached  and  left  behind.  The  prostate  when  free  in  its  sheath 
remains  either  in  one  mass,  or  not  unfrequently  separates  into  two 


BLADDER  AND  PROSTATE  1255 

halves,  which  can  be  peeled,  off  the  urethra  and  removed  separately 
from  the  bladder. 

This  enucleation  is  attended  by  remarkably  little  bleeding  in  the 
majority  of  cases,  and  even  when  at  all  free  it  can  be  quickly  re- 
strained by  irrigating  the  cavity  and  bladder  with  hot  saline  or  boric 
acid  solution  through  a  catheter.  A  large  rubber  tube  is  passed  into 
the  bladder  and  stitched  in  the  lower  angle  of  the  wound,  the  upper 
end  of  which  is  closed  by  deep  sutures.  The  wound  is  covered  with 
a  few  layers  of  cyanide  gauze,  and  over  this  absorbent  wool  is  placed 
in  sufficient  quantity  to  take  up  the  urine  secreted.  Morphia  is  often 
needed  to  combat  the  pain  and  spasm  that  supervene,  and  it  is 
advisably  given  as  a  suppository,  or  as  a  starch  and  laudanum  enema. 
The  subsequent  treatment  varies  somewhat.  Probably  the  best 
method  is  to  dress  the  wound  with  gauze  and  wool,  which  are 
renewed  every  four  or  six  hours  as  may  be  required.  The  amount  of 
dressing  required  is  large,  and  the  expense  is  considerable.  Some 
surgeons  employ  Irving's  apparatus,  a  glass  cap  which  fits  closely 
over  the  wound,  kept  in  place  by  elastic  bands  round  the  body,  and 
draining  into  tubes  which  carry  away  the  urine  to  a  bottle  between 
the  legs.  This  appliance  keeps  the  patient  dry,  and  saves  the 
expense  of  dressing ;  but  it  keeps  the  patient  on  his  back,  it  presses 
on  the  wound  and  lower  abdomen,  and  probably  it  hinders  the  healing 
process  somewhat.  The  bladder  is  irrigated  daily  through  the  supra- 
pubic incision,  and  blood  and  small  sloughs  will  escape  for  some 
days.  As  soon  as  the  suprapubic  wound  is  protected  by  a  layer 
of  granulations,  the  tube  should  be  withdrawn,  and  the  urine  allowed 
to  escape  or  to  collect  in  the  bladder.  A  catheter  is  passed  about  the 
end  of  the  first  week,  and  the  bladder  washed  out  through  it.  The 
patient  is  allowed  up  in  an  arm-chair  as  soon  as  possible  to  avoid 
pulmonary  complications.  Not  unfrequently  he  will  commence  to 
pass  urine  naturally  in  about  a  fortnight  or  three  weeks,  and  subse- 
quently the  function  will  be  maintained  in  a  normal  fashion. 

In  Perineal  Prostatectomy  a  median  staff  is  passed,  and  then  the 
membranous  urethra  and  apex  of  the  prostate  are  exposed,  either  by 
an  antero-posterior  or  transverse  incision  in  the  perineum.  The 
fascial  sheath  of  the  prostate  is  torn  through  or  divided  by  the  knife, 
and  enucleation  is  then  carried  out  by  the  finger,  assistance  being 
derived  by  pressing  the  bladder  downwards  from  above  the  pubes. 
It  is  claimed  that  the  urethra  is  less  damaged  in  this  procedure,  but 
its  advantages  are  not  apparent. 

If  the  patient  refuses  operation,  or  if  his  general  condition 
prevents  it  from  being  undertaken  with  safety,  and  catheterism  is 
insufficient  to  give  relief  to  his  symptoms,  a  permanent  fistula  either 
above  the  pubes  or  through  the  perineum  must  be  established 
necessitating  the  use  of  a  portable  urinal.  This  is  effected  by  intro- 
ducing a  trocar  and  cannula  into  the  bladder,  and  leaving  it  there 
until  a  sufficient  track  has  been  formed. 

Cancer  of  the  Prostate  occurs  in  elderly  men,  but  is  more  common 
than  was  formerly  supposed  ;  it  is  usually  of  a  scirrhous  type,  though 


1256  A  MANUAL  OF  SURGERY 

sometimes  it  is  of  a  soft  nature;  in  either  form  it  early  progresses 
beyond  the  hmits  of  the  capsule.  The  symptoms  produced  are 
at  first  similar  to  those  caused  by  simple  enlargement  of  the  prostate ; 
but  the  progress  of  the  case  is  much  more  rapid,  the  amount  of  pain 
and  discomfort  is  much  greater,  and  the  pain  is  often  referred  to  the 
back  of  the  thighs  and  down  the  legs.  Later  on  haematuria  may 
occur.  On  rectal  examination  a  hard  mass  is  readily  detected,  fixed 
more  or  less  to  surrounding  parts,  and  perhaps  with  outlying  nodules 
distinct  from  the  main  mass ;  secondary  deposits  may  be  found  in  the 
lumbar  and  abdominal  glands  on  palpating  the  abdomen.  Occasion- 
ally phenomena  referable  to  pressure  on  the  abdominal  vessels  and 
nerves  arise,  and  the  symptoms  of  general  cachexia  soon  manifest 
themselves.  Palliative  treatment  alone  can  be  adopted  in  the 
majority  of  cases. 


CHAPTER  XL, 
AFFEOTIONS  OF  THE  URETHRA  AND  PENIS. 

Affections  of  the  Uretkra. 

Congenital  Malformations. — Total  Absence,  or  Occlusion,  of  the  urethra 

has  been  met  with,  the  urine  under  such  circumstances  being  some- 
times retained,  and  leading  to  dilatation  of  the  bladder,  ureters,  and 
kidneys,  a  condition  rapidly  fatal,  even  if  the  child  be  born  alive. 
In  a  few  cases  the  urachus  remains  patent,  and  a  congenital  urinary 
fistula  is  established  at  the  umbilicus,  whilst  in  others  the  cloaca! 
condition  persists,  the  urine  passing  into  the  rectum  (Fig.  498). 

Epispadias  is  a  deformity  in  which  the  urethra  is  partially  or  wholly 
exposed  along  the  upper  surface  of  the  penis.  According  to  Sir 
Henry  Morris,  it  is  not,  properly  speaking,  a  division  or  deficiency  in 
the  upper  wall  of  the  urethra,  but  in  its  floor,  which  has  been  trans- 
posed to  the  dorsum  by  torsion  of  the  penis.  '  It  is  thus,  in  fact,  a 
hypospadias  reversed — /.?., upside  down.'  In  rare  instances,  the  ex- 
ternal meatus  is  situated  just  above  the  glans,  which  is  cleft  and 
deeply  grooved  superiorly.  More  commonly  the  urethra  opens  at  the 
root  of  the  penis,  just  in  front  of  the  sym.physis,  and  in  such  patients 
the  organ  is  always  rudimentary  and  stunted.  Complete  epispadias 
is  only  present  when  associated  with  extroversion  of  the  bladder 
(p.  1211).  The  incomplete  form  has  been  treated  with  success  by 
the  use  of  reversed  flaps  dissected  up  from  the  side  of  the  penis.  For 
details  of  the  operations  on  this  and  the  following  conditions,  see 
larger  text-books  on  operative  surgery. 

Hypospadias,  or  defective  development  of  the  lower  wall  of  the 
urethra,  is  a  much  more  common  malformation  than  the  foregoing. 
Three  varieties  are  described.  In  (a)  hypospadia  glandis  the  opening 
of  the  urethra  corresponds  to  the  position  usually  occupied  by  the 
frsenum,  and  is  thus  directed  downwards  instead  of  forwards.  The 
prepuce  in  these  cases  is  always  voluminous,  and  hangs  like  a  hood 
over  the  glans,  which  is  bent  down  over  the  orifice,  [h)  Hypospadia 
penis  is  characterized  by  the  urethra  opening  somewhere  along  the 
under  surface  of  the  body  of  the  penis,  which  is  often  small  and 
stunted.  Considerable  discomfort  may  arise  in  the  act  of  micturition 
owing  to  the  urethral  orifice  looking  downwards  ;  it  is  also  some- 
times so  small  as  to  require  incision  and  dilatation,     (c)  Complete 

1257 


1258  A  MANUAL  OF  SURGERY 

hypospadias,  or  hypospadia  perinealis,  is  a  somewhat  complicated 
condition,  in  which  the  lower  wall  of  the  urethra  is  defective  as  far 
back  as  the  perineum,  the  scrotum  being  cleft,  and  thus  resembling 
the  vulva.  The  penis  is  always  small,  imperfectly  developed,  and 
bound  down  by  adhesions  between  the  scrotal  segments,  looking 
not  unlike  a  hypertrophied  clitoris,  and  late  descent  of  the  testes  is 
common.  Under  such  circumstances  it  is  not  surprising  that  the 
sex  of  the  child  has  been  mistaken,  and  not  a  few  cases  are  on 
record  where  it  has  been  educated  as  a  female  until  the  age  of 
eighteen  or  twenty. 

In  the  incomplete  varieties,  where  the  deformity  is  slight  and  the 
urethral  opening  well  in  front  of  the  scrotum,  no  interference  is  neces- 
sary ;  but  where  it  encroaches  on  the  scrotum,  causing  inconvenience 
and  discomfort,  and  threatening  to  prevent  effective  sexual  intercourse 
in  the  future,  the  restoration  of  the  urethra  may  be  attempted  by  the 
use  of  reversed  flaps  obtained  from  either  side,  or  from  the  redundant 
prepuce.  In  the  complete  form  the  penis  must  first  be  liberated  from 
its  adhesions  and  set  free ;  the  integument  lining  the  scrotal  cleft  is 
then  dissected  up  and  turned  inwards  toform  the  posterior  part  of  the 
urethra,  whilst  the  lateral  halves  of  the  scrotum  are  brought  together 
with  sutures  ;  the  anterior  portion  of  the  urethra  may  then  be  dealt 
with  as  for  the  incomplete  variety. 

Traumatic  Laceration  of  the  Urethra  usually  results  from  violence 
applied  directly  to  the  perineum,  as  by  falling  astride  a  stile,  fence,  or 
beam  ;  it  has  also  been  caused  by  severe  jolting  in  the  saddle,  or  by 
a  kick  in  the  perineum.  In  fractures  of  the  pelvis  it  may  be  produced 
by  a  spicule  of  bone  puncturing  the  canal,  and  the  membranous  por- 
tion is  that  generally  affected.  The  whole  circumference  of  the  urethra 
may  be  involved,  the  two  segments  being  entirely  disconnected,  or 
only  a  portion  may  be  ruptured,  and  that  most  frequently  the  floor. 

The  Symptoms  consist  of  pain  in  the  perineum  and  shock,  followed 
by  great  distension  of  the  scrotum  from  haemorrhage,  whilst  blood 
trickles  from  the  urethral  orifice.  If  the  patient  is  able  to  restrain 
himself  from  passing  water,  and  is  successfully  treated,  no  extravasa- 
tion of  urine  results,  since  the  lesion  is  below  the  sphincter  vesicae ; 
if,  however,  he  attempts  to  micturate,  the  urine  finds  its  way  into  the 
perineal  and  scrotal  tissues.  Whether  the  rupture  is  complete  or  not, 
an  organic  stricture  of  considerable  density  is  almost  certain  to  follow, 
and  great  difficulty  is  subsequently  experienced  in  keeping  it  dilated. 

Treatment. — In  the  slighter  cases,  where  it  is  probable  that  the 
mucous  membrane  has  alone  been  torn  and  there  is  no  perineal  swell- 
ing, the  patient  .should  be  kept  quiet  in  bed,  and  no  attempts  made  at 
instrumentation.  If  urinary  infection  of  the  wound  occurs  and  an 
abscess  forms,  it  can  be  dealt  with  by  incision  at  a  later  date. 

Where,  however,  it  is  thought  that  the  urethra  is  partially  or 
wholly  divided,  no  temporizing  measures,  such  as  tying  in  a  catheter, 
even  if  that  be  possible,  should  be  adopted.  An  incision  ought  to  be 
made  at  once  into  the  perineum  so  as  to  expose  the  divided  ends  of 
the  urethra,  which  it  is  the  surgeon's  aim  to  unite.     The  blood-clot 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1259 

is  removed,  bleeding  points  are  secured,  and  if  the  ends  of  the 
urethra  can  be  identified,  a  soft  catheter  is  introduced  into  the 
bladder,  and  they  are  sutured  together  around  it  with  fine  catgut. 
When  the  ends  are  much  torn,  it  is  wise  to  cut  away  the  bruised 
extremities  so  as  to  have  clean,  smooth  surfaces  to  deal  with.  Under 
any  circumstances  the  catheter  must  be  kept  in  for  five  or  six  days, 
if  possible,  and  subsequently  an  instrument  should  be  passed  every 
day  for  some  time. 

If  a  catheter  cannot  be  introduced,  or  if  extravasation  has  occurred, 
free  incisions  must  be  made  into  the  scrotum  and  perineum  to  give 
exit  to  the  blood  and  urine,  and  to  expose  the  seat  of  injury.  A 
catheter  is  passed  as  far  as  possible,  and  its  point  felt  for,  cut  down 
on,  and  guided  into  the  bladder ;  a  prolonged  attempt  under  anaes- 
thesia may  be  necessary  to  accomplish  this,  and  even  then  it  is  use- 
less to  attempt  to  stitch  up  the  urethra,  as  the  sutures  are  certain  to 
cut  out.  Occasionally,  and  especially  if  treatment  has  been  delayed, 
the  swelling  of  the  parts  is  so  great  as  to  render  the  passage  of  a 
catheter  impossible.  The  patient  must  then  be  put  to  bed  for  a  few 
days  until  the  blood-clot  has  disappeared,  the  urine  in  the  meantime 
escaping  through  the  perineal  wound  ;  but  as  soon  as  possible  another 
attempt  must  be  made.  When  once  the  catheter  is  passed,  it  must  be 
retained  for  several  days,  so  as  to  establish  the  continuity  of  the  tube. 

Foreign  Bodies  are  sometimes  found  in  the  urethra,  usually  con- 
sisting of  a  portion  of  a  catheter,  pipe-stem,  or  in  children  a  piece  of 
slate-pencil.  Their  presence  gives  rise  to  partial  or  complete  obstruc- 
tion to  the  flow  of  urine,  followed  by  ulceration  of  the  mucous  mem- 
brane, the  formation  of  a  peri-urethral  abscess,  or  even  extravasation. 
They  are  readily  detected  on  the  passage  of  a  sound  or  catheter,  and 
may  be  removed  by  suitable  forceps  if  situated  near  the  orifice. 
Should  this  fail,  the  urethra  may  be  incised  and  the  body  extracted  ; 
a  troublesome  urinary  fistula  is  apt  to  follow  this  proceeding,  even 
when  the  wound  in  the  urethra  has  been  carefully  sutured. 

A  pin  is  sometimes  introduced  voluntarily  into  the  urethra,  and  is 
not  easily  removed,  since  it  has  usually  been  pushed  in  head-foremost. 
The  following  manoeuvre  is  necessary  in  order  to  remove  it :  The 
point  is  made  to  penetrate  the  floor  of  the  urethra  and  skin  by  a 
sharp  push  on  the  head  from  behind.  The  body  is  pulled  out  until 
the  head  catches  against  the  mucous  membrane,  and  then  the  direction 
of  the  pin  can  be  changed,  so  that  the  head  presents  at  or  towards 
the  meatus. 

Impacted  Calculus  is  a  not  unf  requent  cause  of  retention  in  children. 
It  can  usually  be  felt  through  the  walls  of  the  canal.  The  symptoms 
and  treatment  are  much  the  same  as  for  foreign  bodies.  When  near 
the  neck  of  the  bladder,  it  should  be  pushed  back  into  that  viscus,  if 
possible,  and  treated  by  lithotrity. 

Simple  Urethritis  may  arise  from  a  variety  of  causes  apart  from 
gonorrhoea,  e.g.,  the  presence  in  the  female  of  an  irritating  vaginal 
discharge,  such  as  leucorrhoea,  and  possibly  due  to  the  B.  coli.  It 
also  occurs  after  the  passage  of  an  instrument  or  of  a  calculus,  and 


i26o  A  MANUAL  OF  SURGERY 

is  occasionally  excited  in  gouty  individuals  by  highly  acid  urine, 
charged  presumably  with  spiculated  crystals  of  uric  acid.  The 
symptoms  are  much  the  same  as  those  of  gonorrhoea,  but  the  dis- 
charge is  thinner  in  character,  and  on  microscopical  examination 
no  gonococci  are  detected.  The  treatment  consists  in  the  adminis- 
tration of  alkalies  and  saline  purgatives,  all  forms  of  alcohol  being 
interdicted.  In  more  severe  cases  oleo-balsams  may  be  prescribed, 
and  even  mild  injections. 

Polypoid  Tumours,  similar  in  character  to  the  caruncle  met  with  in 
the  urethra  of  women,  have  been  observed  at  the  orifice  of  the  male 
urethra.  They  are  red,  vascular,  and  sometimes  exceedingly  painful, 
and  are  best  dealt  with  by  excision,  followed  by  the  application  of  the 
galvano-cautery,  so  as  to  stop  the  bleeding,  which  is  always  copious. 
If  of  large  size,  the  base  may  be  ligatured  and  the  growth  cut  away. 

Epithelioma  of  the  urethra  is  usually  secondary  to  some  other 
malignant  development  in  the  neighbourhood,  e.g.,  of  the  prostate. 
Occasionally,  however,  it  is  primary,  and  then  frequently  the  sequela 
of  an  old  stricture.  It  constitutes  a  hard  swelling  of  the  urethra,  which 
infiltrates  surrounding  parts,  and  there  is  usually  some  discharge  of 
blood  and  pus  from  the  meatus.  Micturition  is  consistently  painful, 
and  the  introduction  of  an  instrument  increases  both  the  pain  and 
bleeding ;  it  generally  passes  easily,  but  the  irregularity  of  the  surface 
of  the  growth  can  be  recognised.  Amputation  of  the  whole  penis  is 
usually  required. 

Stricture  of  tlie  Urethra. — By  stricture  of  the  urethra  is  meant  a 
condition  in  which  the  onward  passage  of  urine  is  hindered,  owing  to 
some  change  in  the  walls  of  the  urethra,  which  prevents  them  from 
dilating.  When  at  rest,  the  urethra  is  merely  a  potential  canal,  the 
walls  of  which  are  in  complete  apposition,  and  it  is  only  converted 
into  a  tube  when  urine  is  passing  along  it.  When,  owing  to  some 
change  in.  the  structure  of  its  walls,  this  functional  dilatation  is 
impracticable,  the  patient  is  said  to  suffer  from  stricture.  Three  forms 
of  stricture  are  described,  viz.,  the  spasmodic,  congestive,  and  organic. 

Spasmodic  and  Congestive  Strictures  frequently  co-exist,  although 
either  congestion  or'  spasm  may  be  the  predominant  feature  in  any 
particular  case.  Thus,  in  acute  gonorrhoea  the  mucous  membrane 
often  becomes  engorged  and  thickened  to  such  an  extent  as  to  interfere 
with  the  act  of  micturition.  Spasm  is  the  chief  element  under  the 
following  conditions :  (i)  When  a  patient,  suffering  from  slight 
organic  stricture,  is  exposed  to  wet  or  cold,  especially  after  heavy 
drinking ;  (2)  after  operations  on  the  rectum  or  spermatic  cord ; 
(3)  as  a  result  of  catheterism ;  and  (4)  from  perineal  irritation  of  the 
urethra,  as  by  a  blow  or  kick  in  this  region,  or  from  prolonged  riding 
on  a  bicycle  with  a  badly-fitting  saddle  or  on  horseback.  Temporary 
retention  is  the  usual  result  of  any  of  these  conditions,  and,  as  a  rule, 
no  treatment  is  required  beyond  placing  the  patient  in  a  hot  bath,  and 
unloading  the  lower  bowel  by  the  use  of  a  large  warm  enema.  If 
such  fails,  catheterism  will  be  necessary,  and  must  be  conducted 
with  the  greatest  gentleness,  owing  to  the  congested  and  lacerable 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1261 

condition  of  the  mucous  membrane.  Full-sized  soft  instruments 
should  first  be  used,  and  will  usually  succeed  ;  if  not,  a  silver  instru- 
ment must  be  substituted. 

Organic  Stricture  is  the  term  applied  to  an  undilatable  condition  of 
the  urethra,  resulting  from  the  development  of  cicatricial  tissue  within 
its  walls. 

The  Causes  of  organic  stricture  are :  (a)  The  long  continuance  of  a 
urethral  discharge,  following  gonorrhoea,  or  the  frequent  recurrence 
of  this  affection.  Chronic  inflammations  are  always  characterized 
by  a  tendency  to  sclerosis  of  the  tissues  involved,  and  the  urethra  is 
no  exception  to  this  rule,  its  walls  under  these  circumstances  be- 
coming thickened,  indurated,  and  contracted,  (b)  The  cicatrization 
of  a  urethral  chancre,  or  of  an  ulcer  caused  by  the  impaction  of  a 
stone,  or  the  contraction  produced  by  the  healing  of  a  urethral 
abscess,  may  also  lead  to  stenosis,  (c)  The  most  intractable  forms 
of  stricture  are  those  due  to  cicatrization  after  rupture  or  laceration 
of  the  urethral  wall. 

The  usual  Situation  is  within  the  bulb,  i.e.,  just  in  front  of  the 
triangular  ligament ;  but  the  orifice  and  body  are  not  unfrequently 
affected.  It  occurs  in  the  membranous  portion  only  as  a  result  of 
traumatism,  and  never  in  the  prostatic.  To  find  more  than  two 
strictures  in  any  particular  case  is  unusual,  although  three  or  four 
have  been  met  with. 

Various  terms  are  applied  to  a  stricture  according  to  the  physical 
conditions  present ;  thus,  it  is  termed  annular,  if  it  involves  the  whole 
lumen  of  the  urethra ;  bridled,  if  it  affects  only  a  portion  of  the  cir- 
cumference of  the  tube.  A  ribbon- shaped  stricture  is  one  in  which  a 
considerable  extent  of  the  wall  is  contracted  {i.e.,  as  if  a  ribbon  had 
been  tied  around  the  urethra).  It  is  termed  tortuous,  if  the  resulting 
passage  is  not  straight ;  indurated,  if  the  walls  are  very  hard  and 
thickened  ;  and  resilient,  when  the  stricture,  though  readily  dilated, 
rapidly  re-contracts.  The  terms  impassable  and  impermeable  are  applied 
to  strictures  through  which,  on  the  one  hand,  a  surgeon  is  unable  to 
pass  an  instrument,  or  along  which,  on  the  other  hand,  urine  cannot 
find  its  way ;  it  is  doubtful  whether  the  latter  condition  ever  occurs, 
whilst  the  number  of  impassable  strictures  met  with  by  the  surgeon 
diminishes  with  his  experience  and  ability  in  passing  instruments. 

The  Symptoms  of  urethral  stricture  vary  according  to  the  case. 
The  patient  generally  complains  of  difficulty  in  the  act  of  micturition, 
the  stream  becoming  small,  and  perhaps  forked  or  twisted.  It  takes 
a  longer  time  than  usual  to  empty  the  bladder,  and  even  when 
apparently  successful  a  few  drops  of  urine  may  trickle  away,  wetting 
the  patient's  clothes.  Irritability  of  the  viscus  follows,  leading  to 
frequent  attempts  to  pass  water  at  short  intervals  during  the  day 
and  night.  The  urine  under  these  circumstances  often  becomes 
alkaline,  and  loaded  with  muco-pus  and  phosphates.  As  the  obstruc- 
tion increases,  more  and  more  residual  urine  is  left  in  the  bladder, 
which  may  in  time  form  a  tense,  rounded,  dull  swelling  in  the  hypo- 
gastrium.     The  quantity  of  urine  trickling  away  also  increases,  so 


1262  A  MANUAL  OF  SURGERY 

that  the  patient's  garments  are  always  wet,  giving  him  an  unpleasant 
urinous  odour.  A  certain  amount  of  gleety  discharge  is  present, 
whilst  if  the  individual  takes  an  excess  of  alcohol,  or  is  exposed  to 
wet  and  cold,  complete  retention  may  ensue.  Sometimes  the  onset 
of  symptoms  is  so  insidious  that  such  an  attack  of  retention  is  the 
first  marked  feature  in  the  case. 

The  Pathological  Conditions  arising  from  a  stricture  are  best  con- 
sidered under  the  following  five  headings  :  (i)  The  uvetliva  anterior  to 
the  stricture  is  usually  in  a  perfectly  normal  state,  although  possibly 
the  orifices  of  false  passages  may  be  seen.  A  few  granulations  are 
sometimes  present,  projecting  at  the  commencement  of  the  stricture. 
(2)  The  stricture  itself  is  characterized  by  the  development  of  fibro- 
cicatricial  tissue  immediately  under  the  mucous  membrane,  and 
intimately  adherent  to  it.  It  extends  for  a  variable  distance,  and  is 
often  associated  with  a  good  deal  of  peri-urethral  infiltration.  (3)  The 
urethra  behind  the  stricture  is  dilated,  and  the  mucous  mem.brane  velvety 
and  friable  ;  the  orifices  of  the  lacunae  and  other  glands  are  some- 
what enlarged  and  more  than  usually  evident,  and  perhaps  ulceration 
may  be  present  around  them.  In  the  later  stages  the  inflammation 
may  extend  to  the  peri-urethral  tissue  owing  to  lymphatic  absorption, 
or  perhaps  to  the  escape  of  a  few  drops  of  urine  ;  a  perineal  abscess 
then  results,  leading  subsequently  to  perineal  fistulae.  When  the 
obstruction  becomes  almost  absolute,  this  portion  of  the  urethra 
may  give  way,  leading  to  extravasation  of  urine  into  the  perineum 
and  scrotum.  (4)  The  Madder  invariably  manifests  considerable 
changes  in  structure.  At  first  the  vesical  wall  undergoes  a  com- 
pensatory hypertrophy  of  its  muscular  elements  and  is  thickened,  in 
order  to  overcome  the  obstruction  to  the  onward  passage  of  urine 
(Fig.  533).  The  lattice- work  arrangernent  of  the  muscular  bands 
becomes  coarse,  thickened,  and  evident,  causing  the  vesical  wall  to 
assume  a  fasciculated  appearance.  As  the  pressure  increases,  the 
mucous  membrane  protrudes  between  the  muscular  fasciculi,  giving 
rise  to  sacculation  ;  it  is  also  thickened  and  congested  as  a  result  of 
chronic  cystitis ;  the  superficial  veins  become  varicose,  and  haema- 
turia  may  be  caused  by  their  rupture,  whilst  ulceration  may  also 
occur.  The  urine  becomes  alkaline  and  decomposes,  containing 
muco-pus  and  phosphates.  It  is  likely  to  stagnate  in  any  sacculi 
which  exist,  and  may  then  determine  the  formation  of  phosphatic 
concretions ;  or  the  walls  of  the  sacculi  ulcerate,  and  after  a  time 
perforation  and  extravasation  of  urine  into  the  cellular  tissue  lead  to 
a  fatal  issue.  Occasionally  the  bladder,  instead  of  being  thickened, 
is  dilated  and  atonic,  with  very  thin  walls.  (5)  Consequent  on  the 
changes  in  the  bladder,  the  conditions  already  described  as  hydro- 
nephrosis, pyonephrosis,  or  pyelonephritis  may  develop,  partly  as 
the  result  of  the  backward  pressure,  and  partly  from  the  extension 
of  septic  matter  along  the  ureter  to  the  pelvis  of  the  kidney  and 
calyces. 

Physical  Examination. — The  actual  diagnosis  of  a  stricture  can  only 
be  confirmed  by  a  careful  physical  examination  of  the  urethra,  which 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS 


1263 


is  usually  made  by  the  introduction  of  a  full-sized  catheter  or  a 
solid  bougie,  e.g.,  No.  9  or  10  (English),  so  as  to  ascertain  where  the 
obstruction  is  situated.  If  this  cannot  be  passed,  smaller  instru- 
ments, and  even  filiform  bougies,  are  inserted  until  one  is  found 
which  will  enter  the  bladder. 

A  great  variety  of  catheters  is  in  use ;  in  old  days  only  metal  instru- 
ments were  obtainable,  and  even  now  the  silver  catheter  is  the 
favourite  with  many  surgeons  of  eminence.  In  selecting  such  an 
instrument,  care  must  be  taken  that  it  is  suitably  curved,  and  that 
the  '  eye '  is  sufficiently  large 
and  bevelled  inwards,  so  that 
no  projecting  rim  lacerates  the 
urethral  mucous  membrane. 
•  The  great  advantages  of  the 
metal  instrument  are  that  it  is 
easily  kept  aseptic,  and  that  the 
point  can  be  located  and  thus 
guided  more  readily  along  the 
urethra.  Of  late  years  many 
different  forms  of  flexible 
catheters  have  been  introduced, 
and  are  now  extensively  em- 
ployed, inasmuch  as  they  give 
rise  to  less  irritation  than  those 
made  of  metal.  The  objections 
to  them  are  that  the  materials 
of  which  they  consist  are  readily 
attacked  and  injured  by  anti- 
septics, whilst  they  are  less 
easily  directed  through  a  stric- 
ture on  account  of  their  flexi- 
bility, it  being  impossible  to 
know  with  certainty  the  situa- 
tion of  the  point.  Probably  the 
best  means  of  sterilizing  a  soft 
instrument  is  to  expose  it  to 
the  action  of  steam,  which  should 
be  made  to  act  not  only  on  the 
exterior,  but  also  inside  the 
tube  ;  many  appliances  to  obtain 
this  object  have  been  devised. 
Failing     this,    they    may    be 

syringed  through  with  i  in  20  carbolic  lotion  and  allowed  to  soak 
for  a  while  in  a  i  in  2,000  sublimate  solution  ;  or  they  may  be  kept 
aseptic  by  hanging  or  lying  in  an  atmosphere  charged  with  formalin 
vapour,  by  placing  a  few  tabloids  charged  with  this  substance  in 
the  bottom  of  a  jar  in  which  they  are  suspended.  Amongst  the  best 
flexible  instruments  are  the  indiarubber  or  Jacques'  catheter  (the 
distal    end   of    which    beyond    the   eye    should   be   solid   and   not 


Fig.  533. — Stricture  of  the 
Urethra.     (College  of  Surgeons' 

Museum.) 

Glass  rods  have  been  passed  under  the 
strictures.  The  bladder  is  somewhat 
dilated,  and  its  walls  are  thick  and 
hypertrophic,  and  with  commencing 
sacculation. 


1264  A. MANUAL  OF  SURGERY 

hollow),  the  English  or  gum -elastic  catheter,  the  French  olive- 
headed  or  catheter-a-boule,  and  others  made  of  silk-web  coated 
with  shellac,  etc.  Some  varieties  are  now  polished  and  prepared 
inside  as  well  as  out,  and  they  should,  if  possible,  always  be 
selected. 

Bougies  or  solid  instruments  are  preferred  by  some  surgeons  for  the 
examination  and  treatment  of  strictures.  Those  known  as  Lister's 
bougies  are  the  best,  consisting  of  solid  metal  rods,  curved  like 
catheters,  the  bulbous  ends  of  which  are  three  sizes  smaller  than 
the  shanks,  thus  enabling  each  instrument  passed  to  prepare  the 
way  for  the  next.  Flexible  bougies  are  also  made,  whilst  for  finding 
a  way  through  a  tight  and  tortuous  stricture  a  filiform  bougie,  made 
of  whalebone  or  catgut,  or  a  long  graduated  whip-lash  bougie  rriay  be 
"  employed ;  in  the  latter  variety,  the  fine  end  is  passed  through  the 
stricture,  and  coils  up  in  the  bladder,  whilst  the  thicker  portion  is 
thus  brought  to  bear  on  the  stricture. 

In  order  to  introduce  a  silver  catheter  or  bougie,  the  patient  is  laid 
on  his  back,  the  surgeon  standing  on  his  left  side.  The  umbilicus 
should  always  be  exposed,  as  also  the  upper  parts  of  the  thighs. 
The  meatus  and  end  of  the  penis  are  washed  with  a  i  in  2,000 
solution  of  sublimate,  as  also  the  surgeon's  hands.  The  catheter, 
which  has  been  previously  sterilized,  warmed,  and  covered  with 
sterilized  or  antiseptic  oil  or  grease,  is  taken  in  the  right  hand,  and 
inserted  into  the  urethra,  with  the  handle  directed  over  the  left  thigh 
and  slightly  downwards.  The  point  of  the  instrument  is  guided  as 
far  as  the  perineum,  and  then  the  handle  is  carried  round  to  the 
middle  line  of  the  body  towards  the  umbilicus  ;  it  is  gently  raised  to 
the  vertical,  the  penis  being  held  in  the  left  hand,  and  finally 
depressed  between  the  patient's  thighs,  the  so-called  tour-de-mattre. 
The  catheter  finds  its  way  along  the  urethra  into  the  bladder  rather 
by  its  own  weight  than  by  any  forcible  action  of  the  surgeon.  The 
chief  points  at  which  difficulty  may  be  experienced  are :  (a)  The 
orifice,  which  may  be  small  and  contracted  ;  (b)  the  lacuna  magna, 
which  is  avoided  by  keeping  the  point  of  the  instrument  against 
the  floor ;  and  (c)  the  opening  in  the  triangular  ligament,  which  is 
best  entered  by  keeping  the  point  against  the  upper  wall  of  the 
canal. 

Some  authorities  recommend  that  the  patient  should  stand  up, 
with  the  back  resting  against  a  wall  or  firm  support,  the  surgeon 
sitting  in  front,  and  manipulating,  it  is  said,  with  greater  accuracy. 
The  objections  to  this  position  are :  (a)  The  liability  of  the  patient 
to  faint,  and  {b)  the  existence  of  greater  muscular  tension  than 
obtains  in  the  horizontal  posture. 

When  a  flexible  instrument  without  a  stilette  is  used,  it  is  passed 
by  pressing  the  point  on  with  a  little  rotatory  movement  until  the 
bladder  is  reached,  withdrawing  a  little,  and  pushing  on  again,  if  any 
obstruction  is  met.  In  some  instances,  however,  the  use  of  a  stilette 
is  absolutely  necessary. 

The  chief  Dangers  of  catheterism  are  as  follow  :  i.  A  considerable 


AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1265 

degree  of  shock  is  sometimes  experienced,  especially  in  sensitive  in- 
dividuals, and  if  an  instrument  has  not  been  passed  before.  It  may 
be  obviated  to  a  large  extent  by  first  introducing  about  ^  drachm  of 
the  5  per  cent,  solution  of  cocaine  into  the  urethra. 

2.  HcBniorvhage  may  be  induced  by  laceration  or  abrasion  of  the 
mucous  membrane,  even  though  no  false  passage  has  been  made  ; 
it  is  best  avoided  by  gentleness  and  the  use  of  v^ell-finished  instru- 
ments. In  spite  of  these  precautions,  when  the  mucous  membrane 
is  soft  and  congested,  and  in  many  cases  of  stricture,  some  bleeding 
cannot  be  avoided.  It  is  rairely  sufficient  to  call  for  special  treatment, 
but  if  very  abundant  may  be  arrested  by  the  pressure  of  an  instru- 
ment tied  in  or  by  injections  of  hazeline. 

3.  False  passages  are  frequently  produced  in  the  treatment  of  stric- 
tures. The  point  of  the  instrument  is  most  likely  to  leave  the  canal 
at  some  spot  in  the  floor,  travelling  for  a  variable  distance,  according 
to  the  force  employed,  under  the  mucous  membrane,  occasionally 
re-entering  the  dilated  urethra  behind  the  stricture,  which  it  avoids 
altogether,  or  perforating  the  posterior  wall  of  the  bladder  by  tun- 
nelling under  the  prostate,  an  accident  which  can  only  occur  in 
unskilful  hands.  The  occurrence  of  a  false  passage  is  indicated  by 
the  sudden  onward  movement  of  the  instrument,  combined  with 
pain  and  haemorrhage ;  the  point  is  usually  deflected  from  the  middle 
line,  as  is  plainly  seen  by  the  obliquity  of  the  rings  at  the  end  of  the 
shaft ;  no  urine  comes  unless  the  urinary  passages  are  opened  behind 
the  stricture.  On  rectal  examination,  the  instrument'can  be  felt  out 
of  the  middle  line,  and  nearer  the  rectum  than  is  normal,  and  in 
some  exceptional  cases  has  even  been  found  in  it.  False  passages 
are  not  necessarily  matters  of  great  importance,  but  when  extensive 
may  lead  to  peri-urethral  suppuration  and  extravasation  of  urine, 
possibly  followed  by  fatal  results. 

4.  Inflammatory  phenomena  may  be  lighted  up  in  the  prostate, 
and  acute  epididymitis  induced  by  extension  along  the  vas  deferens  ; 
these  are  almost  always  due  to  sepsis. 

5.  Urinary  Fever,  or,  as  it  is  sometimes  termed,  urethral  or  catheter 
fever,  is  always  liable  to  develop  as  a  result  of  the  introduction  of 
instruments.  It  may  occur  as  a  solitary  rigor  even  in  individuals 
with  healthy  urinary  organs,  but  is  much  more  frequently  observed 
in  those,  with  damaged  kidneys.  As  to  its  causation,  there  has  been 
much  discussion,  but  there  can  now  be  little  doubt  that  it  is  essen- 
tially infective  in  origin.  Possibly  the  instrument  employed  may  be 
dirty,  or  the  urethra  itself  contains  infective  material,  especially  in  its 
deeper  parts.  It  is  quite  sufficient  for  a  slight  abrasion  to  occur 
near  the  neck  of  the  bladder,  to  allow  of  the  absorption  either  of 
toxins  or  of  bacteria,  and  then  general  phenomena  show  themselves 
at  once.  If  merely  toxic  products  are  absorbed,  probably  a  passing 
febrile  condition,  such  as  one  or  more  rigors,  will  develop,  with  no 
more  serious  phenomena ;  but  if  bacteria  find  their  way  into  the 
submucous  tissues,  they  are  likely  to  develop  rapidly  in  the  lym- 
phatics, extending  to  the  bladder  and  thence  up  the  ureters  owing' 

80 


1266  A  MANUAL  OF  SURGERY 

to  the  continuity  of  lymphatic  supply,  giving  rise  finally  to  pyelo- 
nephritis (p.  1 1 89).  Formerly  reflex  congestion  of  the  kidneys  was 
thought  to  be  an  important  factor  in  these  cases ;  probably  the 
congestion  which  occurs  is  due  to  the  direct  irritation  of  bacteria, 
and  is  not  of  nervous  origin. 

The  clinical  manifestations  vary  considerably,  according  to  the 
character  of  the  case  and  the  type  of  infection,  (a)  The  simplest 
form  consists  in  the  development  of  a  single  rigor,  the  temperature 
perhaps  running  up  to  105°  F. ;  the  patient  shivers  and  feels  very 
ill,  complaining  of  headache,  but  when  the  temperature  falls  he  soon 
recovers,  and  within  a  few  hours  is  all  right  again,  {b)  Sometimes 
the  temperature  does  not  fall  to  the  normal  after  the  initial  rigor, 
but  remains  elevated  a  few  degrees  for  a  day  or  two,  and  there  may 
even  be  a  repetition  of  the  rigor.  The  patient,  however,  recovers 
perfectly,  and  no  permanent  harm  is  done,  (c)  In  the  more  serious 
cases  the  symptoms  of  pyelonephritis  supervene,  and  are  very  likely 
to  prove  fatal,  the  patient  perhaps  dying  in  seven  or  eight  days. 
{d)  General  pyaemia  may  appear  as  a  complication  of  the  last  con- 
dition, {e)  In  patients  who  are  commencing  the  regular  passage  of 
catheters  for  enlarged  prostate  a  series  of  phenomena  develop,  which 
have  been  already  alluded  to  (p.  1253),  and  though  often  mild,  are 
of  a  similar  nature.  (/)  Finally,  suppression  of  urine  may  accom- 
pany any  of  the  conditions  alluded  to  above. 

Tveatinent. — Whenever  it  seems  probable  that  the  kidneys  are 
damaged,  the  greatest  care  must  be  taken  in  order  to  avoid  infection. 
The  instruments  employed,  whether  bougies  or  catheters,  must  be 
thoroughly  sterilized,  and  it  would  also  be  well  to  irrigate  the  urethra 
with  a  mild  antiseptic  lotion.  It  is  better  to  use  soft  instruments,  if 
possible,  rather  than  silver  ones,  as  the  latter  give  rise  to  more 
irritation  than  the  former,  and  are  more  likely  to  abrade  the  mucous 
membrane. 

For  the  single  rigor  following  catheterism,  the  patient  must  be 
kept  warm,  plenty  of  hot  diluent  drinks  given,  and  quinine  (2  grains) 
administered.  If  the  febrile  symptoms  continue,  the  skin  and  bowels 
are  freely  acted  on,  and  a  milk  diet  prescribed,  although  a  certain 
amount  of  stimulant  may  be  given  if  necessary  ;  all  operative 
measures  must  be  avoided,  unless  it  is  essential  to  relieve  obstruc- 
tion, as  they  are  almost  invariably  fatal.  Should  suppression  of 
urine  ensue,  the  loins  should  be  cupped  in  the  hope  of  relieving 
renal  congestion,  a  free  action  of  the  bowels  obtained  by  the  use  of 
watery  purgatives,  and  the  patient  made  to  sweat  freely,  either  by 
the  use  of  hot-air  baths  or  by  the  injection  of  pilocarpine.  If  the 
urinary  secretion  is  not  quickly  re-established  {i.e.,  in  forty-eight 
hours),  the  surgeon  should  perform  nephrostomy  {i.e.,  opening  and 
draining  the  renal  pelvis)  without  delay,  selecting  for  operation  the 
kidney  which  appears  to  be  most  tender  ;  it  may  be  necessary  to 
incise  both  kidne5^s  (p.  1190).  Uraemic  symptoms  may  sometimes 
be  relieved  by  copious  and  repeated  intravenous  injections  of  saline 
solution,  which  e'xcojrage  diuresis  and  a  watery  diarrhoea. 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS  1267 

The  Treatment  of  Passable  Strictures  is  conducted  either  by  dilata- 
tion or  by  a  cutting  operation  (internal  or  external  urethrotomy). 

Treatment  by  Dilatation  is  effected  in  various  ways,  according 
to  the  nature  of  the  stricture  and  the  urgency  of  the  symptoms. 
Where  the  obstruction  is  not  serious,  and  an  instrument  can  be  easily 
passed,  gradual  dilatation  should  always  be  employed  ;  this  consists 
in  the  use  of  instruments  once  or  twice  a  week,  steadily  increasing 
in  size  until  a  No.  12  is  reached.  If  the  intervals  are  too  short,  the 
urethra  may  become  irritated,  spasm  be  induced,  and  the  lumen  of 
the  canal  temporarily  diminished  in  size  ;  by  keeping  the  patient 
quiet  for  a  few  days  on  a  bland  diet,  and  the  bowels  well  open,  the 
spasm  disappears.  In  cases  where  time  is  an  object,  rapid  dilatation 
may  be  undertaken  by  the  passage  of  several  sizes  of  bougie  at  one 
sitting  ;  for  this  purpose,  Lister's  instruments  are  particularly  useful. 
Where  only  a  very  small  catheter  can  be  introduced,  and  that  with 
difficulty,  continuous  dilatation  may  be  adopted  by  keeping  the  patient 
in  bed,  and  tying  in  the  small  instrument  for  forty-eight  hours  or  more, 
at  the  expiration  of  which  period  a  catheter  several  sizes  larger  can 
be  substituted.  This  in  turn  may  be  tied  in  if  the  patient  can  bear 
it ;  but  the  presence  of  a  catheter  within  the  urethra  for  any  length 
of  time  is  not  always  tolerated,  and  may  give  rise  at  the  end  of  two 
or  three  days  to  considerable  constitutional  disturbance  and  fever. 
-Forcible  dilatation  is  a  plan  which  has  now  but  few  advocates.  It 
consists  in  the  passage  of  an  instrument,  the  shaft  of  which  is  made 
in  two  portions,  which  can  be  separated  from  one  another  in  such  a 
way  as  to  destroy  the  stricture  either  by  distension  or  rupture  of  its 
substance.  It  is  but  little  used,  on  account  of  the  great  tendency, 
when  cicatrization  is  complete,  to  the  formation  of  an  even  more 
intractable  stricture  than  before. 

By  whichever  of  these  methods  dilatation  is  accomplished,  it  is 
essential  that  either  the  surgeon  or  the  patient  should  subsequently 
pass  an  instrument  through  the  stricture  at  first  every  week  or  two, 
and  then  at  longer  intervals,  to  overcome  the  tendency  to  re-contrac- 
tion which  is  ever  present. 

The  Treatment  of  Passable  Stricture  by  a  Cutting  Operation  is  con- 
ducted either  by  excision  or  by  internal  or  external  urethrotomy. 

Excision  is  certainly  the  ideal  treatment,  the  urethra  being  thereby 
restored  to  a  normal  condition.  It  has  now  been  frequently  under- 
taken and  with  great  success  in  strictures  of  the  deeper  perineal 
portion  of  the  urethra  ;  it  is  not  so  satisfactory  when  the  penile 
urethra  is  involved.  Fully  an  inch  of  the  tube  may  be  excised,  and 
the  ends  sutured  together  over  a  catheter.  The  corpus  spongiosum 
must  be  detached  from  its  surroundings  to  permit  of  this.  Sutures 
are  introduced  in  the  upper  wall  first ;  then  the  catheter  is  placed  in 
position,  and  the  remainder  of  the  stitches  inserted. 

Internal  Urethrotomy  is  a  valuable  means  of  treatment  when 
rightly  employed,  but  in  careless  or  inexperienced  hands  may  be 
attended  with  considerable  danger.  It  has  been  performed  either 
by  passing  an  instrument  through  the  stricture,  and  dividing  it  from 


1268 


A  MANUAL  OF  SURGERY 


behind  forwards,  or  by  passing  an  instrument  down  to  the  stricture, 
and  dividing  it  from  before  backwards.  The  latter  plan  of  treat- 
ment, though  recommended  by  some  skilled  authorities,  is  not  an 
operation  which  commends  itself  to  our  judgment,  inasmuch  as  it 
is  almost  impossible  to  gauge  the  amount  of  tissue  divided.  The 
former  plan  of  incising  a  stricture  from  behind  forwards  is,  of  course, 
only  called  for  under  special  circumstances,  since  if  the  urethrotome 
can  be  passed  through  a  stricture,  ordinary  dilatation  is  in  the 
majority  of  cases  practicable.  It  is  useful,  however,  [a)  in  the 
treatment  of  very  old  and  dense  cartilaginous  strictures,  as  also 
(b)  for  resilient  strictures,  and  (c)  when  the  urethra  is  excessively 
irritable.  It  should  only  be  employed  when  the  obstruction  is 
situated  in  the  anterior  two-thirds  of  the  urethra,  and  never  when 
septic  contamination  of  the  urine  is  present.  Many  forms  of 
urethrotome  have  been  devised,  but  perhaps  the  most  useful  is 
that  known  as  Civiale's  (Fig.  534),  which  can  only  be  used  for  a 
stricture  which  will  admit  the  passage  of  a  No.  5  catheter.  The  end 
is  bulbous,  and  contains  a  hidden  knife,  worked  by  means  of  a  button 
in  the  handle.  The  instrument  is  passed  through  the  stricture,  the . 
cutting  blade  projected,  and  by  withdrawing  it  the  cicatricial  tissue 
is  notched  to  such  an  extent  as  to  allow  a  full-sized  catheter  to  be 


Fig.  534. — Civiale's  Urethrotome.     (Down  Brothers.) 


inserted  at  once,  and,  if  possible,  tied  in.  Where  the  deeper  part  of 
the  urethra  is  being  dealt  with,  the  incision  should  be  made  along 
the  roof  so  as  to  avoid  the  bulb.  Care  must  be  taken  not  to  cut 
beyond  the  limits  of  the  cicatricial  tissue,  otherwise  haemorrhage, 
peri-urethral  suppuration,  or  even  extravasation  of  urine,  may  ensue. 
It  is  also  advisable  to  sterilize  the  urethra  as  far  as  possible  by 
washing  it  out  with  weak  antiseptic  solutions  before  operating. 

External  Urethrotomy,  or  Syme's  Operation,  is  required  under  cir- 
cumstances similar  to  those  needing  internal  urethrotomy,  if  the 
stricture  is  situated  in  the  posterior  third  of  the  urethra,  but  is 
chiefly  employed  where  perineal  fistulae  are  present.  It  is  performed 
by  passing  a  special  shouldered  staff  (Syme's,  Fig.  535),  the  distal 
end  of  which  is  small  enough  to  traverse  the  stricture,  and 
grooved  in  the  middle  line,  whilst  the  shaft  of  the  instrument  is  of 
larger  size,  and  ends  abruptly,  so  that  the  shoulder  rests  against  the 
face  of  the  stricture ;  the  groove  extends  on  to  the  larger  portion  for 
about  ^  inch.  The  patient  is  then  placed  in  the  lithotomy  position, 
and  the  surgeon,  seated  opposite  the  perineum,  which  is  shaved  and 
well  purified,  incises  it  in  the  middle  line,  carrying  his  dissection 


AFFECTIONS  OF  THE   URETHRA  AND  PENIS 


1269 


carefully  downwards  so  as  to  reach  the  groove  in  the  staff  behind 
the  stricture.  The  knife  is  then  carried  forwards  to  the  anterior 
extremity  of  the  groove,  and  inasmuch  as  it  extends  on  to  the  shaft 
of  the  instrument,  the  stricture  is  completely  divided. 
Any  fistulae  which  exist  are  laid  open  into  the 
median  wound,  and  thoroughly  scraped  and  purified. 
A  full-sized  soft  catheter  is  then  passed  into  the 
bladder,  through  either  the  penis  or  the  perineum, 
according  to  circumstances,  and  retained  in  position 
for  some  days,  the  urine  being  syphoned  off  in  the 
usual  way,  whilst  the  perineal  wound,  after  all 
haemorrhage  has  been  stopped,  is  packed  with 
strips  of  antiseptic  gauze,  and  allowed  to  heal  by 
granulation.  The  catheter  is  removed  early  or 
late  according  to  the  amount  of  general  disturb- 
ance caused  thereby,  and  subsequently  a  full- 
sized  instrument  can  be  passed  into  the  bladder 
daily. 

The  Treatment  of  Impassable  Stricture  varies 
according  to  whether  or  not  the  condition  is  com- 
plicated with  retention  of  urine. 

If  no  retention  is  present,  it  is  possible  that  the 
inability  to  pass  an  instrument  is  due  to  some 
temporary  spasm  or  congestion  induced  by  errors 
of  diet  or  drink,  or  perhaps  by  exposure  to  cold. 
Hence  the  patient  should  rest  in  bed  for  a  few  days, 
his  bowels  be  well  opened,  the  diet  regulated,  and 
a  mixture  containing  some  alkaline  purgative  and 
tincture  of  henbane  administered.  Further  attempts 
at  instrumentation  should  then  be  made,  if  neces- 
sary, under  an  anaesthetic,  and  if  the  stricture  still 
remains  impassable,  Wheelhouse's  operation  (Fig.  536) 
is  indicated.  This  consists  in  incising  the  urethra  in 
front  of  the  constriction,  tracing  the  passage  back- 
wards, and  dividing  it.  A  Wheelhouse's  straight 
staff  with  a  median  groove  and  a  blunt  hook  at  the 
end  is  inserted  down  to  the  stricture,  and  the 
urethra  opened  just  in  front  of  it  by  cutting  down 
on  the  groove.  The  staff  is  then  twisted  round, 
the  upper  end  of  the  incision  drawn  up  by  the  pro- 
jection of  the  hook,  and  the  sides  of  the  urethra 
held  apart  with  artery  forceps.  The  orifice  of  the 
stricture  is  thus  exposed,  and  granulations  may 
often  be  seen  projecting  from  it.  A  fine  probe- 
pointed  director  can  generally  be  insinuated  along  the  urethra  through 
the  stricture,  which  is  then  divided.  A  full-sized  instrument  is  passed 
into  the  bladder  and  retained  for  a  few  days,  whilst  the  wound  is 
allowed  to  heal  by  granulation. 

If  retention  of  urine  is  present  in  a  case  of  impassable  stricture,  no 


1270 


A  MANUAL  OF  SURGERY 


time  must  be  lost.     If  seen  at  an  early  stage,  and.  the  symptoms  are 
not  urgent,  the  patient  is   given  a  hot  bath,  and  the  bowels  are 


opened   by  a  warm   enema,  whilst 
preferably  a  morphia  suppository  is 


Fig.  536. — Wheelhouse's  Operation 
FOR  Impassable  Stricture.  (Bryant's 
'  Surgery.') 


dangferous 


a  moderate  dose  of  opium  or 
administered.  If  the  urine  is 
not  passed  naturally  in  the 
bath,  and  the  bladder  is  be- 
coming distended,  being  felt 
in  the  lower  part  of  the  ab- 
domen, suprapubic  aspiration, 
or  puncture  with  a  trocar  and 
cannula,  should  be  under- 
taken, and  temporary  relief 
thus  obtained.  Probably, 
when  tension  has  been  re- 
moved from  the  posterior  part 
of  the  urethra,  a  catheter  will 
be  introduced  without  much 
difficulty.  Failing  this,  aspira- 
tion may  be  several  times 
resorted  to,  but  it  is  generally 
wiser  to  open  the  urethra  in 
front  of  or  behind  the  stricture, 
and  drain  the  bladder,  since 
the  risks  of  septic  troubles, 
pressure    upon    the    kidneys. 


the  lines   of   puncture,    are   thereby 


extravasation    of    urine. 

and  urinary  infiltration  a?!ong 

lessened. 

Cock's  Operation,  or  Perineal  Section,  is  sometimes  adopted  when 
no  guide  can  be  passed 
into  the  bladder  (Fig. 
537).  The  patient  is 
placed  in  the  lithotomy 
position,  and  the  situa- 
tion of  the  membranous 
urethra  ascertained  by 
inserting  the  index 
finger  into  the  rectum. 
A  median  perineal  in- 
cision is  then  made, 
and  after  dividing  the 
cutaneous  structures, 
the  surgeon  plunges 
the  scalpel  boldly  in 
towards  the  apex  of 
the  prostate,  guided  by 
his  finger  in  the  rectum. 
He  must  keep  strictly  in  the  middle  line,  so  as  to  avoid  the  impor- 
tant vascular  and  other  structures  which  are  so  abundantly  present 
in  the  perineum.      As  soon  as   the  urethra  is  opened,  a  gush  of 


Fig.  537. — Cock's  Operation  of  Perineal 
Section.     (Bryant's  'Surgery.') 


AFFECTIONS  OF   THE  URETHRA  AND  PENIS  1271 

urine  often  escapes ;  the  upper  urethral  wall  should  not  be  damaged 
with  the  knife,  for  fear  of  opening  up  the  deep  pelvic  cellular 
tissue. 

This  operation  may  be  tolerably  simple  if  the  urethra  behind  the 
stricture  is  dilated,  as  is  not  uncommonly  the  case  ;  but  sometimes 
it  is  extremely  difficult,  especially  if  the  urethra  has  been  displaced 
laterally.  If  the  stricture  is  not  situated  too  far  from  the  incision, 
it  is  always  wise  to  complete  the  operation  by  dividing  it,  and  a 
full-sized  catheter  can  then  be  passed  into  the  bladder,  and  the 
perineal  wound  allowed  to  granulate.  If  the  stricture  cannot  be 
dealt  with  during  the  operation,  and  is  of  a  dense  cartilaginous 
nature,  a ^ tube  is  inserted  into  the  bladder  through  the  perineum; 
probably  at  the  end  of  a  few  days  the  tissues  will  yield  sufficiently 


Fig.  538. — Perineal  Fistula;.     (Bryant's  '  Surgery.') 

to  allow  of  the  passage  of  a  catheter,  or  Wheelhouse's  operation 
can  be  subsequently  adopted. 

The  chief  complications  of  stricture  other  than  those  already 
mentioned  are  peri-urethral  abscess,  perineal  fistula,  and  extravasa- 
tion of  urine. 

A  Peri-urethral  Abscess  is  due  either  to  a  limited  extravasation  of 
urine,  or  to  the  absorption  of  infective  material  through  an  ulcerated 
surface.  It  is  indicated  by  the  formation  of  a  hard,  brawny  swelling 
in  the  perineum  or  above  the  scrotum,  which  is  tender  to  the  touch. 
As  it  approaches  the  surface,  fluctuation  can  be  detected,  and  the 
skin  over  it  becomes  congested  and  oedematous.  Constitutional 
disturbance  and  fever  of  an  asthenic  type  are  also  present.  Left  to 
itself,  it  bursts  and  usually  gives  rise  to  a  perineal  sinus  or  fistula, 
discharging  either  pus  or  urine  mixed  with  pus.  One  or  many  of 
these  fistulae  may  occur  (Fig.  538),  and  the  openings  are  not  limited 
to  the  perineum,  but  may  also  be  found  in  the  thighs,  buttocks,  or 
even  the  groins.  In  chronic  cases,  the  scrotal  or  perineal  tissues 
become  infiltrated  and  of  an  almost  cartilaginous  consistency. 

Diagnosis. — Every  abscess  in  the  scrotum  or  perineum  is  not  neces- 


1272  A   MANUAL  OF  SURGERY 

sarily  associated  with  stricture,  for  simple  irritation  of  the  skin  may 
lead  to  a  superficial  abscess  ;  suppuration  in  the  lacunae,  or  Cowper's 
glands,  may  follow  gonorrhoea  ;  a  prostatic  or  ischio-rectal  abscess 
may  point  in  the  perineum  ;  whilst  the  injury  inflicted  by  the  passage 
of  instruments,  or  the  existence  of  false  passages,  may  lead  to  a 
similar  result. 

The  Treatment  of  a  Perineal  Abscess  consists  in  the  application  of 
fomentations  during  the  early  stages ;  as  soon  as  pus  is  present,  it 
should  be  let  out  through  a  free  incision,  and  it  is  often  advisable 
to  take  the  opportunity  of  dealing  radically  with  the  stricture  by 
section  at  the  same  time.  Perineal  fistulse  can  rarely  be  cured  with- 
out operation,  since,  although  the  stricture  may  be  completely  dilated, 
the  discharge  of  urine  and  pus  continues.  Under  these  circumstances 
Syme's  or  Wheelhouse's  operation  is  the  proper  treatment. 

Extravasation  of  Urine  is  a  condition  due  to  a  solution  of  con- 
tinuity of  the  urethral  walls,  allowing  the  urine  to  find  its  way  into 
the  perineal  and  scrotal  tissues.  It  usually  results  from  over-disten- 
sion of  the  urethra  behind  a  neglected  stricture  ;  during  some  violent 
effort  at  micturition,  the  patient  experiences  severe  pain  and  a  sensa- 
tion as  if  something  had  given  way  in  the  perineum,  followed  by  a 
feeling  of  relief.  This,  however,  is  of  short  duration,  as  it  is  soon 
succeeded  by  the  local  and  constitutional  effects  of  extravasation. 
Occasionally  the  onset  of  symptoms  is  more  gradual,  being  preceded 
by  a  peri-urethral  abscess,  which  bursts  into  the  urethra  ;  at  each 
act  of  micturition  the  cavity  becomes  more  and  more  distended  with 
urine  ;  finally  the  wall  yields,  resulting  in  diffuse  extravasation.  The 
same  phenomena  are  produced  in  cases  of  traumatic  laceration  oi 
the  urethra  if  the  patient  attempts  to  empty  his  bladder. 

The  membranous  urethra  is  almost  always  the  site  of  the  rupture, 
the  urine  finding  its  way  subsequently  through  the  anterior  layer 
of  the  triangular  ligament,  and  being  guided  towards  the  anterior 
abdominal  wall  by  the  arrangement  of  the  fasciae.  The  root  of  the 
penis,  covered  by  its  appropriate  muscles,  lies  in  an  interfascial  cul- 
de-sac,  formed  by  the  anterior  layer  of  the  triangular  ligament  above, 
and  the  deep  layer  of  the  perineal  fascia  (or  fascia  of  Colles)  below  ; 
these  two  layers  are  continuous;  passing  round  the  transversus 
perinei  muscles,  and  are  both  attached  laterally  to  the  ischio-pubic 
rami.  Into  this  space  the  urine  finds  its  way,  after  the  anterior 
layer  of  the  triangular  ligament  has  yielded,  and  owing  to  the  fact 
that  its  passage  backwards  and  laterally  is  checked  by  the  attach- 
ment of  the  fasciae,  it  is  necessarily  forced  forwards,  infiltrating  in 
order  the  perineum,  scrotum,  and  body  of  the  penis.  If  more  ex- 
tensive, it  travels  along  the  spermatic  cords  to  the  anterior  abdominal 
parietes,  its  passage  downwards  into  the  thighs  being  prevented  by  the 
attachment  of  the  deep  layer  of  the  superficial  fascia  of  the  abdomen 
to  the  fascia  lata  just  below  Poupart's  hgament.  In  the  most  severe 
cases  the  urine  may  even  find  its  way  as  far  as  the  axillae. 
<  The  Effects  of  extravasation  of  urine  are  always  serious.  Possibly, 
if  the  urine  were  pure  and  aseptic,  part  of  it  might  be  absorbed ;  but 


'AFFECTIONS  OF  THE  URETHRA  AND  PENIS  1273 

even  then  prolonged  infiltration  of  the  tissues  is  hkely  to  result  in 
suppuration  and  sloughing.  In  cases  of  stricture,  however,  the  urine 
is  almost  certain  to  be  foul  and  alkaline,  and  hence  wherever  it 
travels  it  gives  rise  to  a  gangrenous  celluhtis.  The  parts  at  first 
become  infiltrated  and  brawny,  but  soon  emphysematous  crackling 
and  putrefaction  are  observed,  owing  to  necrosis  of  the  cellular  tissue. 
The  congested  and  oedematous  skin  turns  to  a  dusky  purple  or  black 
colour,  and  finally  gives  way  or  separates,  allowing  exit  to  a  mixture 
of  pus,  urine,  and  decomposing  slough  of  a  most  offensive  and  pene- 
tratmg  odour.  The  superficial  loss  of  substance  may  be  so  extensive 
as  to  lay  bare  both  testicles,  and  even  the  body  of  the  penis,  or 
part  of  the  anterior  abdominal  wall.  The  inflammatory  process  is 
necessarily  associated  with  severe  constitutional  disturbance,  at  first 
characterized  by  high  fever  and  a  quick,  bounding  pulse  ;  but  later  on 
the  temperature  may  become  subnormal,  and  the  patient  profoundly 
collapsed  from  toxagmia. 

The  Treatment  consists  in  early  and  free  incisions,  so  as  to  give 
exit  to  the  urine  and  pus,  and  to  prevent,  if  possible,  the  sloughing 
of  the  skin  and  subcutaneous  tissues.  Every  part  that  the  urine  has 
infiltrated  must  be  dealt  with  in  this  way ;  thus  the  perineum  should 
be  incised  in  the  middle  line  ;  the  scrotum  is  similarly  divided,  if 
need  be,  down  to  the  urethra,  the  testicles  being  laid  on  either  side.  • 
but,  if  possible,  this  should  be  avoided.  The  penis  should  be  incised, 
if  necessary,  on  either  side  of  the  urethra,  and  along  the  dorsal 
surface.  It  is  often  possible  to  expel  a  large  portion  of  the  urine, 
especially  in  the  scrotum,  by  firmly  squeezing  the  infiltrated  tissues. 
A  full-sized  catheter  must  be  passed  into  the  bladder,  and  to  effect 
this  the  urethra  has  often  to  be  laid  open  and  the  stricture  divided ; 
perineal  drainage  is  always  preferable  for  these  cases.  The  parts 
should  be  subsequently  dusted  over  with  iodoform,  and  dressed  with 
warm  antisleptic  applications,  e.g.,  a  charcoal  or  carbolic  linseed 
poultice,  or  boracic  fomentations.  Frequent  hip-baths  should  be 
employed,  and,  if  practicable,  a  continuous  sitz-bath  would  be  the 
•  very  best  means  of  treating  the  case.  As  soon  as  the  wounds 
become  clean,  they  should  be  dressed  in  the  ordinary  way  to  allow 
them  to  granulate.  The  general  health  of  the  patient  must  of  course 
be  attended  to,  plenty  of  easily  assimilated  nourishment,  stimulants, 
and  quinine  being  administered. 

Urinary  Fistulae  are  most  commonly  found  in  the  perineum, 
scrotum,  or  body  of  the  penis.  They  usually  result  from  peri- 
urethral suppuration  in  connection  with  a  stricture,  but  are  occa- 
sionally due  to  other  causes,  e.g.,  a  lacunar  abscess  after  gonorrhoea, 
or  a  prostatic  abscess.  They  vary  much  in  size  and  number  ;  when 
the  result  of  a  stricture,  many  may  be  present  (Fig.  53S),  and  great 
infiltration  of  the  surrounding  tissues  is  usually  produced.  The 
Treatment  of  perineal  fistulas  has  been  already  in  measure  described, 
external  urethrotomy  being  necessary  if  a  stricture  exists.  Occa- 
sionally the  perinealwound  does  not  close  after  such  an  operation, 
even  when  the  stricture  has  been  divided  ;  the  edges  of  the  fistula 


1274  A  MANUAL  OF  SURGERY 

should  then  be  pared,  and  the  wound  brought  together  by  deep 
quilled  sutures.  A  catheter  should  be  kept  in  the  bladder  for  a  few 
days,  and  the  urine  regularly  drawn  off  after  its  removal. 

When  of  small  size,  and  situated  either  in  the  perineum  or  the 
penis,  cure  may  be  determined  by  cauterizing  the  passage  either 
with  a  probe  coated  with  nitrate  of  silver  or  by  a  galvano-cautery, 
but  in  other  cases  some  form  of  urethroplasty  is  necessary. 

Affections  of  the  Penis. 

PMmosis,  when  complete,  is  a  condition  in  which  the  prepuce  is 
so  long,  and  the  orifice  so  narrow,  that  it  cannot  be  retracted  behind 
the  corona.  It  is  usually  Congenital  in  origin,  and  may  exist  to 
such  a  degree  as  to  render  micturition  impossible.  More  frequently 
the  opening  is  a  very  small  one  (pinhole  prepuce),  permitting  mic- 
turition, but  leading  to  irritability  of  the  bladder  from  the  obstruc- 
tion. In  such  cases  the  prepuce  is  usually  adherent  to  the  glans, 
and  considerable  irritation  is  caused  by  the  retention  of  the  smegma 
secreted  by  Tyson's  glands  ;  this  may  collect  and  become  so  in- 
spissated as  to  give  rise  to  definite  concretions.  The  child  pulls  at 
the  foreskin,  owing  to  the  itching  produced,  and  thus  the  symptoms 
of  vesical  calculus  may  be  simulated.  Attacks  of  balanitis  are  also 
frequent,  and  should  the  prepuce  be  withdrawn,  paraphimosis  is 
almost  certain  to  follow.  If  allowed  to  remain  untreated  long 
enough,  distension  of  the  bladder,  and  even  hydronephrosis,  may 
supervene.  Not  only  is  this  condition  in  itself  a  cause  of  irritation 
to  the  individuals  affected,  but  it  is  often  provocative  of  masturbation ; 
moreover,  it  is  certain  to  aggravate  the  symptoms  of  venereal  disease, 
and  there  is  but  little  doubt  that  it  acts  as  a  predisposing  cause  to 
epithelioma  of  the  penis.  Phimosis  also  occurs  as  an  AccLuired  condi- 
tion, resulting  from  the  cicatrization  of  venereal  sores. 

The  Treatment  of  phimosis  consists  in  circumcision.  Other 
methods  have  been  suggested — e.g.,  dilatation  of  the  prepuce,  and 
merely  slitting  it  up — but  they  are  not  satisfactory. 

Circumcision  should  always  be  performed  on  children  with  a  long 
prepuce  within  the  first  year  of  life,  since  at  that  time  the  parts  are 
but  slightly  developed,  the  operation  is  a  trifling  one,  and  but  little 
inconvenience  is  subsequently  experienced  ;  the  longer  it  is  post- 
poned, the  more  troublesome  does  it  become.  The  best  method  of 
operating  is  as  follows :  The  dorsal  aspect  of  the  prepuce  is  put  on 
the  stretch  by  grasping  it  on  either  side  of  the  median  line  with  a 
pair  of  catch  forceps ;  a  director  is  then  introduced  between  it  and 
the  glans,  and  held  exactly  in  the  middle  line,  and  the  prepuce  slit 
up  with  a  curved  pointed  bistoury  or  scissors.  The  lateral  halves  are 
now  separated  from  the  glans,  adhesions,  if  necessary,  being  broken 
down ;  this  must  be  very  thoroughly  attended  to,  so  as  to  enable  all 
retained  smegma  to  be  removed,  and  the  corona  glandis  defined. 
The  redundant  preputial  tissue,  both  skin  and  mucous  membrane,  is 
cut  away  on  each  side  by  scissors,  special  attention  being  directed 


AFFECTIONS  OF  THE   URETHRA   AND  PENIS 


1275 


to  the  removal  of  sufficient  tissue  on  the  under  side  to  prevent  the 
unsightly  projection  so  frequently  seen  just  below  the  fraenum.  In 
adults  several  vessels  will  bleed  and  require  to  be  ligatured,  especially 
that  in  the  fraenum,  but  in  a  child  the  haemorrhage  is  trifling. 
Having  carefully  trimmed  up  the  edges,  and  snipped  off  all  ragged 
corners,  so  as  to  render  the  margins  of  the  wound  regular,  catgut 
sutures  are  inserted  to  prevent  any  raw  surface  being  left  exposed  ; 
in  children  only  a  few  are  required,  but  possibly  a  considerable 
number  in  adults  ;  a  continuous  suture  should  never  be  employed. 
The  wound  is  dressed  with  strips  of  gauze,  and  around  this  a  wisp  of 
sterile  wool,  retained  in  adults  by  a  narrow  bandage.  Considerable 
after-trouble  is  sometimes  experienced 
from  nocturnal  erections,  which  may  be 
so  marked  and  prolonged  as  to  tear 
through  the  stitches  ;  to  control  this 
the  patient's  bowels  should  be  freely 
opened,  and  he  should  be  kept  on  a  low 
and  unstimulating  diet,  and  bromide  of 
potassium  or  other  sedatives  adminis- 
tered. The  stitches  are  usually  re- 
moved at  the  end  of  five  days,  and  the 
parts  are  then  dusted  over  with  a 
mixture  of  powdered  boric  acid,  zinc 
oxide,  and  starch,  so  as  to  reduce  their 
sensitiveness. 

When  a  phimosed  prepuce  is  com- 
pletely retracted,  the  patient  often  finds 
it  impossible  to  replace  it,  thus  giving 

rise  to  a  condition  known  as  ParapMmosis.  It  is  due  to  the  narrow 
orifice  of  the  prepuce  getting  behind  the  corona,  and  is  characterized 
by  great  oedema  and  congestion,  not  only  of  the  exposed  mucous 
membrane,  but  also  of  the  glans  itself.  If  left  untreated,  ulceration 
takes  place  along  the  line  of  constriction,  and  the  parts  become  fixed 
in  their  deformed  position,  the  vessels  sooner  or  later  accommodating 
themselves  to  the  new  conditions,  and  the  oedema  slowly  disappear- 
ing.    In  some  cases  sloughing  of  the  glans  may  occur. 

Treatment  consists  in  forcible  replacement  of  the  prepuce.  This 
is  accomphshed  by  grasping  the  penis  between  the  first  and  second 
fingers  of  each  hand,  and  compressing  the  glans  penis  with  the  thumbs 
so  as  to  empty  the  vessels  and  diminish  the  amount  of  oedema  present, 
and  thus  reduce  its  size  (Fig.  539).  At  the  same  time  the  fingers 
draw  the  prepuce  forwards,  and  thus  finally  reposition  is  effected. 
When  the  oedema  of  the  prepuce  is  very  marked,  it  should  be  punc- 
tured in  several  places  to  permit  the  escape  of  serum  and  diminish 
the  tension,  previous  to  reduction  as  just  described.  In  more  advanced 
cases  reposition  becomes  impossible,  and  then  the  narrow  constricting 
band  caused  by  the  Orifice  of  the  prepuce  must  be  divided  on  the 
dorsal  aspect.  This  will  free  the  parts,  which  can  be  subsequently 
drawn  forwards,  and  after  the  oedema  has  been  reduced  by  applying 


Fig. 


539. — Reduction  of 
Paraphimosis. 


1276  A  MANUAL  OF  SURGERY 

lotio  plumbi  for  a  few  days,  circumcision  may  be  advantageously 
undertaken. 

Balanitis,  or  inflammation  of  the  glans,  may  be  simple  in  nature, 
arising  from  want  of  cleanliness  in  a  person  with  a  long  foreskin,  but 
more  frequently  is  associated^with  gonorrhoea  or  soft  chpncres.  The 
under  surface  of  the  prepuce  is  often  involved,  and  then  the  term 
Balano-postMtis  is  sometimes  applied  to  it.  A  muco-purulent  or 
purulent  discharge  escapes  from  under  the  prepuce,  which  is  often 
swollen  and  cedematous.  Occasionally,  when  a  considerable  degree 
of  phimosis  exists,  the  under  surface  of  the  prepuce  may  become 
ulcerated,  and  even  perforated  ;  whilst  in  very  neglected  cases,  and 
especially  if  phagedena  is  present,  the  prepuce  will  slough,  and 
allow  the  glans  to  protrude,  usually  through  its  upper  surface. 

Treatment. —  In  simple  cases,  all  that  is  required  is  to  cleanse  the 
parts  thoroughly  by  washing  beneath  the  foreskin,  and  then  apply 
lead  lotion  on  lint  between  the  glans  and  the  prepuce  ;  but  when 
there  is  much  discharge,  and  the  foreskin  is  long  and  swollen,  or  if 
perforation  is  threatening,  the  prepuce  must  be  slit  up,  and,  after  the 
parts  have  been  restored  to  a  healthy  state,  the  redundant  tissues 
should  be  cut  away  by  a  modified  circumcision. 

For  Soft  Chancre  and  Syphilis,  see  pp.  140  and  142. 

Herpes  not  uncommonly  affects  the  prepuce  and  glans.  It  may 
result  from  simple  local  irritation,  more  especially  in  gouty  indi- 
viduals ;  but  is  most  frequently  seen  in  patients  who  have  suffered 
from  syphilis,  and  is  then  likely  to  be  somewhat  intractable.  It 
manifests  itself  as  a  crop  of  small  vesicles  on  a  hyperaemic  base, 
which  become  abraded,  leaving  a  number  of  small  ulcers.  It  is 
preceded  by  pain  of  a  neuralgic  type,  and  accompanied  by  much 
itching  and  irritation.  The  only  treatment  required  is  to  keep  the 
parts  clean,  and  dust  them  over  with  powdered  oxide  of  zinc  and 
starch.  In  the  majority  of  cases  the  disease  lasts  from  a  week  to  ten 
days.  During  the  healing  of  the  herpetic  ulcers,  a  patient  is  very 
liable  to  be  inoculated  with  the  virus  of  either  the  soft  chancre  or 
syphilis  if  he  exposes  himself  to  the  risk  of  infection. 

Warts  often  arise  on  the  penis  in  the  shape  of  red,  vascular 
excrescences,  usually  pedunculated,  and  sometimes  of  considerable 
size.  They  are  met  with  most  frequently  as  a  sequela  of  gonorrhoea, 
and  must  be  carefully  distinguished  from  mucous  tubercles.  They 
should  be  treated  by  snipping  them  away  with  scissors,  and  cauteriz- 
ing the  base  with  a  galvano-cautery.  The  X  rays  are  also  useful  in 
their  removal  when'  very  extensive. 

Horns  are  also  occasionally  seen  arising  from  the  body  of  the  penis. 
They  are  of  the  usual  sebaceous  type,  as  described  at  p.  407,  and 
should  be  excised. 

Epithelioraa  of  the  penis  rarely  arises  except  in  patients  who  are 
the  subjects  of  congenital  phimosis  or  possess  long  foreskins,  and 
hence  it  is  stated  that  the  disease  is  unknown  amongst  the  Jews.  It 
usually  commences  in  the  sulcus  behind  the  corona  glandis,  and 
rapidly  spreads  to  the  surrounding  parts,  manifesting  itself  either  as 


AFFECTIOMS  OF  THE    URETHRA  AND  PENIS 


1277 


an  irregular,  papillated,  wart-like  outgrowth,  or  as  a  diffuse  infiltra- 
tion, ulcerating  early,  and  leading  to  considerable  destruction  of 
tissue  (Fig.  540)-  At  first  the  tumour  is  mainly  beneath  the  prepuce, 
which  becomes  distended,  producing  a  sanious  discharge,  which 
contains  epithelial  cells  as  well  as  pus  corpuscles  ;  but  as  the  case 
progresses,  the  prepuce  itself  is  attacked,  and  even  perforated. 
Later  on  the  body  of  the  penis  is  invaded  and,  owing  to  its  great 
vascularity,  the  disease  makes 
rapid  progress.  The  inguinal 
glands  are  early  affected,  but 
when  the  body  of  the  penis  is 
involved,  the  'lumbar  glands 
are  also  implicated. 

The  Diagnosis  of  epithelioma 
from  warts  is  easily  made  by 
contrasting  the  infiltration  of 
the  base  produced  by  the  former 
with  the  soft  and  normal  con- 
dition of  the  glans  in  the  latter 
condition, 

The  Treatment  of  epithe- 
lioma consists  in  amputation 
of  the  penis  whenever  the 
disease  is  sufficiently  limited  to 
lead  to  the  hope  that  it  can  be 
eradicated.  When  confined  to 
the  distal  end  of  the  organ,  the 
operation  may  possibly  be  per- 
formed through  the  body  ;  but 
it  is  much  more  logical  and  more  in  accord  with  modern  scientific 
dicta  to  remove  the  whole  organ. 

Amputation  through  the  body  of  the  penis  is  an  operation  of  but  little 
difficulty.  A  short  flap  is  reflected  from  the  dorsum,  and  the 
corpora  cavernosa  cut  through,  the  urethra  and  remaining  portions 
of  the  organ  being  divided  at  a  lower  level.  Bleeding  is  then 
arrested  by  securing  the  divided  vessels  ;  five  ligatures  are  usually 
required,  viz.,  one  for  the  artery  to  the  corpus  cavernosum  on  either 
side,  one  for  each  dorsal  artery,  and  one  for  the  artery  to  the  septum. 
The  urethra  is  then  isolated,  and  passed  through  an  opening  made 
in  the  upper  integumental  flap.  It  is  split  along  its  upper  wall,  and 
secured  by  sutures  to  the  margins  of  the  opening,  so  as  to  prevent 
subsequent  retraction  ;  the  flaps  are  then  united  by  stitches. 

Amputation  of  the  whole  penis  is  a  more  serious,  but  very  successful, 
operation.  The  patient  is  placed  in  the  lithotomy  position,  and  the 
perineum,  after  being  shaved  and  purified,  incised  freely  in  the 
middle  line.  The  corpus  spongiosum  is  traced  backwards,  and 
divided  at  such  a  level  as  to  allow  the  mucous  membrane  lining  the 
proximal  portion  of  the  urethra  to  be  stitched  to  the  skin  at  the 
posterior  angle  of  the  incision.     The  corpora  cavernosa  are  freed 


FiG-  540. — Epithelioma    of.  Penis. 
(King's  College  Hospital  Museum.) 


1278  A  MANUAL  OF  SURGERY 

from  their  connections,  and  separated  at  their  origins  from  the 
ischio-pubic  rami  by  the  knife  or  suitable  raspatories.  An  elHptical 
incision  is  then  made  round  the  root  of  the  penis,  the  dorsal  vessels 
are  divided  and  secured,  and  the  suspensory  ligament  cut  through. 
The  penis  can  then  be  drawn  forwards,  and  by  a  few  final  touches 
of  the  knife  completely  removed.  All  bleeding-points  are  ligatured, 
and  the  anterior  wound  closed  by  a  continuous  suture  in  the  middle 
line,  a  drainage-tube  being  placed  in  the  perineal  portion  for  a  few 
days.  The  results  of  this  operation  have,  on  the  whole,  been  very 
satisfactory,  and  by  the  use  of  a  suitable^  contrivance  the  patient 
need  not  assume  the  sitting  posture  in  order  to  micturate.  He  will 
require  to  carry  about  with  him  a  small  metal  funnel,  bevelled  to  fit 
the  perineum,  and  with  a  spout  directed  forwards.  An  excellent 
one  was  extemporized  by  a  patient  from  the  rose  of  a  watering-can, 
the  perforated  top  having  been  removed  and  the  edges  smoothed 
and  bevelled. 


CHAPTER  XLI. 

AFFECTIONS  OF  THE  TESTIS,  CORD,  SOEOTUM,  AND 
SEMINAL  VESICLES. 

Congenital  Affections  of  the  Testis. — It  is  scarcely  necessary  to  state  that  the 
testicles  are  not  developed  in  the  scrotum,  but  from  the  posterior  wall  of  the 
abdominal  cavity,  so  that  they  lie  at  first  behind  the  peritoneum  close  to  the 
kidneys.  The  body  of  the  gland  arises  from  the  so-called  genital  ridge,  which  is 
covered  by  columnar  epithelial  cells,  and  lies  to  the  mesial  side  of  the  Wolffian 
body.  The  vasa  efferentia  are  developed  from  the  tubules  of  the  latter  structure, 
coming  into  relation  at  a  later  date  with  the  seminal  tubules ;  the  vas  deferens 
is  formed  by  the  Wolffian  duct. 

Occasionally  the  body  of  the  testis  is  entirely  absent,  whilst  a  few  cases  are 
on  record  of  absence  or  deficiency  of  the  vas.  Very  rarely  two  testicles  have 
been  developed  on  one  side,  and  have  both  found  their  way  into  the  scrotum 
{polyorchism). 

The  passage  of  the  testis  from  the  abdominal  cavity  to  the  scrotum  takes  place 
at  about  the  end  of  the  eighth  month  of  intra-uterine  life.  '  The  gubernaculum 
testis  is  the  active  agent  in  bringing  about  the  descent  of  the  testis.  This  is 
a  band  of  involuntary  muscular  fibres  which  traverses  the  inguinal  canal,  and 
establishes  important  connections  both  within  and  without  the  abdominal  cavity. 
Below,  three  main  attachments  of  the  gubernaculum  may  be  recognised,  viz. : 
(fl)  to  the  abdominal  wall  ;  (b)  to  the  pubis  ;  (c)  to  the  bottom  of  the  scrotum. 
Above,  the  gubernacular  fibres  are  chiefly  connected  with  the  testicle  ;  but 
many  of  them  are  also  attached  to  the  peritoneum  on  the  posterior  wall  of  the 
abdomen.  By  the  traction  which  the  gubernaculum  exerts  on  the  testicle,  the 
descent  of  that  organ  is  brought  about.  By  the  portion  attached  to  the  abdominal 
wall  the  testicle  is  pulled  down  to  the  internal  abdominal  ring,  the  pubic  portion 
drags  it  through  the  inguinal  canal,  whilst  the  scrotal  part  finally  leads  it  into 
the  scrotum. 

'  The  formation  of  the  processus  vaginalis  is  accounted  for  in  the  same  way. 
Some  of  those  gubernacular  fibres  which  are  inserted  into  the  peritoneum  drag 
down  the  peritoneal  diverticulum  which  lines  the  inguinal  canal  and  scrotum, 
and  prepares  the  way  for  the  testicle.'  (Cunningham's  'Manual  of  Anatomy,' 
vol.  i.,  pp.  426,  427.) 

Two  chief  forms  of  malposition  of  the  testis  are  described,  arising  either  from 
its  incomplete  or  abnormal  descent. 

I.  Incomplete  Descent  or  Retention  of  the  Testis. — The  testis  may  remain  in 
the  abdominal  cavity  attached  to  the  abdominal  wall  by  a  mesorchium  [rctentio 
abdominalis) ;  more  frequently,  it  is  found  just  within  the  internal  abdominal 
ring  {retentio  iliaca) ;  but  most  commonly  it  occupies  the  inguinal  canal,  or  lies 
just  outside  of  it  {retentio  ingiiinalis).  The  organ  in  the  latter  position  is  freely 
mobile,  being  readily  pressed  up  towards  the  abdominal  cavity.  The  Causes  of 
this  condition  must  be  looked  for  mainly  in  some  abnormal  attachment  of  the 
gubernaculum,  or  possibly  in  the  existence  of  intra-uterine  peritonitis.      I-ess 

1279 


l28o  A  MANUAL  OF  SURGERY 

commonly  a  contracted  condition  of  the  external  abdominal  ring,  or  an  undulj 
large  epididymis,  may  determine  its  occurrence. 

The  condition  is  easily  recognised  by  the  absence  of  the  testicle  in  the 
scrotum,  and  in  the  inguinal  variety  the  organ  can  usually  be  detected  as  a  small 
moveable  swelling  about  the  size  of  a  horse-bean,  giving  the  characteristic, 
testicular  sensation  on  pressure.  The  scrotum  on  the  affected  side  is  imperfectly 
developed. 

In  any  of  these  varieties  a  late  descent  of  the  testis  may  occur,  usually  accom- 
panied by  a  congenital  hernia,  possibly  of  an  interstitial  type. 

2.  Malposition  of  the  Testis. — Two  distinct  forms  are  described  :  (a)  Ectopia 
Perinealis. — In  this' variety  the  testis  finds  its  way  into  the  perineum,  slipping 
along  the  groove  between  the  thigh  and  the  scrotum.  It  may  exist  as  a  con- 
genital condition,  being  then  due  to  the  contraction  of  an  accessory  band  of 
■gubernacular  fibres  ;  or  it  may  happen  in  consequence  of  a  late  descent  of  the 
testicle,  owing  to  atrophy  of  the  scrotum.  It  always  causes  considerable  incon- 
venience to  the  patient,  especially  on  sitting  or  riding,  [b)  Ectopia  Cruralis. — 
The  testicle  here  lies  on  the  inner  side  of  Scarpa's  triangle,  in  the  region  of  the 
saphenous  opening.  It  is  said  to  escape  along  the  crural  canal,  but  more  prob- 
ably it  passes  down  the  inguinal  canal  as  usual,  and  then  finds  its  way  over 
Poupart's  ligament  to  this  situation,  guided  by  a  second  accessory  band  of  guber- 
nacular tissue.  When,  as  not  .uncommonly  happens,  a  congenital  hernia  also 
exists,  it  may  travel  outwards  to  the  anterior  superior  spine,  being  directed  there 
by  the  arrangement  of  the  fasciae,  as  in  a  femoral  hernia  (extra-parietal  inter- 
stitial hernia,  p.  1095). 

In  cases  of  retained  or  misplaced  testis  the  spermatoge.nic  function  of  the 
organ  is  rarely  developed,  or  at  most  merely  for  a  year  or  two  about  the  age  of 
twenty.  Pain  is  not  unfrequently  complained  of,  coming  on  in  bouts  which  last 
for  a  short  time  and  then  disappear,  probably  due  to  slight  injuries  or  torsion. 
Fibrosis  of  the  testis  follows  in  time,  and  total  degeneration  is  the  ultimate 
outcome.  If  only  one  organ  is  affected,  but  little  harm  follows  ;  but  if  both  are 
involved,  the  individual  is  probably  sterile. 

Complications  of  a  Retained  or  Misplaced  Testicle. — Any  of  the  conditions  to 
be  described  hereafter  in  this  chapter  may  involve  a  retained  or  misplaced 
testicle,  just  as  if  it  were  in  the  scrotum,  and  give  rise  to  considerable  trouble, 
especially  when  the  organ  is  lying  in  close  proximity  to  the  peritoneum.  A 
testis  misplaced  or  retained  in  the  inguinal  canal  is  much  exposed  to  injury,  and 
a  subacute  traumatic  orchitis  often  occurs.  It  is  stated  that  such  organs  are  very 
prone  to  become  the  seat  of  malignant  disease  at  a  later  period  of  life,  but  the 
accuracy  of  this  statement  is  a  little  doubtful. 

Trea,tment. — Taking  into  consideration  the  discomfort  occasioned  by  this  con- 
dition, as  well  as  the  risk  arising  from  the  tendency  to  malignant  disease,  there 
can  be  little  doubt  that  the  best  method  of  treatment  is  the  removal  of  the  testicle. 
Many  operations  have  been  devised  with  the  idea  of  placing  the  organ  in  its 
normal  position  in  the  scrotum,  but  the  majority  of  such  methods  have  proved 
useless,  owing  to  the  defective  length  of  the  spermatic  vessels  and  cord  ;  more- 
over, the  traction  and  handling  required  to  draw  the  organ  down  into  the  scrotum 
may  determine  the  occurrence  of  fibrotic  changes,  even  if  they  are  not  already 
present.  Some  authors  advise  the  replacement  of  the  organs  in  the  abdominal 
cavity  in  patients  before  the  age  of  twenty-three,  but  it  is  doubtful  whether  much 
value  is  to  be  attached  to  such  a  suggestion. 

Another  condition  met  with  congenitally  is  Inversion  of  the  testis,  the  epi- 
didymis lying  in  front,  and  the  body  of  the  organ  behind.  It  is  of  no  clinical 
significance,  except  that  in  careless  hands  it  may  be  injured  whilst  tapping  a 
hydrocele. 

Torsion  of  the  Spermatic  Cord  results  in  acute  strangulation  of  the  testis. 
The  cause  still  remains  unknown,  but  several  of  the  cases  recorded  have  been 
associated  with  late  descent  of  the  testicle,  and  others  have  been  attributed  to 
twists  and  strains.  The  symptoms  are  tolerably  characteristic  :  the  patient 
complains  of  an  acute  sickening  pain  in  the  testis  which  persists  until  gangrene 
has  supervened,  and  may  then  disappear  ;  it  is  accompanied  by  a  certain  amount 
of  pj'rexia,  and  the  appearance  of  a  tumour,  either  in  the  inguinal  region  or  in 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC.         1281 

the  scrotum.  The  testicle,  slightly  enlarged,  is  felt  below,  and  above  it  a  larger 
mass,  consisting  of  the  twisted  cord  and  the  congested  and  swollen  epididymis. 
In  some  cases  the  latter  swelling  has  been  crepitant,  owing  to  the  development 
of  gases  due  to  its  putrefaction.  The  condition  is  very  likely  to  be  mistaken  for 
a  strangulated  hernia,  which  it  closely  resembles  ;  but  the  presence  of  fever,  and 
the  absence  of  abdominal  distension  and  of  fsecal  vomiting,  are  important  dis- 
tinctive signs  ;  moreover,  constipation,  though  often  present,  is  never  absolute. 
If  the  testis  is  situated  in  the  scrotum,  the  cord  and  inguinal  canal  are  found  to  be 
clear  ;  whilst  if  in  the  canal,  the  affected  side  of  the  scrotum  is  empty.  The  only 
Treatment  possible  is  exploration  and  removal  of  the  inflamed  or  gangrenous 
testis  and  cord,  unless  the  case  is  seen  very  early,  when  it  may  be  feasible  to 
untwist  it. 

Injuries  of  the  Testis  and  Cord. — Contusion  is  a  very  common  form 
of  injury.  It  arises  from  blows,  kicks,  squeezes,  and  the  like,  and  is 
always  associated  with  immediate  pain  of  a  most  sickening  and  in- 
tense character,  which  is  not  only  experienced  in  the  testicle,  but  also 
radiates  along  the  cord  towards  the  loins  and  back,  and  down  the 
front  of  the  thigh.  Severe  shock  accompanies  the  pain,  and  may  be 
so  profound  as  to  lead  to  a  fatal  issue.  A  well-marked  traumatic 
orchitis  often  follows,  and  this  may  in  turn  induce  atrophy  of  the 
organ,  although  the  same  condition  sometimes  occurs  without  much 
evidence  of  inflammation,  as  a  result  of  thrombosis  and  occlusion  ot 
the  spermatic  vessels.  A  haematocele  is  also  induced  by  a  sub- 
cutaneous lesion  of  this  nature.  Treatment  consists  in  keeping  the 
patient  in  the  recumbent  posture  with  the  scrotum  well  raised,  and  in 
applying  fomentations  or  an  icebag. 

Penetrating  Wounds  or  Punctures  are  uncommon  except  as  a  result 
of  surgical  treatment  {e.g.,  tapping  a  hydrocele).  A  certain  amount 
of  haemorrhage  usually  follows,  whilst  the  immediate  lesion  is  asso- 
ciated with  severe  testicular  pain.  If  the  wound  becomes  septic,  the 
tubules  are  likely  to  protrude,  and  a  hernia  testis  may  result.  Ali 
that  is  ordinarily  required  is  to  purify  the  parts  and  allow  them  to 
heal ;  sutures  should  not  be  inserted  into  the  tunica  albuginea,  if 
there  is  any  doubt  as  to  the  wound  being  sterile.  If  the  gland  is 
totally  disorganized,  castration  must  be  undertaken. 

Haematocele,  or  a  localized  collection  of  blood  in  the  tunica  vaginalis 
or  cord,  is  a. common  result  of  injuries. 

I.  Haematocele  of  the  Tunica  Vaginalis  arises  from  traumatism,  such 
as  a  sudden  blow  or  severe  strain,  and  occasionally  follows  the  tap- 
ping of  a  hydrocele  if  a  superficial  vessel  has  been  ruptured  or  punc- 
tured, or  if  the  body  of  the  testis  has  been  wounded  ;  it  may,  however, 
be  due  to  general  oozing  from  dilated  capillaries  in  the  serous  mem- 
brane owing  to  the  sudden  relief  of  tension.  It  also  occurs  more  or 
less  spontaneously  in  connection  with  malignant  disease.  The  History 
generally  given  is  that  the  patient  was  seized  with  a  sudden  sicken- 
ing pain  in  the  testicle,  which  became  quickly  enlarged  without  any 
evidence  of  inflammation.  If  blood  is  extravasated  at  the  same  time 
into  the  scrotum,  the  integument  becomes  discoloured  in  the  course 
of  a  few  days  owing  to  a  diffusion  of  the  blood  pigment.  At  first  the 
swelling  is  smooth  and  fluctuating,  exactly  resembling  a  hydrocele, 
except  in  the  absence  of  translucency ;  but  owing  to  a  deposit  of 

.    Si 


1282  A  MANUAL  OF  SURGERY 

fibrin  on  the  walls  from  the  coagulation  of  the  blood,  it  becomes 
hard  and  firm  in  a  short  time,  closely  simulating  a  solid  tumour.  In 
slight  cases  the  blood  is  entirely  absorbed,  but  when  the  effusion  is 
considerable  the  coagulum  is  likely  to  persist.  On  laying  open  such 
a  swelling,  the  testicle  is  usually  found  in  a  healthy  state,  whilst  the 
enlarged  tunica  is  occupied  by  some  blood-stained  brownish-yellow 
fluid,  and  surrounded  by  a  mass  of  fibrinous  coagulum,  part  of  which 
is  deposited  in  laminae  upon  the  walls,  and  part  remains  as  shreddy 
masses  projecting  into  its  lumen.  In  very  chronic  cases  the  walls  of 
the  tunica  become  thick  and  indurated,  and  may  even  undergo  cal- 
careous changes.  Suppuration  is  sometimes  met  with  as  a  result  of 
auto-infection.  The  Diagnosis  of  a  haematocele  in  the  earlier  stages 
is  easily  made  ;  but  when  it  has  solidified  it  can  only  be  suspected  by 
the  history,  and  by  the  exclusion  of  other  sources  of  enlargement, 
whilst  an  exploratory  incision  or  puncture  is  often  necessary  to  settle 
the  diagnosis.  Treatment. — When  the  patient  is  seen  soon  after  the 
injury,  he  must  be  kept  at  rest,  the  parts  elevated,  and  evaporating 
lotions  applied ;  whilst  if  the  effusion  is  large,  removal  of  a  portion 
by  aseptic  tapping  will  expedite  the  process  of  absorption.  In  more 
chronic  cases  it  may  be  necessary  to  lay  the  cavity  open  and  remove 
its  contents,  whilst  in  the  later  stages,  if  the  tunica  has  become  thick 
and  indurated  and  the  testis  atrophied,  castration  may  be  advisable. 

2.  Hsematocele  of  the  Cord  is  but  rarely  seen.  It  is  due  to  the  rup- 
ture of  one  of  its  vessels,  as  a  result  of  injury  or  strain.  A  swelling 
of  considerable  size  rapidly  forms,  extending  along  the  cord  from  the 
inguinal  region  to  the  scrotum,  but  the  testis  remains  free  and  unim- 
plicated.  Such  a  condition  may  be  mistaken  for  an  omental  hernia, 
but  on  careful  examination  the  tumour  is  felt  to  be  more  uniform  in 
consistency,  more  rounded  in  outline,  and  even  semi-fluctuating.  It 
is  irreducible  and  without  impulse,  whilst  the  history  of  the  case  will 
assist  the  surgeon  in  making  a  correct  diagnosis.  Treatment  in  the 
early  stages  consists  in  the  application  of  evaporating  lotions,  and 
later  on,  if  the  blood-clot  is  not  absorbed,  the  cavity  may  be  laid  open 
and  the  coagulum  removed. 

Rupture  of  the  Vas  Deferens  has  resulted  from  excessive  strain  ;  it 
is,  however,  very  rare,  not  more  than  half  a  dozen  cases  being  on 
record.  It  may  affect  the  intra-abdominal  portion  of  the  vas,  and 
then  gives  rise  to  haemorrhage  from  the  urethra,  together  with  some 
amount  of  fever  and  hypogastric  pain,  leading  possibly  to  atrophy  of 
the  organ.  Rupture  of  the  scrotal  portion  is  followed  by  enlargement 
of  the  testis,  and  perhaps  scrotal  haemorrhage.  This  was  associated 
in  a  case  under  our  observation  with  haemorrhage  from  the  urethra 
on  attempting  coitus  shortly  after  the  accident,  and  subsequently 
with  severe  pain  and  sweUing  of  the  testis  produced  by  the  same  act, 
but  atrophy  did  not  follow.  If  it  occasions  any  inconvenience,  it  is 
best  treated  by  castration. 

Inflammatory  Affections  of  the  Testis  may  be  chiefly  confined  at 
their  onset  either  to  the  body  of  the  organ  or  to  the  epididymis  ;  in 


AFFECTIONS  OF  THE  TESTIS,  CORD,   SCROTUM.  ETC.         i^^S 

the  former  case  the  term  Orchitis  is  applied  to  it,  in  the  latter 
Epididymitis  ;  as  the  case  progresses  both  portions  are  involved  in 
the  process  ;  either  condition  may  be  acute  or  chronic. 

Acute  Orchitis  most  frequently  results  from  injury,  but  it  is  also 
met  with  as  a  primary  affection  in  gouty  and  rheumatic  individuals 
sometimes  arising  spontaneously  ;  or  it  may  follow  mumps,  typhoid^ 
or  other  eruptive  fevers,  as  a  result  of  metastasis,  whilst  it  is  always 
to  some  extent  associated  with  epididymitis.  In  mumps  it  may  pre- 
cede the  parotid  lesion,  or  may  even  occur  without  it. 

The  testicle  becomes  considerably  enlarged,  exceedingly  painful 
and  tender  to  the  touch.  The  shape  of  the  organ  is  more  or  less 
globular  (Fig.  541,  A),  whilst  the  pain  is  of  a  peculiarly  sickening 
character,  extending  upwards  along  the  course  of  the  cord  towards 


Fig.  541. — Diagrammatic  Sections  of  (A)  Orchitis,  (B)  Epididymitis 
AND  (C)  Hydrocele  of  Tunica  Vaginalis. 

T,  Testis;  E,  epididymis;  HY,  hydrocele. 


the  back  and  loins.  The  scrotal  integuments  become  red  and  in- 
filtrated, and,  owing  to  the  acuteness  of  the  process,  more  or  less 
adherent  to  the  coverings  of  the  gland.  A  plastic  or  serous  effusion 
into  the  tunica  vaginalis  is  sometimes  present,  giving  rise  to  what  is 
known  as  an  '  acute  hydrocele.'  Some  constitutional  disturbance 
accompanies  the  process,  the  temperature  being  elevated  two  or  three 
degrees,  whilst  vomiting  and  constipation  are  marked  symptoms.  It 
is  unusual  for  suppuration  to  ensue,  but  an  abscess  occasionally  forms, 
and  then,  after  the  pus  has  been  let  oTit,  a  hernia  testis  may  follow. 
Atrophy  is  a  more  common  sequela,  especially  in  adults,  being  caused 
by  constriction  of  the  vessels  and  tubules,  owing  to  organization  of 
the  inflammatory  exudation. 

Acute  Epididymitis  is  almost  always  due  to  the  extension  of  an 
inflammatory  process  from  the  urethra,  the  usual  cause  being  gonor- 
rhoea ;  it  occasionally  follows  the  passage  of  instruments  or  the 
lodgment  of  a  calculus  ;  or  it  may  be  secondary  to  a  suppurative 
prostatitis,  unconnected  with  gonorrhoea.  It  is  ushered  in  by  pain 
in  the  inguinal  region  and  perhaps  in  the  hypogastrium  along  the 
course  of  the  vas  deferens,   which   soon   extends  to  the  scrotum. 


I2S4  A  MANUAL  OF  SURGERY 

The  testicle  becomes  enlarged,  but  its  shape  is  that  of  an  elongated 
oval,  somewhat  flattened  laterally.  The  epididymis  is  readily  felt 
as  a  crescentic  swelling,  partially  overlapping  the  gland  in  all  direc- 
tions, and  in  its  concavity  the  rounded  outline  of  the  anterior  wall 
of  the  testis  can  usually  be  distinguished  (Fig.  541,  B),  or  the  tunica 
vaginalis  distended  with  fluid.  The  scrotum  is  red,  oedematous,  and 
adherent  to  the  testis,  whilst  the  cord  is  infiltrated,  enlarged,  and 
tender.  The  same  constitutional  symptoms  are  met  with  as  in 
orchitis.  Suppuration  is  perhaps  more  common  than  after  the  latter 
affection,  since  the  condition  is  usually  due  to  a  suppurating  in- 
flammation of  the  deeper  parts  of  the  urethra  ;  but  it  is  a  rare 
complication.  Atrophy  of  the  testis  is  a  not  unfrequent  result  in 
cases  which  are  not  efficiently  treated,  the  plastic  material  exuded 
into  the  epididymis  being  organized  into  fibro-cicatricial  tissue,  and 
constricting  the  spermatic  vessels  ;  an  acute  attack  of  double  epididy- 
mitis may  in  this  way  render  the  individual  sterile. 

The  Treatment  of  both  these  conditions  in  the  acute  stage  consists 
in  keeping  the  patient  in  bed,  with  the  scrotum  supported  on  a  small 
pillow.  The  part  is  assiduously  fomented,  except  when  the  case  is 
seen  very  early,  an  icebag  or  Leiter's  coil  being  then  employed. 
Leeching  should  not  be  utilized,  as  the  triangular  leech-bites  are  very 
liable  to  become  irritated  and  infected,  and  never  heal  well  in  the 
scrotum  ;  if  local  abstraction  of  blood  appears  desirable,  one  or  more 
of  the  scrotal  veins  may  be  punctured ;  the  haemorrhage  is  easily 
arrested  by  elevating  the  part.  Pain,  if  severe,  may  be  mitigated 
by  a  hot  sitz-bath,  or  by  morphia  suppositories.  As  regards  general 
treatment,  the  patient,  after  a  preliminary  dose  of  calomel,  is  kept 
on  a  fluid,  unstimulating  diet,  whilst  alkaline  purgatives  are  ad- 
ministered, with  the  addition  of  tincture  of  henbane  or  opium  as  a 
sedative ;  if  the  pulse  is  hard  and  the  temperature  high,  vinum  anti- 
monialisin  lo-minim  doses  is  also  beneficial.  When  the  acute  stage 
is  passed,  the  organ  usually  remains  enlarged,  and  for  a  time  some- 
what tender ;  it  is  then  best  treated  by  strapping  with  lead  plaster,  or 
with  the  emplastrum  ammoniaci  cum  hydrargyro.  This  must  be 
continued  until  all  signs  of  thickening  and  induration  have  dis- 
appeared. 

Subacute  or  chronic  forms  of  inflammation  are  also  met  with  affect- 
ing the  testis  or  epididymis,  either  as  a  consequence  of  the  above,  or 
resulting  primarily  from  blows  or  strains.  The  characteristic  enlarge- 
ment is  readily  detected,  associated  with  a  certain  amount  of  tender- 
ness. A  useful  diagnostic  point  between  the  chronic  epididymitis 
following  gonorrhcea  and  that  due  to  syphilis  is  that  the  former  usually 
involves  the  globus  minor,  and  the  latter  is  almost  limited  to  the 
globus  major.  The  condition  is  best  treated  by  strapping,  and  per- 
haps the  administration,  of  small  doses  of  mercury  and  iodides  may 
assist  in  the  absorption  of  the  inflammatory  products.  Chronic 
orchitis  is  very  similar  to  the  enlargement  produced  by  syphilis, 
from  which,  indeed,  it  can  only  be  distinguished  by  the  absence  of 
a  syphilitic  history. 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.         1285 


Tuberculous  Disease  of  the  Testis  (Syn.  :  Tuberculous  Sarcocele, 
Chronic  Tuberculous  Orchitis). — This  affection  is  most  commonly  seen 
in  young  adults  with  a  distinct  tuberculous  history,  but  it  also  occurs 
in  otherwise  healthy  individuals.  It  may  commence  as  a  primary 
affection  of  the  epididymis,  or  may  be  secondary  to  tuberculous 
disease  elsewhere. 

Pathological  Anatomy. — The  process  originates  in  the  connective 
tissue  of  the  epididymis,  and  runs  its  usual  course,  at  first  consisting 
merely  of  miliary  elements  deposited  around  the  vessels,  which  by 
their  coalescence  and 
caseation  lead  to  the 
formation  of  cheesy 
masses,  and  these  at 
a  later  stage  may 
emulsify  and  give  rise 
to  abscesses.  It  may 
be  limited  to  any  one 
part  of  the  epididymis 
(most  often  the  globus 
major),  or  may  widely 
infiltrate  its  substance, 
causing  a  general  en- 
largement (Fig.  542). 
In  the  latter  case  it 
early  tends  to  spread, 
either  into  the  body 
of  the  testis  or  along 
the  vas  deferens.  The 
corpus  Highmori- 
anum  becomes  first 
involved  by  a  similar 
deposit,  and  finally  the 
intertubular  connec- 
tive tissue  of  the  gland  ;  this  is  always  associated  with  overgrowth 
of  the  epithelium  in  the  tubuh  seminiferi,  the  cells  after  a  time 
undergoing  fatty  degeneration,  and  perhaps  to  such  an  extent  that, 
on  microscopic  section,  the  normal  appearance  of  the  organ  has 
entirely  disappeared.  An  abscess  may  form  within  it,  and  find  its 
way  to  the  surface  by  burrowing  through  the  tunica  albuginea,  the 
visceral  and  parietal  layers  of  the  tunica  vaginalis  having  previously 
become  adherent.  After  the  pus  has  escaped,  a  hernia  testis  is 
likely  to  develop.  If  the  process  extends  upwards  along  the  cord, 
the  vas  is  mainly  implicated,  becoming  perceptibly  thickened,  the 
other  structures  of  the  cord  being  but  little  affected.  The  disease 
spreads  along  the  vas  on  the  outside  of  the  bladder  to  the  vesiculae 
seminales  and  prostate,  and  may  even  involve  the  base  of  the  bladder, 
the  ureters,  and  kidneys.  Lastly,  general  dissemination  of  tuber- 
culous disease  may  occur,  and  it  is  a  curious  fact  that  meningeal 
mischief  is  not  very  uncommonly  associated  with  genital  tuberculosis. 


Fig.     542. — ToBERCDLOUs 

MAINLY     INVOLVING     THE 


Disease      of      Testis, 
Epididymis  and    Cord. 


(King's  College  Hospital  Museum. 


1286  A  MANUAL  OF  SURGERY 

Clinical  Signs.— The  disease  is  generally  unilateral,  although  the 
other  testicle  often  becomes  involved  at  a  somewhat  later  date.  Its 
onset  maybe  abrupt  or  gradual  ;•  in  the  former  case  the  attack  simu- 
lates an  acute  orchitis,  but  at  the  end  of  a  week,  although  the  pain 
subsides,  the  swelling  persists,  being  followed  by  the  development  of 
abscesses  containing  cheesy  pus.  In  the  more  chronic  cases,  one  or 
more  firm  and  indurated  nodules,  which  are  free  from  tenderness, 
are  felt  in  the  epididymis,  but  more  often  the  whole  of  this  structure 
is  found  to  be  enlarged  and  thickened,  forming  a  painless  crescentic 
swelling,  surrounding  the  posterior  half  of  the  body  of  the  testis,  from 
which  it  is  usually  separated  by  a  deep  groove  or  sulcus.  The  epi- 
didymis is  nodular  and  craggy  to  the  feel,  and  may  be  of  unequal 
consistency,  areas  of  softening  being  interposed  between  portions 
which  are  distinctly  hard.  The  vas  is  early  thickened,  whilst  the 
other  structures  of  the  cord  are  but  little  involved  ;  the  thickening 
is  more  or  less  nodular,  and  almost  beaded  in  its  consistency.  The 
body  of  the  testis  maybe  involved  and  enlarged,  the  line  of  demarca- 
tion between  it  and  the  epididymis  becoming  indistinct.  Testicular 
sensation  remains  as  long  as  any  normal  glandular  tissue  exists,  but 
effusion  into  the  tunica  vaginalis  is  not  usual.  When  suppuration 
occurs,  the  pain  increases,  especially  if  the  abscess  is  in  the  substance 
of  the  organ.  As  it  finds  its  way  to  the  surface,  the  skin  becomes 
adherent  to  the  testis,  and  is  red  and  congested.  Gradually  fluctua- 
tion manifests  itself,  and  escape  of  the  pus  may  be  followed  by  a  hernia 
testis.  An  abscess  forming  in  connection  with  the  epididymis  is  less 
painful,  and  may  attain  considerable  dimensions  before  it  bursts ;  it 
never  gives  rise  to  a  hernia  testis.  Extension  of  the  disease  to  the 
seminal  vesicles  causes  no  characteristic  symptoms,  and  is  only 
detected  on  rectal  examination ;  when,  however,  the  base  of  the 
bladder  and  prostate  are  affected,  considerable  dysuria  and  irritabihty 
of  the  bladder  are  induced. 

The  diff'erential  diagnosis  is  discussed  at  p.  1299. 

Treatment. — If  seen  in  the  very  earliest  stage,  when  only  a  small 
nodule  exists  in  the  epididymis,  it  is  possible  that  residence  at  the 
seaside  or  at  a  suitable  sanatorium,  combined  with  constitutional 
treatment  (perhaps  vaccination  with  tuberculin)  and  local  strapping 
to  induce  venous  congestion,  may  lead  to  its  disappearance.  If  ap- 
parently limited  to  one  portion  of  the  epididymis,  the  disease  may  be 
dealt  with  by  the  conservative  measure  of  incision,  curetting,  and 
applying  pure  carbolic  acid ;  but  such  is  seldom  feasible,  since  the 
disease  is  seldom  sufficiently  localized. 

If  the  whole  epididymis  is  enlarged  and  solid,  and  the  body  of  the 
testis  more  or  less  normal,  epididymectomy  may  be  undertaken.  In 
this  procedure  the  tuberculous  mass  is  freed  from  the  body  of  the 
organ,  the  spermatic  vessels  lying  on  the  inner  side  are  carefully 
guarded,  and  the  vas  is  dissected  out  and  cleared  as  high  as  possible. 
The  presence  of  an  abscess  or  sinus  is  no  contra-indication,  since  it 
merely  involves  a  somewhat  freer  removal  of  scrotal  integument. 
Should  foci  exist  in  the  body  of  the  testis,  they  are  likely  to  atrophy 


AFFECTIONS  OF  THE  TESTIS    CORD,  SCROTUM,  ETC         12S 


subsequently,  or  they  can  be  scraped  out  at  a  later  date.  In  this  way 
the  function  of  the  gland  as  the  producer  of  a  valuable  internal 
secretion  can  be  retained,  although  its  use  as  a  generative  organ  is 
lost — ^a  retention  the  more  important  owing  to  the  likelihood  of  the 
other  testis  being  subsequently  invaded.  If  the  vas  is  thickened  at 
the  external  abdominal  ring,  it  need  not  deter  the  surgeon  from 
operating,  even  if  the  vesiculae  are  enlarged,  since  tuberculous  disease 
is  not  like  cancer ;  if  the  great  bulk  of  the  mischief  is  removed, 
Nature  can  frequently  eliminate  any  small  portion  that  remains.  In 
such  cases  the  inguinal  canal  should  be  freely  opened,  and  the  vas 
traced  backwards  and  divided.  In  one  case  thus  dealt  with,  the 
bladder  was  distended  with  boracic  lotion,  the  patient  placed  in  the 
Trendelenburg  position,  and  the  vas  fol- 
lowed back  along  the  side  of  the  bladder 
nearly  as  far  as  the  seminal  vesicles. 
For  tuberculous  disease  of  the  seminal 
vesicles,  see  p.  1301. 

Castration  (p.  1300)  is  reserved  for  cases 
where  the  testis  is  disorganized,  and  its 
value  as  a  secreting  gland  totally  de- 
stroyed. Of  course  the  cord  is  also  re- 
moved after  division  as  high  up  as  possible. 

Syphilitic  Disease  of  the  Testicle. — The 
testicle  may  become  affected  by  syphilis, 
either  in  the  late  secondary  or  in  the 
tertiary  stage ;  most  commonly  it  results 
from  the  acquired  variety,  but  occasion- 
ally is  met  with  in  the  inherited. 

Secondary  SypMlitic  Epididymitis  is  not 
very  frequently  seen.  It  occurs  in  the 
form  of  a  chronic  enlargement  of  the 
epididymis,  associated  perhaps  with  a 
hydrocele,  about  six  to  twelve  months  after  infection.  The  case  is 
very  similar  to  a  simple  chronic  epididymitis,  but  the  nodular 
thickening  mainly  involves  the  globus  major,  and  is  usually  sym- 
metrical.     It  readily  disappears  on  the  administration  of  mercury. 

Tertiary  Syphilitic  Orchitis  is  observed  at  a  much  later  period  of 
the  disease,  even  twenty  or  thirty  years  after  infection.  It  is  not  un- 
frequently  bilateral.  Pathologically,  it  resembles  the  majority  of 
tertiary  manifestations  in  consisting  of  a  diffuse  infiltration  accom- 
panied by  overgrowth  of  the  connective  tissue.  If  the  process  affects 
equally  the  whole  organ,  the  ordinary  syphilitic  sarcocele  or  sclerosis 
of  the  testis  results  ;  if  it  is  more  localized  in  its  distribution,  the 
gummatous  variety  is  said  to  be  present  (Fig.  543).  The  former 
affection  is  much  more  common  than  the  latter. 

In  the  tertiary  syphilitic  sarcocele,  the  body  of  the  testis  is 
primarily  involved,  and  becomes  evenly  enlarged  and  stony  hard. 
It  is  globular  in  outline,  frequently  accompanied  by  a  hydrocele, 
and  the  normal  testicular  sensation  early  disappears.     The  same 


Fig.  543. — Tertiary  Syphi- 
litic Disease  of  Testis 
WITH  Gumma  of  the  Body. 
(Treves'  '  Surgery.') 


1288  A   MANUAL  OF  SURGERY 

process  occasionally  extends  to  the  epididymis  and  cord.  Suppura- 
tion is  exceedingly  rare.  On  section  the  characteristic  appearance 
of  a  testicle  has  entirely  vanished ;  the  tunica  albuginea  is  much 
thickened,  and  extending  from  it  through  the  substance  of  the  organ 
are  bands  of  connective  tissue,  representing  the  normal  septa ;  in 
bad  cases  the  gland  substance  is  almost  completely  destroyed. 

In  the  gummatous  variety  a  similar  condition  involves  the  greater 
part  of  the  organ,  but  in  addition  one  or  more  gummatous  foci  are 
present.  On  section  they  appear  as  yellowish-white  masses,  fairly 
well  defined,  and  since  the  central  portions  are  non-vascular,  they 
undergo  the  usual  degenerative  changes,  becoming  soft  and  diffluent. 
If  the  gumma  comes  to  the  surface,  the  skin  may  give  way,  and  a 
deep  syphilitic  ulcer  with  a  sloughy  base  like  wet  wash-leather 
results.  Hernia  testis  very  rarely  follows  such  an  occurrence.  The 
clinical  features  of  the  gummatous  variety  are  at  first  similar  to 
those  of  the  former,  but  after  a  time  one  portion  of  the  organ 
becomes  prominent  and  painful,  and  as  this  increases  in  size  the 
central  parts  become  soft  and  fluctuating,  and  finally  yield,  giving 
exit  to  the  characteristic  gummy  contents.  Under  suitable  treat- 
ment the  swelling  in  each  of  these  varieties  may  disappear  entirely, 
leaving  the  testicle  either  of  normal  size  or  atrophied;  but,  as  in 
tuberculous  disease,  its  functional  utility,  if  not  entirely  destroyed,  is 
probably  impaired  considerably. 

For  the  differential  diagnosis,  see  p.  1299. 

Treatment  consists  in  the  administration  of  iodide  of  potassium 
and  mercury,  whilst  the  hydrocele  may  be  tapped,  and  the  organ 
strapped  or  supported  by  a  suspender.  If  a  gummatous  ulcer  is 
produced,  it  may  be  possible  to  excise  the  greater  portion  of  the 
characteristic  slough  at  its  base ;  but  in  all  cases  it  should  be 
dressed  with  lint  or  gauze  steeped  in  lotio  nigra  or  some  other 
mercurial  preparation.   ■ 

Hernia  Testis  is  the  term  applied  to  a  protrusion  of  the  substance 
of  the  gland,  more  or  less  infiltrated  with  granulation  tissue,  through 
an  opening  in  the  tunica  albuginea  and  skin  of  the  scrotum.  It 
arises  from  various  causes,  such  as  a  septic  penetrating  wound  of 
the  testis,  acute  suppurative  orchitis,  or  from  a  chronic  abscess, 
whether  simple  or  tuberculous  in  nature.  It  is  rarely  produced  by 
the  breaking  down  of  a  gumma,  owing  to  the  extensive  infiltration  of 
the  organ  with  fibro-cicatricial  tissue,  and  necessarily  it  never  follows 
suppuration  in  the  epididymis.  It  is  always  preceded  by  a  condition 
of  increased  pressure  within  the  tunica  albuginea,  and  consequently 
as  soon  as  an  aperture  is  formed  in  this  membrane,  its  natural 
elasticity,  allowing  of  its  contraction,  forces  a  portion  of  its  contents 
out  of  the  opening ;  this  may  even  proceed  to  such  an  extent  as  to 
cause  the  whole  of  the  substance  of  the  gland  to  protrude,  the  tunica 
albuginea  being  practically  turned  inside  out.  A  mass  resembling 
granulation  tissue  is  then  seen  to  project  through  an  opening  in  the 
scrotum ;  it  is  often  somewhat  pedunculated  or  mushroom-like  in 
shape,  possibly  overhanging  the  margins  of  the  skin,  but  in  less 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC. 


1289 


advanced  cases  the  integument  may  be  distinctly  undermined.  A 
considerable  discharge  of  pus  usually  accompanies  it.  The  condition 
must  be  distinguished  from  the  fungating  growth  which  occasionally 
results  from  malignant  disease  of  the  organ,  when  the  protrusion 
consists  of  tumour  substance,  with  no  trace  of  testicular  tissue. 

The  Treatment  of  hernia  testis  usually  consists  in  extirpation  of 
the  organ,  especially  when  it  is  affected  by  tuberculous  disease.  In 
simple  cases  healing  of  the  wound  may  be  obtained  by  keeping  the 
part  aseptic,  and  applying  pressure  by  means  of  a  pad  of  gauze. 
In  other  cases  it  may  be 
possible  to  separate  the 
protruding  mass  from  the 
surrounding  skin,  and  after 
paring  the  edges  of  the 
wound,  to  bring  thern  to- 
gether by  sutures,  and  thus 
bury  the  gland  substance, 
which,  however,  remains 
projecting  from  the  opening 
in  the  tunica  albuginea. 
Such  proceedings  are  sel- 
dom very  satisfactory. 

Tumours  of  the  Testis 
are  generally  malignant  in 
character,  only  one  non- 
malignant  'form  being  at 
all  common,  viz.,  fibro- 
cystic disease,  or  adenoma 
testis. 

Fibro-Cystic  Disease 
(Syn. :  Adenoma  Testis, 
Cystic  Sarcocele).  —  This 
condition  is  characterized 
by  the  formation  of  a 
tumour  of  variable  size, 
scattered  through  the  sub- 
stance of  which  are  numerous  cystic  cavities,'  lined  with  cuboidal  or 
stratified  epithelium.  These  cysts  are  usually  rounded,  but  occa- 
sionally tubular  in  shape,  and  may  communicate  with  one  another ; 
they  contain  serous  fluid  and  sometimes  intracystic  growths.  They 
are  surrounded  by  connective  tissue,  the  amount  and  character  of 
which  vary  greatly  in  different  cases.  It  consists  mainly  of  simple 
fibrous  tissue,  but  it  is  very  common  to  see  cartilaginous  nodules 
(Fig.  544,  2)  and  myxomatous  foci  scattered  through  its  substance, 
and  is  very  prone  after  a  time  to  undergo  a  malignant  transformation. 
According  to  Bland- Sutton  and  Eve,  these  tumours  arise  from  the 
remains  of  the  Wolffian  body  or  mesonephros,  which  is  almost 
always  normally  represented  in  the  neighbourhood  of  the  globus 
major  of  the  epididymis  by  the  structure  known  as  the  organ  of 


Fig.    544. — FiBRO-cYSTic   Disease   of   the 
Testis.  (College  of  Surgeons'  Museum.) 

I,  Body  of  testis  spread  out  over  the  growth  ; 
2,  nodules  of  cartilage  contained  in  the 
growth. 


i290 


A   MANUAL  OF  SURGERY 


Giraldes   (paradidymis).     The  testicle  can  be  found  in  most  cases 
spread  out  in  a  thin  layer  over  the  tumour  substance  (Fig.  544,  i). 

Clinical  Signs.— This  condition  is  met  with  in  young  adults,  and 
may  possibly  be  attributed  to  an  injury.  The  organ  steadily 
becomes  enlarged,  but  this  gives  rise  to  no  inconvenience  except  by 
its  size  and  weight.  It  is  round  in  outline  and  elastic  in  consistency, 
the  cord  remaining  unaffected  unless  malignant  disease  supervenes. 
When  of  great  size,  the  skin  of  the  scrotum  may  ulcerate.  Thfe 
case  runs  a  chronic  course,  and  even  should  the  growth  become 
malignant,  the  change  of  type  only  appears  late  in  the  disease. 

Treatment  consists  in  removal  after  an  exploratory  incision  has 
demonstrated  the  nature  of  the  growth. 

Other  non-malignant  tumours  have  been  described,  such  as  chon- 
droma, osteoma,  fibroma,  myxoma,  etc.,  but  they  are  exceedingly  un- 
common, if  they  occur  at  all  apart  from  sarcoma  or  fibro-cystic  disease. 

Sarcoma  of  the  Testis  commences  in  the  body  of  the  organ,  either 
within  the  first  decade  of  life  or  between  the  ages  of  thirty  and  forty, 
and  is  sometimes  a  sequela  of  late  or  imperfect  descent.  It  is  usually 
a  soft,  round-celled  growth,  taking  on  the  form  of  a  lympho-sarcoma  ; 
m  other  cases  it  is  harder,  and  of  the  nature-  of  a  fibro-sarcoma. 
Frequently  cartilaginous  nodules  are  incorporated  in  its  substance, 
and  patches  of  myxomatous  tissue  or  cystic  degeneration  from  haemor- 
rhage are  also  seen.  As  already  stated,  it  is  sometimes  secondary 
to  iibro  -  cystic  disease.  It  originates  in  the  connective  -  tissue 
elements  of  the  organ,  the  glandular  substance  being  early  destroyed. 
It  appears  as  a  rounded  swelling,  and  at  first  its  outline  is  irregularly 
smooth ;  as  the  disease  progresses,  however,  it  may  become  nodulated 
from  the  development  of  cysts.  The  tumour  may  attain  very  large 
dimensions,  but  the  cord  and  scrotal  tissues  only  become  affected  m 
the  later  stages,  and  then  ulceration  and  the  formation  of  a  fungus 
testis  occasionally  follow  with  involvement  of  the  inguinal  lymphatic 
glands.  Secondary  growths  are  always  found  in  the  lymphatic- 
glands  which  lie  over  the  bifurcation  of  the  aorta  and  vena  cava,  and 
thence  the  disease  is  disseminated  locally  and  may  cause  severe  pain 
by  involvement  of  the  nerve  roots  of  the  lumbar  plexus,  or  give  rise 
to  visceral  deposits.  There  are  but  few  subjective  symptoms  at  first, 
a  feeling  of  weight  and  dragging  being  alone  experienced,  whilst 
testicular  sensation  is  soon  lost ;  but  at  a  later  date,  when  the  cord  is 
involved,  pain  and  cachexia  become  very  marked.  The  Course  of 
these  cases  is  slow  up  to  a  certain  point,  but  the  tumour  may  then 
rapidly  increase  in  size,  spreading  along  the  cord  to  the  interior  of  the 
abdomen  even  in  the  course  of  a  few  weeks,  thereby  rendering  removal 
utterly  impossible,  although  it  would  have  been  easily  practicable  at 
an  earlier  period.  Treatment  consists  in  the  extirpation  of  the  growth 
with  the  testis  as  early  as  possible,  the  cord  being  divided  high  up. 

Carcinoma  of  the  Testis  is  usually  of  the  encephaloid  type,  and 
arises  in  the  body  of  the  organ  as  a  soft  rapidly-growing  tumour, 
which  soon  extends  to  the  tissues  of  the  cord,  and  contracts  adhesions 
to  the  scrotum ;  ulceration  and  the  formation  of  a  f ungating  mass 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.         la-i 

follow,  whilst  secondary  deposits  are  found  in  the  abdominal  and 
inguinal  glands  as  in  sarcoma,  and  sometimes  in  the  viscera.  It  is 
impossible  to  distinguish  a  carcinoma  from  a  sarcoma  of  the  testis  by 
clinical  signs,  since  it  usually  occurs  at  the  same  period  of  adult  life, 
and  very  rarely  in  children.  Very  rapid  growth,  and  early  enlarge- 
ment of  the  cord  and  lymphatic  glands,  point  to  cancer  rather  than 
sarcoma.  The  only  Treatment  is  removal  of  the  diseased  organ, 
including  the  spermatic  cord,  as  high  as  possible,  and  the  incision 
may  advisably  be  carried  up  along  the  line  of  the  iliac  vessels  with 
stripping  aside  of  the  peritoneum  and  its  contents  so  as  to  allow  of 
the  exposure  of  the  bifurcation  of  the  aorta  and  the  removal  of  any 
enlarged  glands  in  that  position — a  serious  addition  to  the  operation, 
but  essential,  if  the  patient's  life  is  to  be  saved.  The  outlook  is  any- 
thing but  favourable,  and  becomes  still  less  so  if  the  glands  in  the 
groin  are  involved. 

Hydrocele. — Any  collection  of  fluid,  other  than  pus  or  blood,  in 
the  neighbourhood  of  the  testis  or  cord  is  termed  a  hydrocele.  The 
fluid  usually  consists  of  serum,  but  in  some  forms  spermatozoa  are 
also  present,  and  in  rare  cases  it  may  consist  of  chyle  or  a  similar 
milky  fluid  (chylous  hydrocele).  Two  chief  varieties  are  described, 
according  to  whether  the  testis  or  the  cord  is  involved. 

I.  In  Hydrocele  of  the  Testis  the  fluid  is  contained  in  the  tunica 
vaginalis  (vaginal  hydrocele),  or  exists  as  a  circumscribed  swelling  in 
its  neighbourhood  (encysted  hydrocele). 

I.  A  Vaginal  Hydrocele  is  one  in  which  there  is  an  accumulation 
of  fluid  in  the  tunica  vaginalis,  and  the  following  varieties  may  be 
differentiated  : 

(a)  Acute  Hydrocele  occurs  in  conjunction  with  acute  inflammation 
of  the  testis  or  epididymis.  The  effusion  of  fluid  is  never  abundant,, 
and  is  often  only  made  out  on  careful  examination  ;  at  first  it  consists 
of  plasma,  as  in  all  acute  inflammations  of  a  serous  membrane,  and 
is  therefore  spontaneously  coagulable.  It  may  become  chronic,  or 
may  disappear  entirely,  perhaps  leaving  a  few  adhesions. 

(b)  A  Congenital  Hydrocele  occurs  in  cases  in  which  the  funicular 
process  is  still  patent.  The  general  signs  of  a  vaginal  hydrocele,  as 
described  below,  are  present,  but  the  fluid  can  be  returned  by 
pressure  into  the  abdominal  cavity.  It  is  rarely  seen  in  others  than 
infants,  and  may  be  treated  by  the  application  of  evaporating  lotion 
to  the  scrotum,  whilst  a  light  truss  or  woollen  support  is  placed  over 
the  inguinal  canal,  as  for  congenital  hernia.  It  is  often  associated 
with  phimosis,  which  should,  of  course,  be  dealt  with  by  circumcision. 
If  it  persists,  it  may  be  treated  by  operation  as  for  congenital  hernia, 
to  which,  indeed,  it  frequently  leads. 

(c)  An  Infantile  Hydrocele  is  due  to  non-obliteration  of  the  funicular 
process  of  peritoneum,  except  at  its  upper  extremity.  It  presents 
the  signs  of  an  ordinary  acquired  hydrocele,  the  fluid,  however, 
extending  along  the  cord,  even  into  the  inguinal  canal.  Its  treat- 
ment is  the  same  as  for  an  acquired  hydrocele. 


1292  A  MANUAL  OF  SURGERY 

(d)  A  Biloculav  Hydrocele  is  one  in  which  there  is  an  additional 
loculus  within  the  abdominal  cavity,  compiunicating  by  a  neck  of 
variable  size  with  the  distended  tunica  vaginahs.  It  is  due  to  a 
persistence  of  the  intra-abdominal  portion  of  the  funicular  process 
between  the  peritoneum  and  internal  abdominal  ring  ;  this  becomes 
distended  with  fluid,  and  the  collection  burrows  downwards  in  front 
and  by  the  side  of  the  bladder  towards  the  pelvis.  A  similar  condi- 
tion occurs  in  the  female,  arising  in  the  upper  part  of  the  canal  of 
Nuck. 

{e)  Acquired  Vaginal  Hydrocele  is  the  most  common  variety. 
Causes. — It  may  arise  in  middle-aged  persons  without  any  apparent 
cause,  but  is  usually  associated  with  chronic  orchitis.  A  hydrocele 
almost  always  accompanies  a  tertiary  syphilitic  enlargement  of  the 
organ,  but  is  uncommon  in  tuberculous  or  mahgnant  disease. 
Hydrocele  is  very  frequently  seen  in  those  who  dwell  in  hot  climates, 
probably  as  the  results  of  a  lax  and  pendulous  condition  of  the 
scrotum  and  testicles.  In  India  natives  always  support  the  scrotum. 
The  tunica  is  usually  thickened  and  hyperaemic,  and  that  covering 
the  testis  may  be  pitted  and  scarred.  Here  and  there  thick  plaques 
of  fibrous  material  are  visible,  sometimes  yellowish  from  fatty 
degeneration,  sometimes  calcified,  or  even  cartilaginous  or  osseous. 

Signs. — Vaginal  hydrocele  appears  as  a  rounded  pyriform  swelling 
in  the  scrotum,  which  extends  for  a  variable  distance  along  the  cord. 
Its  tension  differs  with  the  amount  of  fluid  present,  and  with  the 
thickness  of  its  walls ;  it  is  generally  elastic,  and  with  obvious 
fluctuation.  The  cord  is  felt  distinctly  above  the  rounded  upper 
part  of  the  tumour,  and  the  testis  is  generally  situated  posteriorly 
(Fig.  541,  C),  although  it  projects  forwards  into  the  cavity,  and  is 
thus  not  readily  detected.  Its  position  may  be  ascertained  by 
pressure  over  it,  when  the  characteristic  testicular  sensation  is 
produced.  On  holding  a  light  close  to  the  scrotum,  the  tumour  is 
seen  to  be  translucent,  and  the  position  of  the  testicle  can  also  be 
demonstrated.  In  old-standing  cases  when  the  walls  have  become 
exceedingly  thick,  the  translucency  will  be  lost.  Occasionally,  when 
inflammation  has  existed,  adhesions  may  form  between  the  testis 
and  the  anterior  wall,  and  irregularity  in  the  shape  of  the  tumour  is 
thereby  induced,  or  the  cavity  may  be  divided  into  compartments  by 
fibrous  bands  or  septa. 

As  a  result  of  traumatism,  subcutaneous  rupture  of  a  hydro- 
cele has  occurred,  leading  to  increased  swelling  of  the  part,  and 
perhaps  oedema  of  scrotum  and  penis ;  the  parts  become  bruised, 
but  after  a  time  the  swelling  diminishes,  and  perhaps  a  spontaneous 
cure  follows. 

It  is  scarcely  necessary  to  mention  that  there  is  no  impulse  on 
coughing,  and  that  the  tumour  is  dull  on  percussion.  When  the 
distension  is  very  great,  its  weight  causes  a  dragging  pain  ;  the  penis 
becomes  buried  in  the  swelling,  and  eczema  of  the  scrotum  may 
result  from  the  urine  trickling  over  it.  The  fluid  in  the  sac  is 
yellowish  or  straw-coloured;  its  specific  gravity  varies  from  1015  to 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.        1293 


1025  ;  it  contains  a  large  amount  of  albumen,  especially  fibrinogen. 
In  old-standing  cases  cholesterine  may  also  be  present. 

The  Treatment  of  vaginal  hydrocele  is  palliative  or  radical. 
Palliative  treatment  consists  in  tapping  the  cavity  and  removing  the 
fluid,  the  patient  being  subsequently  directed  to  wear  a  suspender, 
and,  where  inflammation  of  the  testis  exists,  to  apply  cooling  lotions. 
For  chronic  orchitis  strapping  of  the  testis  may  be  required. 

In  order  to  tap  a  hydrocele,  the  tumour  must  be  firmly  grasped  in  the 
palm  of  the  left  hand,  and  the  skin  over  its  anterior  wall  purified  and 
made  tense.  A  spot  at  the  antero-inferior  margin  is  then  selected, 
as  free  from  vessels  as  possible,  and 
a  fine  sterilized  trocar  and  cannula 
inserted  almost  directly  upwards, 
so  as  to  pass  in  front  of  the  body 
of  the  testis  (Fig.  545).  The  site 
selected  for  tapping  must,  of  course, 
vary  with  the  position  of  the  testicle, 
which  should  be  previously  demon- 
strated. The  fluid  having  been 
withdrawn,  the  canriula  is  removed 
and  the  puncture  covered  with 
wool  and  collodion.  The  condition 
usually  recurs  after  a  longer  or 
shorter  period,  and  the  operation 
may. then  be  repeated.  If  a  dirty 
instrument  is  employed,  inflamma- 
tion, and  even  suppuration,  may. 
follow,  whilst  if  a  vessel  or  the 
body  of  the  testis  is  punctured,  a 
haematocele  may  result. 

Radical  treatment  consists  in  in- 
jection of  the  cavity,  or  excision  of 
the  lining  membrane,  (i.)  Injection 
of  the  cavity  after  tapping  has  long  been  a  favourite  method.  Many 
different  reagents  have  been  employed,  such  as  port  wine,  tincture  of 
iodine,  solution  of  corrosive  sublimate  (i  in  500),  or  glycerine  of  carbolic 
acid.  Perhaps  the  best  is  the  tincture  of  iodine,  but  that  contained 
in  the  British  Pharmacopoeia  is  not  strong  enough,  and  the  old 
Edinburgh  tincture,  which  is  nearly  the  same  strength  as  the  lin. 
iodi,  B.P.,  should  be  employed.  The  amount  used  varies  with  the 
size  of  the  hydrocele,  but  for  one  of  moderate  dimensions  it  will 
suffice  to  inject,  after  tapping,  2  drachms  of  the  tincture,  and  after 
manipulating  it  well  within  the  cavity,  a  pa,rt,  say  i  drachm,  is 
allowed  to  escape.  Smart  inflammatory  reaction  follows,  and  a  cure 
may  result,  probably  from  obliteration  of  the  vaginal  space  by  the 
formation  of  adhesions.  In  a  certain  percentage  of  cases  failure  may 
be  expected,  and  this  is  more  likely  to  happen  if  too  weak  an  irritant 
has  been  employed,  or  if  the  hydrocele  is  a  chronic  one  with  thick 
and  indurated  walls,  or  has  been  tapped  on  several  previous  occasions. 


Fig.  545.  — Method    of    Tapping 
Hydrocele.     (Tillmanns.) 

Te,  Testis  ;  Ep,  epididymis; 
Hy,  hydrocele 


1294 


A  MANUAL  OF  SURGERY 


(ii.)  The  open  method  of  operation  is  now  generally  adopted,  and  is 
particularly  recommended  in  large  and  chronic  cases.  The  hydrocele 
is  cut  down  on  through  an  incision  in  the  upper  part  of  the  scrotum, 
and  the  tunica  vaginalis  isolated  from  the  superjacent  structures. 
The  cavity  is  opened,  and  the  parietal  portion  of  the  tunica  snipped 
away  with  scissors  close  to  the  testicle.  A  number  of  vessels  will  need 
to  be  ligatured ;  a  drainage-tube  is  inserted,  and  the  wound  closed  in 
the  ordinary  v.'ay.  The  results  of  this  practice  are  most  satisfactory. 
When  the  sac  is  not  too  large,  and  the  tunica  supple  and  uninfil- 

trated,  it  often  suffices  to  turn  it 
inside  out,  and  stitch  its  edges  to 
the  back  of  the  epididymis. 

In  infants  hydrocele  is  by  no 
means  uncommon,  and  may  be,  but 
is  not  always,  of  the  congenital  type. 
The  communication  is  sometimes 
very  small,  so  that  reduction  is  im- 
practicable, although  on  lying  up 
the  cavity  slowly  empties  j  it  is 
desirable  to  make  certain  as  to  this 
point  before  undertaking  treatment. 
If  the  sac  communicates  with  the 
peritoneal  cavity,  it  may  be  treated 
as  a  hernia  by  truss  pressure,  or 
more  satisfactorily  by  operation. 
If  no  communication  exists,  many 
cases  get  well  spontaneously,  but  as 
a  useful  placebo  the  scrotum  may  be 
pamted  over  frequently  with  a  lotion 
of  chloride  of  ammonium  (grs.  x. 
ad  51.  mixed  with  rectified  spirit 
and  water)  ;  failing  this,  acupunc- 
ture may  be  tried,  the  fluid  being 
allowed  to  escape  into  the  scrotal 
tissues  ;  in  the  few  cases  in  which 
this  fails,  an  open  operation  (incision  with  drainage  or  partial  re- 
moval of  the  sac)  will  be  required. 

2.  Encysted  Hydrocele  of  the  testis  occurs  in  two  main  forms, 
according  to  whether  it  arises  in  connection  wnth  the  epididymis  or 
the  body  of  the  testis. 

(a)  Encysted  Hydrocele  of  the  Epididymis  exists  usually  as  a  rounded 
globular  swelling,  tense  and  elastic  in  consistency,  and  translucent. 
It  is  situated  above  the  body  of  the  testis,  and  close  to  the  head  of 
the  epididymis  (Fig.  546).  As  a  rule,  it  does  not  attain  a  size  greater 
than  that  of  the  body  of  the  testis  itself,  so  that  it  may  appear  as  if 
a  double  testicle  was  present ;  the  hydrocele  is,  of  course,  devoid  of 
testicular  sensation.  Less  frequently  it  may  attain  considerable 
dimensions,  even  projecting  below  and  around  the  testicle  which, 
though  enveloped  by  it,  is  quite  distinct  from  it.     The  fluid  con- 


FiG.  546. — Encysted  Hydrocele 
OF  Epididymis.  (College  of 
Surgeons'  Museum/) 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.         1295 

tained  within  these  cysts  is  usually  milky  and  opalescent  in  appear- 
ance, owing  to  an  admixture  of  semen ;  under  the  microscope 
spermatozoa,  either  living  or  dead,  can  be  demonstrated  ;  on  account  of 
this  it  is  sometimes  termed  a  spermatocele.  The  specific  gravity  is  lower 
than  that  of  ordinary  hydrocele  fluid,  and  there  is  but  little  albumen. 
The  origin  of  these  cysts  has  given  rise  to  much  discussion.  They  are 
of  a  very  different  nature  to  the  ordinary  vaginal  hydrocele,  or  even  to 
the  encysted  hydrocele  of  the  cord,  since  the  walls  are  not  lined  with 
endothelium,  but  with  cuboidal  or  columnar  epithelium.  They  are 
probably  due  either  to  a  dilatation  of  one  or  more  of  the  vasa  effer- 
entia  testis,  or  more  frequently  to  distension  of  some  of  the  foetal 
relics  always  found  near  the  head  of  the  epididymis,  especially  of 
those  known  as  Kobelt's  tubes ;  these,  as  also  the  vasa  efFerentia 
testis,  are  derived  from  the  tubules  of  the  Wolffian  body,  differing, 
however,  from  them  in  not  becoming  attached  to  the  body  of  the 
testis  (Fig.  69,  p.  223).  They  are  thus  homologous  with  the  parovarian 
.  cysts  found  in  the  female.  Smaller  pedunculated  cysts  containing 
clear  serum  are  sometimes  met  with  in  this  region,  arising  from  a 
distension  of  the  hydatid  of  Morgagni,  which  is  developed  from  the 
remains  of  the  Miillerian  duct. 

Treatment  is  conducted  along  the  same  lines  as  for  vaginal  hydro- 
cele, viz.,  by  tapping  as  a  palliative  measure,  and  injection  or  ex- 
cision in  order  to  establish  a  radical  cure. 

{b)  Encysted  Hydrocele  of  the  Tunica  Alhuginea  is  a  condition  rarely 
seen,  consisting  of  a  small  collection  of  serous  fluid  beneath  the  vis- 
ceral portion  of  the  tunica  vaginalis.  It  is  probably  due  to  dilatation 
of  lymphatic  spaces,  and  has  absolutely  no  clinical  significance. 

II.  Hydrocele  of  the  Cord  occurs,  as  already  described,  in  connec- 
tion with  the  congenital  and  infantile  varieties  of  vaginal  hydrocele. 
If  limited  to  the  cord,  it  exists  in  one  of  two  forms,  the  encysted  or 
the  diffuse. 

1.  Encysted  Hydrocele  of  the  Cord  arises  from  imperfect  obliteration 
of  the  funicular  process  of  peritoneum,  the  patent  portion  becoming 
distended  with  fluid  and  giving  rise  to  a  cavity  lined  with  endothe- 
lium. It  is  usually  detected  as  a  rounded  elastic  swelling,  occupying 
the  inguinal  canal,  moving  freely  up  and  down  within  it.  The  upper 
border  is  sharply  limited,  and  in  favourable  cases  translucency  can 
be  demonstrated.  On  fixing  the  testicle  the  cyst  is  no  longer  move- 
able. The  fluid  contained  within  it  is  identical  in  nature  with  that 
in  a  vaginal  hydrocele.  In  the  female  a  similar  condition  arises  from 
imperfect  obliteration  of  the  canal  of  Nuck,  giving  rise  to  what  is 
known  as  a  hydrocele  of  the  round  ligament.  Treatment  consists  in 
removal  of  the  fluid  by  tapping,  or,  if  a  more  radical  proceeding  is 
necessary,  by  injection  or  excision. 

2.  Diffuse  Hydrocele  of  the  Cord  is  but  rarely  seen.  It  results  from 
a  diffuse  oedema  of  its  cellular  tissue,  and  presents  on  examination  a 
fusiform  or  sausage-shaped  tumour,  which  extends  along  the  cord  for 
a  variable  distance. 

The  term  Chylous  Hydrocele  is  applied  to  a  distension  of  the  tunica 


1296 


A  MANUAL  OF  SURGERY 


vaginalis  with  chylous  fluid,  recognised  by  being  milky  in  appear- 
ance, and  under  the  microscope  seen  to  consist  of  a  fatty  emulsion. 
Several  modes  of  -origin  have  been  suggested,  but  none  are  very 
satisfactory.  In  one  case  under  our  care,  a  series  of  dilated  lymphatics 
filled  with  a  similar  fluid  extended  upwards  from  the  testicle  to  the 
inguinal  canal. 

Varicocele. — A  varicose  condition  of  the  pampiniform  plexus 
(Fig.  547)  is  very  commonly  met  with  in  young  men,  but  seldom  in 
those  of  advanced  age,  except  when  it  has  become  chronic,  or  is  due 
to  malignant  disease  of  the  kidney  (p.  1207).  It  usually  occurs  in 
individuals  with  a  lax  and  pendulous  scrotum,  and  is  often  associated 
with  masturbation,  which  induces  abnormal  vascularity  of  the  testis. 
The  fact  that  it  sometimes  develops  in  quite  young  boys  suggests, 
however,  that  there  is  some  congenital  condition  associated  with  it. 
It  may  also  be  caused  by  the  pressure  of  a  truss  applied  for  the  relief 
of  a  hernia.  It  is  almost  invariably  on  the  left  side,  and  the  reasons 
given  for  this  are  as  follow^s  :  (a)  The  left 
testis  usually  hangs  lower  than  the  right, 
and  hence  the  spermatic  veins  are  longei 
and  exposed  to  greater  blood  pressure. 
(b)  The  left  spermatic  vein  opens  into  the 
left  renal  vein  at  right  angles,  and  no  valve 
is  present  at  the  orifice,  whilst  that  on  the 
right  side  opens  obliquely  into  the  vena 
cava  and  is  valved.  {c)  The  presence  of 
the  sigmoid  flexure  on  the  left  side  of  the 
body,  and  its  distension  by  accumulated 
fasces  as  a  result  of  constipation,  may  lead 
to  pressure  on  the  abdominal  portion  of  the 
left  spermatic  vein. 

A  varicocele  is  characterized  by  the 
presence  of  a  soft  irregular  swelling  in  the 
scrotum,  which  is  somewhat  pyramidal  in 
shape,  the  main  mass  being  below  and 
slightly  overlapping  the  testis,  and  the  apex 
above.  It  consists  of  dilated  and  tortuous 
veins,  the  outlines  of  which  can  often  be 
seen  through  the  skin  (Fig.  548).  They 
impart  a  sensation  to  the  finger  which  has  been  likened  to  a  collec- 
tion of  worms  in  a  bag  ;  there  is  a  distinct  impulse  down  the  veins 
on  coughing.  On  assuming  the  recumbent  posture  the  swelling 
almost  disappears,  owing  to  the  vessels  being  emptied  of  their  con- 
tained blood  ;  if  pressure  is  subsequently  applied  over  the  external  ab- 
dominal ring,  and  the  patient  allowed  to  stand,  the  tumour  reappears, 
filling  from  below  upwards.  A  sensation  of  weight  and  pain  usually 
accompanies  a  varicocele,  whilst  severe  neuralgia  of  the  testis  may  be 
induced.  It  is  a  frequent  source  of  seminal  emissions,  and  may  result 
in  testicular  atrophy.    Phlebitis  is  liable  to  follow  an  injury,  and  may 


Fig.    547. — Varicocele. 
(Treves'  '  Surgery.') 


AFFECTIONS  OF  THE  TESTIS,  CORD.  SCROTUM,  ETC.         1297 

lead  to  a  spontaneous  cure  ;  if  one  of  the  dilated  veins  is  ruptured, 
severe  haemorrhage  ensues,  causing  a  diffuse  hsematocele  of  the  cord. 
In  favourable  cases  the  condition  disappears  spontaneously. 

The  Diagnosis  of  varicocele  is  easily  made,  the  only  condition  for 
which  it  is  likely  to  be  mistaken  being  an  omental  hernia  ;  the  differ- 
ence between  the  two  conditions  has  been  discussed  at  p.  1097. 

The  Treatment  of  slight  cases  of  varicocele  consists  in  supporting 
the  testicle  and  scrotum  by  means  of  a  well-fitting  suspender,  whilst 
the  patient  is  also  instructed  to  bathe  the  parts  with  cold  water  night 
and  morning,  and  to  take  such  measures  as  shall  ensure  a  daily 
action  of  the  bowels. 

Eadical  Treatment  by  excision  of  the  veins  is  advisable  in  neuralgic 


Fig.  548.— Large  Varicocele  in  a  Patient  Aged  35  Years,  who  had  used 
No  Support  for  Many  Years. 

cases,  where  atrophy  of  the  testis  is  threatening,  or  in  order 
to  fit  the  patient  for  admission  into  any  of  the  public  services. 
The  operation  is  conducted  as  follows  :  The  pubic  region  having 
been  shaved  and  purified,  an  incision  i-|-  inches  long  is  made  in  the 
direction  of  the  cord,  with  its  centre  a  little  below  the  external 
abdominal  ring.  The  structures  of  the  cord  are  raised  on  the 
fingers,  and  the  coverings  divided,  so  as  to  expose  the  spermatic 
veins  at  their  upper  end.  Two  main  branches  are  usually  found  in 
this  situation,  but  occasionally  there  is  only  one.  These  are  cleaned 
and  carefully  isolated  from  the  other  structures  of  the  cord,  and  a 
ligature  is  applied  to  them  at  the  external  abdominal  ring.  The 
vessels  are  now  clamped  with  a  pair  of  Spencer  Wells  forceps 
below  the  ligature,  and  divided  between  it  and  the  forceps.  The 
lower  end,  grasped  by  the  forceps,  is  stripped  downwards,  so  as  to 
free  the  pampiniform  plexus  from  the  other  elements  of  the  cord, 
and  the  dissection  can  be  carried  nearly  as  far  as  the  epididymis  by 
drawing  the  testicle  up  into  the  wound.     The  lower  end  of  the  veins 

82 


I29S  A   MANUAL  OF  SURGERY 

is  ligatured  in  one  or  two  portions  and  divided.  By  this  means  the 
whole  varicocele  is  removed.  If  the  scrotum  is  pendulous,  and  the 
testicle  hangs  low,  it  may  be  advisable  to  raise  it  by  tying  the  upper 
and  lower  ligatures  together,  care  being  taken  not  to  pull  them  off 
in  so  doing  ;  perhaps  it  is  wiser  to  introduce  a  suture  through  the 
divided  ends  of  the  veins  above  and  below,  which  are  purposely  left 
long.  The  wound  is  then  closed  without  a  drainage-tube,  and 
dressed  as  usual.  The  patient  is  kept  in  the  recumbent  posture  for 
a  fortnight,  until  organization  has  occurred  in  the  divided  ends  of  the 
veins,  and  a  firm  cicatrix  has  formed.  This  method  of  treatment  is 
infinitely  superior  to  that  often  practised  of  exposing  the  veins  in  the 
scrotum,  since  a  wound  in  the  groin  always  heals  much  more  readily 
than  one  in  the  scrotum  ;  whilst  it  is  easier  to  dissect  the  veins  out 
from  above,  where  only  one  or  two  trunks  exist.  The  venous  return 
after  the  operation  is  maintained  by  the  vein  or  veins  running  with 
the  artery  to  the  vas  in  the  posterior  portion  of  the  cord.  Occasionally, 
if  the  removal  of  veins  has  been  too  complete,  a  hydrocele  develops 
subsequently,  owing  to  the  passive  congestion  of  the  testis.  It  is 
usually  unnecessary  to  remove  any  scrotal  integument,  although  it  is 
often  redundant ;  but  after  the  wound  is  soundly  healed,  the  dartos 
may  be  stimulated  daily  by  brushing  the  scrotum  with  a  clothes- 
brush. 

Neuralgia  of  the  Testis  is  characterized  by  the  organ  becoming 
exquisitely  tender  and  painful,  although  apparently  healthy.  It 
usually  occurs  in  young  adults  of  nervous  temperament,  or  in 
middle-aged  gouty  men.  It  is  not  uncommonly  associated  with 
a  varicocele.  The  pain  is  usually  paroxysmal  in  character,  and  very 
intractable.  Treatment  must  be  directed  mainly  to  the  general 
health,  consisting  in  the  administration  of  nerve  tonics,  such  as  iron 
and  quinine,  whilst  locally  sedatives,  e.g.,  belladonna  and  aconite, 
may  be  applied.  It  is  also  advisable  that  a  suspender  should  be 
worn. 

Atrophy  of  the  Testis  results  from  several  causes  :  (i.)  It  may  be 
due  to  a  congenital  arrest  of  development,  as  met  with  in  displace- 
ment or  late  descent,  (ii.)  It  is  most  frequently  the  consequence  of 
inflammatory  affections,  either  of  the  body  or  epididymis,  owing  to 
the  cicatricial  contraction  caused  thereby  leading  to  compression  of 
the  vessels.  It  occasionally  follows  the  metastatic  orchitis  of  mumps, 
especially  in  adults,  whilst  it  is  also  due  to  syphilitic  disease,  (iii.)  It 
arises  from  impaired  nutrition,  as  after  the  division  of  the  supplying 
arteries  in  operations  for  varicocele  or  hernia,  or  from  compression 
of  the  cord  by  closing  the  inguinal  canal  too  firmly,  in  the  operation 
for  the  radical  cure  of  hernia.  It  appears,  however,  that  division  of 
the  spermatic  vessels  alone  will  not  suffice  to  determine  atrophy,  if 
the  artery  to  the  vas  with  its  accompanying  veins  and  nerves  are 
preserved  intact,  (iv.)  Chronic  congestion  of  the  organ,  as  by  a 
varicocele,  may  induce  atrophy ;  whilst  (v.)  sexual  excesses  are  also 
stated  to  lead  to  it.  If  unilateral,  it  is  of  comparatively  little  impor- 
tance ;  but  where  both  organs  are  affected,  sterility  is  sure  to  result, 


AFFECTIONS  OF  THE  TESTIS,   CORD,  SCROTUM,  ETC.         1299 

and  the  patient,  if  previously  young  and  healthy,  is  likely  to  become 
depressed  in  spirits  and  melancholic.  This  may  be  due  in  part  to 
mental  causes,  but  also  in  measure  to  the  absence  of  seminal  secre- 
tion, the  reabsorption  of  which  into  the  system  is,  according  to 
Brown- Sequard,  an  important  factor  in  the  maintenance  of  a  vigorous 
state  of  mind  and  body. 

General  Diagnosis  of  Scrotal  Tumours. 

When  a  patient  presents  himself  for  examination  with  a  swelling 
in  the  scrotum,  the  surgeon  has  to  decide  whether  it  is  a  hernia,  a 
hydrocele,  a  haematocele,  a  varicocele,  or  a  solid  enlargement  of  the 
testis,  and,  if  the  latter,  of  what  nature.  The  first  point  to  which 
attention  is  directed  is  the  condition  of  the  cord  immediately  below 
the  external  ring.  If  this  is  of  normal  size  and  consistency,  hernia 
and  diffuse  hydrocele  of  the  cord  are  thereby  excluded,  whilst  the 
existence  of  a  rounded  tense  swelling,  moveable  within  the  canal, 
but  becoming  fixed  on  holding  the  testis,  indicates  that  an  encysted 
hydrocele  of  the  cord  is  probably  present.  When,  however,  the 
cord  is  more  or  less  masked,  further  examination  speedily  determines 
whether  a  hernia  or  a  diffuse  hydrocele  or  haematocele  of  the  cord 
exists,  since  the  former  is  often  reducible,  has  an  impulse  on  cough- 
ing, and  is  rounded  or  nodular  in  outline,  and  the  latter  are  sausage- 
shaped,  always  irreducible,  and  semi-fluctuating. 

When  the  swelling  is  purely  scrotal,  inspection  and  manipulation 
will  at  once  decide  if  it  is  a  varicocele,  by  its  characteristic  feel,  by 
its  disappearance  on  assuming  the  recumbent  posture,  and  filling 
again  from  below  on  standing  up.  If  the  swelling  is  rounded  in 
outline,  the  next  point  to  be  determined  is  whether  it  is  solid  or  fluid. 
If  fluid,  it  is  probably  a  hydrocele,  or  the  early  stage  of  a  haemato- 
cele ;  the  translucency  of  the  former,  and  the  sudden  appearance  and 
non-translucency  of  the  latter,  should  suffice  to  demonstrate  its 
nature.  It  is  possible  that  the  hydrocele  is  merely  a  secondary  com- 
plication, and  hence  no  final  opinion  should  be  given  until  it  has  been 
tapped,  and  the  condition  of  the  body  of  the  testis  investigated.  If 
however,  a  solid  mass  exists  in  the  scrotum,  it  is  either  a  haemato- 
cele in  its  later  stages,  or  some  form  of  sarcocele,  whether  simple, 
syphilitic,  tuberculous,  or  neoplastic.  A  hematocele  is  possibly  recog- 
nised by  its  history,  and  by  there  being  a  fluid  centre  to  the  swelling, 
surrounded  by  solidified  tissue.  Chronic  orchitis  and  syphilitic  enlarge- 
ment of  the  testis  are  so  much  alike  as  to  render  diagnosis  always 
uncertain  in  the  absence  of.  a  distinct  syphilitic  history ;  but  if  the 
sv/elling  is  extremely  hard,  with  a  smooth  and  regular  outline,  with 
out  testicular  sensation,  limited  to  the  body  of  the  testis,  and  accom- 
panied by  a  hydrocele,  it  is  probably  syphilitic.  Tuberculous  disease, 
on  the  other  hand,  occurs  more  frequently  in  younger  individuals 
than  does  the  syphiHtic  variety,  whilst  the  epididymis  is  usually  first 
attacked,  becoming  nodulated,  the  cord  is  early  implicated,  hydrocele 
is  rare,  suppuration  is  frequent,  and  testicular  sensation  remains  till 


I300  A  MANUAL  OF  SURGERY 

the  body  of  the  testis  is  disorganized.  Tumours  always  impart  a 
distinct  sense  of  weight  to  the  hand,  quite  different  to  that  noticed 
in  tuberculous  or  syphilitic  disease ;  if  a  simple  tumour  is  present,  it 
is  rounded,  slow  in  growth,  and  the  cord  is  unaffected.  Malignant 
disease  is  characterized  by  rapid  growth,  more  severe  pain,  and  early 
implication  of  the  structures  of  the  cord  and  of  the  lumbar  lymphatic 
glands.  The  enlargement  of  both  testes  is  in  favour  of  tubercle  or 
syphilis  rather  than  of  malignant  disease.  A  certain  small  number 
of  cases  will  remain  where,  in  spite  of  every  care,  the  nature  of  the 
mass  is  still  a  matter  of  doubt ;  in  such  the  diagnosis  cannot  be 
established  without  puncture  or  an  exploratory  incision. 

Whilst  weighing  carefully  the  local  conditions,  we  must  not  omit 
thoroughly  to  investigate  and  appreciate  the  general  history  and  con- 
dition of  the  patient,  his  age,  appearance,  previous  habits  and  ill- 
nesses, etc.  At  the  same  time,  an  examination  of  the  internal  organs 
should  be  made  to  ascertain,  as  far  as  possible,  the  existence  or  not 
of  concurrent  disease,  e.g.,  tuberculous  disease  of  the  lungs  or  kidneys, 
or  secondary  malignant  deposits. 

Castration  is  required  for  many  different  conditions,  which  have 
been  already  described,  e.g.,  for  malposition,  tuberculous  disease,  old- 
standing  hasmatoceles,  and  simple  or  malignant  tumours.  The  opera- 
tion is  conducted  as  follows  :  The  pubes  and  perineum  having  been 
previously  shaved  and  purified,  the  surgeon,  standing  on  the  same 
side  of  the  patient  as  the  organ  to  be  removed,  makes  an  incision 
down  to  the  testis.  If  large  and  adherent  to  the  scrotal  tissues,  the 
incision  must  necessarily  involve  the  scrotum,  but  wherever  prac- 
ticable it  is  wise  to  avoid  the  scrotal  integuments,  making  the  incision 
over  the  cord.  It  should  always  extend  upwards  as  far  as  the  external 
abdominal  ring,  so  as  to  enable  the  structures  of  the  cord  to  be  divided 
high  up — a  most  important  matter  in  tuberculous  and  malignant 
disease ;  the  inguinal  canal  can  then  also  be  closed,  if  necessary. 
The  testis  or  tumour  is  enucleated  from  its  surroundings,  and  the 
cord  isolated  and  divided  as  high  as  possible,  after  transfixing  and 
securely  ligaturing  it  with  silk.  Some  surgeons  prefer  to  separate 
the  tissues  of  the  cord,  and  to  take  them  up  individually,  but  this  is 
a  matter  of  little  importance.  The  stump  should  not  be  allowed  to 
slip  back  into  the  canal  until  all  bleeding  has  completely  stopped,  and 
it  has  been  suggested  that  the  cut  end  of  the  vas  should  be  touched 
with  pure  carbolic  acid  as  a  precautionary  measure.  All  bleeding- 
points  in  the  scrotum  are  now  secured  by  ligature,  and  these  may  be 
numerous ;  the  wound  is  closed  by  sutures,  a  drainage-tube  being 
inserted  in  the  scrotum,  and  by  choice  coming  to  the  surface  at  the 
upper  end  of  the  wound — that  is,  as  far  from  the  perineum  as  possible. 

In  the  performance  of  double  castration,  it  is  recommended  to 
make  two  crescentic  incisions  from  side  to  side^  so  as  to  include 
between  them  a  portion  of  the  scrotal  integument,  in  order  to  reduce 
the  subsequent  redundancy  of  unnecessary  tissue. 


AFFECTIONS  OF  THE  TESTIS,  CORD,  SCROTUM,  ETC.         1301 


Affections  of  the  Vesiculse  Seminales. 

Acute  Vesiculitis  is  not  often  met  with,  but  sometimes  arises,  in  association 
with  prostatitis,  as  a  complication  of  gonorrhoea.  It  is  characterized  by  deep- 
seated  pain  in  the  perineum,  together  with  irritability  of  the  neck  of  the  bladder 
and  increased  frequency  of  micturition.  Defaecation  becomes  painful,  and  on 
examination  of  the  rectum  the  vesiculse  can  be  felt  enlarged  and  tender.  If 
suppuration  ensues,  an  abscess  forms,  which  usually  bursts  into  the  rectum,  but 
sometimes  into  the  bladder  or  peritoneal  cavity.  As  a  rule,  the  condition  dis- 
appears pari  passu  with  the  gonorrhoea  ;  but  when  suppuration  has  supervened, 
it  is  advisable  to  open  the  abscess  by  a  deep  incision  through  the  perineum, 
guided  by  a  finger  in  the  rectum. 

Subacute  or  Chronic  Vesiculitis  is  not  uncommon,  the  latter  condition  being 
often  associated  with  prostatitis,  and  one  of  the  most  frequent  causes  of  gleet. 
Seminal  emissions  and  priapism  may  be  caused  by  it,  and  the  enlarged  organ 
can  be  felt  through  the  rectum.  A  good  deal  of  pain,  often  referred  to  the  back, 
is  experienced.     The  treatment  is  the  same  as  for  chronic  prostatitis. 

Tuberculous  Disease  attacks  the  vesiculas  seminales  as  a  result  of  extension 
from  the  testis  along  the  vas,  being  almost  always  associated  with  similar  disease 
of  the  prostate  and  base  of  the  bladder.  The  organs  can  be  felt  enlarged,  and  if 
suppuration  occurs,  the  abscess  may  burst  into  the  rectum  or  bladder,  or  possibly 
into  both,  a  recto-vesical  fistula  being  thereby  developed.  It  is  possible  to  reach 
the  vesiculae  through  a  semilunar  incision  in  the  perineum,  displacing  the  rectum 
backwards,  and  the  bladder  and  prostate  forwards,  or  from  behind  by  removing 
the  coccyx  and  part  of  the  sacrum,  as  in  Kraske's  operation.  When  exposed, 
complete  excision  is  sometimes  possible,  or  an  opening  is  made  into  them,  and 
the  cheesy  contents  scooped  out. 

Affections  of  the  Scrotum. 

Injuries  of  the  Scrotum. — Contusions  and  blows  give  rise  to  ecchymosis,  which 
may  be  so  extensive  as  to  warrant  the  term  hcsmatoma  scroti  which  has  been 
applied  to  it. 

Incised  wounds  may  affect  the  skin  and  subcutaneous  tissues,  or  may  lay  open 
the  tunica  vaginalis,  with  or  without  protrusion  of  the  testicle.  All  that  is  needed 
in  such  cases  is  to  render  the  wound  aseptic,  and  to  deal  with  it  on  general 
principles.  Considerable  destruction  of  scrotal  tissue  may  be  repaired  by  trans  ■ 
plantation  of  flaps  from  the  inguinal  region,  or  by  grafting  according  to  Thiersch's 
method. 

Cellulitis  of  the  Scrotum  most  commonly  results  from  extravasation  of  urine,  for 
which  see  p.  1262.  It  may  occasionally  arise  from  other  causes,  and  leads  to  great 
constitutional  disturbance,  usually  of  an  asthenic  type,  and  often  to  considerable 
sloughing  ;  the  testes  may  be  exposed  when  the  sloughs  come  away,  or  may 
even  be  involved  in  the  same  process.  As  a  general  rule  repair  is  very  active  in 
the  scrotum. 

CEdema  of  the  Scrotum  is  usually  due  ta  dropsy,  being  often  associated  with 
general  anasarca  and  ascites.  It  may  attain  considerable  dimensions.  Acute 
inflammatory  cedcma  of  the  scrotum  is  a  term  sometimes  applied  to  erysipelas 
affecting  this  region,  on  account  of  the  absence  of  the  vivid  red  colour  usually 
caused  by  that  affection.  Considerable  oedema  is  always  present,  and  gangrene 
of  the  skin  may  result.  As  soon  as  the  gangrene  becomes  limited,  it  should  be 
excised,  and  the  margins  of  the  wound  brought  together  by  sutures,  or  allowed  to 
heal  by  granulation. 

Scrotal  Fistulse  are  usually  due  to  the  bursting  of  abscesses  in  connection  with 
the  urethra  (see  Perineal  Abscess). 

Sinuses  of  the  Scrotum  are  often  found  in  connection  with  tuberculous  or 
syphilitic  disease  of  the  testicle. 

Eczema  of  the  Scrotum  is  a  troublesome  affection,  giving  rise  to  great  pruritus 
and  irritation.     It  results  from  the  presence  of  pediculi,  but  the  more  chronic 


1362  A  MANUAL  OF  SURGERY 

forms  occur  amongst  workers  in  tar  and  paraffin,  and  also  in  chimne3--sweeps, 
being  due  to  the  constant  irritation  of  the  corrugated  scrotal  integument  by  dirty 
clothes.  It  is  characterized  by  the  presence  of  warty  outgrowths,  and  not  un- 
frequently  runs  on  to  epithelioma,  originating  the  condition  known  as  chimney- 
sweep's or  paraffin  cancer-  The  usual  characteristics  of  such  a  new  growth  are 
present,  and  in  some  of  the  deeper  cells  particles  of  soot  have  been  demonstrated. 
The  inguinal  glands  are  usually  involved,  but  not  till  late,  and  the  progress  of 
the  case  is  slow.  The  only  treatment  which  can  be  adopted  is  complete  removal, 
the  wound  caused  thereby  being  closed  or  allowed  to  granulate. 
For  Elephantiasis  Scroti,  see  p.  363. 


CHAPTER  XLII. 
SURaERY  OF  THE  FEMALE  GENITAL  ORGANS.* 

Affections  of  the  Vulva. — Injuries   to  the  External  Genitalia   may 

arise  from  direct  violence,  or  during  parturition  from  the  forcible 
expulsion  of  the  head.  In  the  non-pregnant  condition  the  results 
differ  but  little  from  other  similar  lesions,  and  require  no  special 
treatment  or  consideration.  Occasionally  a  kick  or  a  fall  on  a  stick  or 
paling  may  result  in  laceration  of  the  recto-vaginal  septum.  The  wound 
is  usually  contused,  and  the  margins  irregular,  so  that  immediate 
suture  is  unlikely  to  succeed.  The  parts  are  therefore  kept  clean  by 
frequent  douches  and  allowed  to  granulate,  and  the  loss  of  substance 
is  in  that  way  often  made  good  ;  should  a  fistula  persist,  a  plastic 
operation  will  be  subsequently  necessary.  Of  course,  if  the  original 
injury  is  a  clean  incision,  immediate  operation  to  close  the  defect  is 
desirable. 

In  the  pregnant  state  or  when  large  varicose  veins  are  present,  an 
injury  to  the  vulva  may  result  in  serious  haemorrhage  if  there  is  an 
external  wound,  or  in  the  formation  of  a  large  hematoma.  The 
labium  becomes  much  swollen  and  firm  to  the  touch,  owing  to  the 
coagulation  of  the  blood  ;  suppuration  often  follows,  especially  if  the 
injury  is  associated  with  a  superficial  abrasion.  Treatment. — If  the 
hsematoma  should  hinder  parturition,  it  may  be  necessary  to  incise 
it  at  once  and  turn  out  the  blood-clot.  Under  other  circumstances 
it  may  be  treated  by  the  application  of  cooling  lotions ;  but  should 
it  persist  or  if  suppuration  ensues,  operation  will  be  required  ;  the 
cavity  is  opened,  emptied  and  stuffed  with  gauze  to  ensure  healing 
by  granulation. 

Varix  of  the  vulva  is  not  unfrequently  associated  with  a  similar 
condition  in  the  legs,  or  may  sometimes  arise  as  a  result  of  block- 
ing of  the  external  iliac  vein,  owing  to  the  opening  up  of  collateral 
branches.  One  or  two  veins  may  become  enlarged,  often  running 
transversely  across  the  Mons  Veneris,  or  large  bunches  of  veins  may 

*  It  is  impossible  in  a  work  of  this  size  to  include  more  than  a  comparatively 
brief  notice  of  the  more  important  gynascological  conditions  which  encroach  on 
the  domain  of  the  general  surgeon.  As  a  means  of  distinction  we  have  considered 
that  all  vaginal  operations,  etc.,  are  purely  gynaecological,  whilst  those  neces- 
sitating abdominal  section  belong  as  much  to  the  general  surgeon  as  to  the 
gynaecologist.     Vulval  lesions,  of  course,  may  come  under  the  care  of  either 

1303 


.1304  A  MANUAL  OF  SURGERY 

form  in  the  labia.  Pregnancy  usually  aggravates  this  condition  to  an 
alarming  degree,  and  a  very  slight  injury  may  determine  a  rupture 
of  the  veins.  Treatment. — If  troublesome  and  causing  much  pruritus 
or  irritation,  the  veins  may  be  excised  under  careful  antiseptic 
precautions. 

Vulvitis,  or  inflammation  of  the  lining  membrane  of  the  vestibule, 
is  due  to  uncleanliness,  gonorrhoea,  of  to  irritating  discharges  coming 
from  above.  It  is  characterized  by  injection  of  the  mucous  mem- 
brane, by  itching  or  smarting  pain,  especially  on  walking,  and  a 
secretion  of  mucus  or  muco-pus,  causing  the  labia  to  stick  together. 
The  mucous  follicles  may  become  affected,  and  a  localized  abscess 
result,  situated  either  immediately  beneath  the  mucous  membrane 
or  in  the  substance  of  the  labium.  The  treatment  consists  in  the  use 
of  warm  and  mild  astringent  or  antiseptic  lotions  to  purify  the  part 
{e.g.,  lotio  plumbi),  sitting  in  hot  water  being  most  beneficial.  At  the 
same  time  the  patient  is  kept  quiet,  and  the  bowels  are  opened  by  a 
saline  purge.  When  a  follicular  abscess  forms,  it  should  be  incised 
through  the  mucous  membrane  and  its  cavity  stuffed  with  a  small 
portion  of  dressing.  A  labial  abscess  should  be  freely  opened  at 
any  spot  where  it  is  threatening  to  point,  and  the  cavit)^  packed  with 
gauze  to  ensure  healing  from  the  bottom. 

Vaginitis  may  be  secondary  to  vulvitis,  or  associated  with  an 
inflammatory  affection  of  the  uterus.  As  a  primary  lesion  it  is 
most  commonly  due  to  injury,  such  as  the  injection  of  too  hot  water, 
or  the  presence  of  a  foreign  body,  e.g.,  a  badly-fitting  and  retained 
pessary,  or  aw^kward  or  violent  coitus.  Vaginitis  is  not  generally 
a  marked  feature  in  gonorrhoea.  The  symptoms  are  a  sense  of  heat 
and  pain,  frequent  and  painful  micturition,  and  a  free  muco-purulent 
leucorrhoea.  Complications  may  arise  from  extension  upwards  to 
the  uterus  and  tubes.  Treatment  consists  in  warm  soothing  in- 
jections in  acute  cases,  together  with  hot  hip-baths;  in  the  more 
chronic  types  astringent  injections  are  required. 

Cysts  of  the  Labia  are  occasionally  seen,  being  due  to  the  blocking 
of  the  duct  of  a  mucous  follicle,  or  of  the  more  specialized  vulvo- 
vaginal glands  (glands  of  Bartholin)  ;  they  may  attain  considerable 
dimensions,  and  must  be  freely  dissected  out  if  causing  any  incon- 
venience. 

Various  other  tumours  of  the  vulva  occur,  e.g.,  elephantiasis, 
epithelioma,  etc.,  but  have  no  special  peculiarities. 

Affections  of  the  Round  Ligament  are  not  very  uncommon.  Non- 
obliteration  of  the  canal  of  Nuck  leads  to  the  appearance  of  a 
congenital  inguinal  hernia,  which  is  very  frequent  in  girls  and  young 
unmarried  women.  In  the  operation  required  for  its  cure  the  round 
ligament  is  included  in  the  ligature  which  encircles  the  neck  of  the 
sac.  A  hydrocele  of  the  round  ligament  is  due  to  a  partial  obliteration 
of  the  same  structure,  the  patent  portion  becoming  distended  with  a 
serous  exudation.  It  presents  as  a  tense,  rounded  swelling  just 
below  the  external  abdominal  ring  or  in  the  inguinal  canal,  and  is 
treated   by   dissecting   it   away.      Occasionally   cases    of   bilocular 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1305 

hydrocele  are  met  with,  in  which  an  external  cavity  communicates 
with  a  large  pelvic  collection  of  fluid  enclosed  in  a  serous  membrane. 
Tumours  of  the  round  ligament  are  unusual,  but  occur  in  the  form  of 
lymphangioma  and  fibro-myoma.  An  interesting  instance  of  the 
latter  was  seen  in  a  woman  who  was  also  the  subject  of  uterine 
fibro-myomata  necessitating  hysterectomy.  The  tumour  of  the 
round  ligament  was  as  large  as  an  orange. 

Uterine  Displacements. — The  maintenance  of  the  uterus  in  its 
normal  position  of  slight  anteversion  is  due  to  the  associated  influence 
of  many  diverse  factors.  Displacements  are  caused  by  many  lapses 
from  the  normal  condition,  e.g.,  lack  of  support,  as  by  rupture  of  the 
perineum,  increased  pressure  from  above,  increased  weight  of  the 
uterus,  as  from  subinvolution  after  pregnancy,  chronic  inflammation 
or  the  presence  of  tumours,  the  traction  of  adhesions  resulting  from 
pelvic  cellulitis,  etc.  The  most  common  displacements  are  forwards, 
constituting  anteversion  or  anteflexion  ;  backwards,  in  the  form  of 
retroversion  or  retroflexion ;  and  downwards,  giving  rise  to  prolapse 
or  procidentia. 

It  is  unnecessary  to  enter  into  the  symptoms  and  ordinary  treat- 
ment of  these  conditions ;  but  the  operative  treatment  of  them 
requires  notice. 

Anterior  displacements  require  no  external  operative  treatment. 

Posterior  displacements  are  not  unfrequently  dealt  with  by 
operations  through  the  anterior  abdominal  wall.  Two  chief  methods 
are  employed,  viz.,  shortening  the  round  ligaments  and  hysteropexy. 
Shortening  of  the  round  ligaments  can  be  undertaken  as  an  extra-  or  as 
an  intra-peritoneal  procedure,  (i.)  Alexander's  operation  is  extra- 
peritoneal, and  suitable  only  for  uncomplicated  cases.  The  inguinal 
canal  on  each  side  is  exposed  and  the  external  oblique  slit  up ;  the 
round  ligament  is  identified,  isolated,  drawn  taut,  and  the  slack  portion 
cut  away ;  the  posterior  end  is  then  fixed  in  the  canal  by  sutures,  which 
also  serve  to  close  it ;  the  external  oblique  is  also  carefully  sutured, 
(ii.)  In  the  intra-abdominal  operation  a  complete  investigation  of 
the  pelvic  viscera  is  possible.  A  small  median  incision  is  made ; 
the  round  ligament  on  either  side  is  isolated,  doubled  over,  and 
stitched  to  itself  so  as  to  remove  all  slackness.  This  latter  opera- 
tion is  probably  much  the  more  satisfactory  of  the  two.  Of  course, 
the  additional  use  of  a  suitable  pessary  may  be  desirable. 

Hysteropexy,  or  the  fixation  of  the  uterus  to  the  anterior  abdominal 
wall,  is  a  procedure  that  must  be  cautiously  undertaken  in  married 
patients  who  have  not  reached  the  climacteric.  An  incision  2  or 
3  inches  in  length  is  made  immediately  above  the  symphysis,  and 
the  fundus  uteri  is  drawn  forwards  by  a  volsellum.  Three  silkworm 
gut  stitches  are  inserted  through  the  abdominal  parietes  and  perito- 
neum, and  also  through  the  body  of  the  uterus  just  posterior  to  its 
axis.  The  stitches  should  include  about  f  inch  of  the  uterine  wall 
in  their  grasp,  and  go  about  ^  inch  deep.  On  drawing  them  tight, 
the  uterus  is  fixed  forwards  against  the  abdominal  wall  and  contracts 
adhesions.     In  some  cases  it  may  be  desirable  to  scarify  the  uterine 


1306 


A  MANUAL  OF  SURGERy 


wall  before  tying  the  stitches,  so  as  the  better  to  determine  adhesions. 
As  a  general  rule  the  adhesions  stretch  somewhat,  and  hence  allow 
a  certain  degree  of  play,  but  without  the  likelihood  of  a  return  of 
the  displacement. 

Prolapse  of  the  Uterus  is  most  commonly  associated  with  a 
ruptured  perineum  and  chronic  metritis.  The  anterior  vaginal  wall 
often  gives  way  first  and  brings  down  the  bladder,  causing  consider- 
able  dysuria  or   vesical    irritability  ;    and    then   the   uterus   itself 


Fig.  549. 


Fig.  550. 


Fig.  551, 


Fig.  549. — Incision  for  Repairing  Ruptured  Perineum. 

Fig.  550. — Vaginal   Flap   dissected  up   from    Recto-vaginal   Septum   and 

DRAWN  Forwards.     (Some  of  the  sutures  are  introduced.) 
Fig.  551. — Operation  for  Repairing  a  Ruptured  Perineum  completed. 


descends,  and  may  even  protrude  from  the  vulva,  the  vagina  being 
turned  inside  out,  and  its  walls  becoming  dry  like  skin,  and  perhaps 
ulcerated  from  persistent  irritation.  Treatment  varies  according  to 
the  condition  present  and  with  the  causes.  The  uterus,  if  enlarged 
and  inflamed,  may  need  to  be  curetted  so  as  to  diminish  its  bulk  and 
weight.  The  perineum,  if  defective,  must  be  repaired-  by  one  of  the 
many  forms  of  perineoplasty  now  in  vogue.  Possibly  the  introduc- 
tion of  a  suitable  pessary  may  suffice  to  keep  the  uterus  in  place  for 
a  sufficient  time  to  allow  the  uterine  supports  to  regain  their  tone. 
In  some  cases  hysteropexy  will  be  indicated,  but  in  the  worst  forms 
vaginal  hysterectomy,  combined  with  some  operation  to  diminish 
the  size  of  the  vaginal  canal,  may  be  required. 

The  operation  for  repairing  a  ruptured  perineum  necessarily'  varies 
with  the  extent  and  completeness  of  the  tear.     Obstetricians  should 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1307 

always  endeavour  to  stitch  up  these  ruptures  immediately  after 
labour,  as  the  parts  are  then  very  insensitive,  owing  to  the  stretching 
which  they  have  suffered,  and  patients  are  very  loth  to  undergo  a 
secondary  operation  soon  after.  The  plan  usually  adopted  for 
remedying  a  defect  which  does  not  quite  extend  to  the  anus  is  indi- 
cated in  Figs.  549-551.  An  incision  is  made  skirting  the  posterior 
vulval  margin,  and  extending  forwards  on  either  side  to  the  ter- 
minations of  the  nymphse.  By  deepening  this  the  posterior  vaginal 
wall  can  be  separated  from  the  rectum,  great  care  being  taken  not  to 
encroach  on  either  cavity,  and  the  flap  thus  produced  is  drawn  for- 
wards. The  wound  is  then  stitched  up  transversely,  and  an  effective 
perineal  body  produced.  A  more  extensive  intravaginal  operation 
is  needed  when  the  rent  involves  the  anal  orifice. 

Uterine  Tumours. 

Fibro-myomata  are  by  no  means  uncommon,  developing  during 
sexual  activity,  and  causing  symptoms  partly  from  their  location  in 
the  uterus,  partly  from  the  size  which  ttaey  may  attain.  Any  part 
of  the  uterus  may  be  affected  primarily,  but  they  generally  originate 
in  the  substance  of  the  wall,  and  that  usually  the  posterior  wall ;  if 
they  remain  in  this  relation,  they  are  known  as  interstitial  or  iiitra- 
mural  fibroids  (Fig.  552,  i).  When  they  are  situated  near  the  inner 
or  outer  uterine  wall  they  may  project  either  into  the  uterine  or 
peritoneal  cavities,  constituting  the  suhmucous  (2)  and  subserous  (3) 
fibroids.  Occasionally  they  become  pedunculated,  and  then  a  fibroid 
polypus  of  the  uterus  may  develop,  and  project  through  the  os  into 
the  vagina,  where  it  may  undergo  strangulation  or  torsion,  and  may 
slough  away  or  become  acutely  inflamed.  A  pedunculated  subserous 
fibroid  may  similarly  become  twisted  or  inflamed,  and  then  may 
either  slough,  or  may  gain  adhesions  elsewhere,  e.g.,  to  the  omentum, 
and  finally  become  separated  from  the  uterus. 

The  actual  structure  of  these  tumours  varies  slightly,  but  they  are 
all  more  or  less  of  a  fibro-myomatous  nature,  i.e.,  they  consist  of 
muscle  fibres  similar  to  those  of  the  uterus,  with  a  varying  amount 
of  fibrous  stroma  and  bloodvessels.  Occasionally  they  are  very  hard 
and  not  specially  vascular  ;  in  other  cases  they  are  softer  and  more 
vascular,  and  then  usually  grow  more  quickly.  They  are  surrounded 
by  a  capsule  of  varying  density,  which  is  often  the  seat  of  many 
enlarged  veins,  and  if  these  are  ulcerated  into,  considerable  haemor- 
rhage follows.  The  uterus  generally  becomes  hyperaemic  and  en- 
larged, and  the  mucous  membrane  thickened ;  not  unfrequently 
endometritis  is  present,  and  the  inflammation  may  spread  up  to  the 
tubes,  causing  pyosalpinx. 

Various  secondary  changes  may  occur  in  uterine  fibroids.  They 
may  become  (edematous,  or  undergo  cystic  degeneration,  as  a  result  of 
defective  nutrition,  and  that  generally  in  young  people ;  fibro-cystic 
disease  of  the  uterus  is  thereby  determined.  Occasionally  in  old 
women,  where  the  evolution  of  the  growth  has  long  ceased,  calcareous 


i3o8 


A  MANUAL  OF  SURGERY 


occurs,  and  the  growth  is  converted  into  a  stony  mass. 
In  younger  women  a  somewhat  similar  change  may  be  present,  and 
the  fibroid  becomes  hard,  but  not  stony.  The  existence  of  this  con- 
dition must  be  remembered  in  connection  with  the  skiagraphic 
examination  of  the  pelvis,  as  circular  shadows  of  a  perplexing  nature 
may  be  produced  by  these  tumours.  Inflammation  and  pyogenic  injection, 
with  perhaps  abscess  formation,  may  follow  abrasion  of  the  mucous 
membrane  with    a  sound,  and  sloughing  of   the  growth  may  result 

either  from  an  inflammatory  attack 
or  from  defective  blood-supply. 
It  is  possible  that  sarcoma  may 
supervene  in  some  few  cases,  but 
the  association  is  not  yet  absolutely 
proven. 

The  Symptoms  vary  much  in 
different  cases,  but  are  mainly 
those  of  haemorrhage  and  pressure. 
H (smorvhage  occurs  either  as  a  pro- 
longation of  the  normal  menstrual 
periods  (menorrhagia),  or  as  a 
chronic  and  persistent  effusion  of 
blood  (metrorrhagia).  It  may  be 
absent  in  subserous  and  interstitial 
fibroids,  and  is  most  marked  in 
the  submucous  variety,  in  which 
the  endometrium  is  congested  and 
succulent.  The  amount  of  blood 
lost  may  drain  the  patient,  who 
looks  anaemic  and  dehydrated. 
There  may  be  but  little  pain  in 
the  subserous  variety,  unless  the 
growth  becomes  twisted  or  im- 
pacted in  the  pelvis.  When  the' 
tumour  projects  upwards  into  the 
abdomen  nothing  but  a  sense  of  weight  is  experienced  unless  the  size 
is  so  great  as  to  encroach  seriously  on  the  viscera.  When  the  growth 
is  mainly  pelvic,  and  especially  when  a  fibroid  of  the  cervix  extends 
sideways  into  the  broad  ligament,  or  when  impaction  occurs,  the 
symptoms  may  be  very  distressing.  Vesical  irritability  may  be  very 
marked,  and  micturition  may  be  painful  and  difficult.  Tenesmus 
or  constipation  may  arise  from  pressure  on  the  rectum  ;  hydrone- 
phrosis, when  the  ureters  are  compressed ;  and  severe  neuralgic  pain 
down  the  leg,  should  the  pelvic  nerves  be  encroached  on.  The 
presence  of  a  polypoid  submucous  growth  is  likely  to  cause  violent 
expulsive  contraction  of  the  uterus. 

The  Diagnosis  is  made  by  palpation,  digital  examination,  and  the 
use  of  the  sound.  Bimanual  examination  should  reveal  the  size  and 
shape  of  the  uterus,  and  much  useful  information  can  often  be  ob- 
tained by  a  combined  vaginal  and  rectal  examination.     The  sound 


Fig 


552- — Diagram  of  Uterus  with 

FiBROMYOMATA. 

Interstitial  fibroid  ;    2,  submucous 
fibroid  ;  3,  subserous  fibroid. 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1309 

will  demonstrate  the  increased  length  of  the  uterine  canal,  which  is 
often  in  addition  twisted. 

The  Prognosis  has  to  be  considered  carefully  in  every  case  before 
determining  for  or  against  operative  treatment.  The  majority  of  the 
cases  improve  at  the  menopause,  the  growth  shrinking  and  the 
haemorrhage  ceasing ;  exceptions  to  this  rule  are,  however,  not  un- 
known. It  is  therefore  obvious  that  if  the  patient  is  approaching 
the  climacteric  and  the  symptoms  are  not  grave,  it  may  be  advisable 
to  wait  for  that  event.  On  the  other  hand,  if  the  condition  occurs 
in  a  young  w^oman,  and  especially  if  the  haemorrhage  is  sufficiently 
severe  to  necessitate  prolonged  rest  and  more  or  less  chronic  in- 
validism, operation  is  certainly  desirable.  Of  course,  the  existence 
of  severe  hemorrhage,  or  of  symptoms  of  pelvic  pressure,  would  at 
all  ages  justify  operation. 

Treatment. — If  the  symptoms  are  not  such  as  to  warrant  opera- 
tion, all  that  is  required  is  that  the  patient  should  rest  at  the 
menstrual  periods,  and  that  ergot  and  iron  should  be  administered  if 
necessary. 

Operative  Treatment  consists  in  either  the  enucleation  of  the  tumour  or 
the  extirpation  of  the  uterus,  and  the  removal  of  the  ovaries  and  tubes. 

(i)  Myomectomy,  or  the  enucleation  and  removal  of  the  tumour 
apart  from  the  uterus,  is  only  suitable  under  special  circumstances. 
When  the  growth  projects  into  the  uterus  or  vagina  as  a  polypus,  the 
vaginal  route  may  be  adopted  ;  the  cervix  is  dilated  if  need  be,  and 
after  incising  the  mucous  membrane  the  growth  can  be  enucleated 
by  the  finger.  A  subserous  fibro-myoma  can  similarly  be  removed 
without  difficulty  if  it  be  thought  desirable.  Not  unfrequently  this 
condition  is  met  with  in  laparotomies  for  other  conditions,  and  the 
surgeon  may  think  it  desirable  to  remove  the  growth.  A  longitudinal 
incision  down  to  the  capsule  and  a  sweep  round  of  the  finger  usually 
suf&ces  to  enucleate  the  tumour,  and  that  with  very  little  bleeding. 
Two  or  three  deep  stitches  may  be  introduced  into  the  uterine  sub- 
stance, and  the  peritoneum  adjusted  and  apposed  by  superficial 
stitches.     No  drainage  is  required  as  a  rule. 

(2)  Abdominal  Hysterectomy  for  fibroids  is  a  most  successful  pro- 
cedure. It  may  suffice  to  remove  the  organ  through  or  above  the 
cervix  (supra-vaginal  hysterectomy),  or  it  may  be  needful  to  include 
the  cervdx  in  the  mass  that  is  removed  (pan-hysterectomy).  The 
procedure  is  identical  up  to  a  certain  point,  but  the  latter  operation 
is  rather  the  longer,  and  the  dangers  are  a  little  greater. 

The  patient  must  be  carefully  prepared  as  for  any  other  abdominal 
operation  (p.  969),  but  in  addition  the  pubes  and  vulva  must  be 
shaved  and  thoroughly  purified ;  the  vagina  should  be  douched  for 
some  days  previously,  and  an  antiseptic  dressing  worn,  and  if  need 
be  the  uterme  canal  should  be  curetted  and  disinfected  with  some 
powerful  antiseptic.  , 

After  anaesthesia  has  been  induced,  the  Trendelenburg  position  is 
adopted,  and  an  incision  of  suitable  length  made  in  the  median  line. 
The  parts  are  then  carefully  explored,  and  if  no  adhesions  exist. 


1310  A  MANUAL  OF  SURGERY 

an  abdominal  cloth  is  packed  in  over  the  intestines  in  order  to 
protect  and  keep  them  from  exposure  and  injury.  If  adhesions  to 
omentum  or  gut  are  present,  they  must  be  carefully  divided ;  it  is, 
of  course,  most  desirable  that  a  complete  peritoneal  covering  should 
be  secured  for  any  adherent  organs ;  omental  grafts  may  be  some- 
times useful  in  this  direction.  The  uterus  is  now  lifted  up  and  drawn 
into  the  incision  by  a  Doyen's  myoma  screw  or  a  stout  volsellum. 

The  broad  ligaments  are  then  examined,  and  a  decision  made  as  to 
whether  or  not  the  ovaries  and  tubes  are  to  be  saved.  It  is  certainly 
desirable  that  in  a  young  woman  an  effort  should  be  made  to  retain 
at  any  rate  one  ovary,  thereby  avoiding  the  nervous  symptoms  often 
determined  by  an  acute  artificial  menopause.     The  lines  of  section 


Fig.  553. 


-Diagram  of  Uterus,  Vagina,  and  Broad  Ligament,  seen  from 
IN  Front. 


O.A.,  Ovarian  artery  ;  U.A.,  uterine  artery  ;  U.,  ureter.  The  dotted  lines  represent 
the  division  of  the  broad  ligament  in  hysterectomy  according  to  whether  or 
not  the  ovary  is  removed.  The  continuous  dark  lines  crossing  the  uterus 
indicate  the  incisions  through  the  uterine  substance  in  supra- vaginal 
hysterectomy. 

of  the  broad   ligament  under  these   two   conditions   are   indicated 
diagrammatically  in  Fig.  553. 

A  pedicle  needle  carrying  a  sufficient  length  of  well-boiled  silk  is 
carried  through  the  round  ligament  so  as  to  secure  the  ovarian  artery 
and  veins,  and  tied  as  far  away  from  the  uterus  as  possible ;  a  broad 
ligament  clamp  may  then  be  placed  in  position  close  to  the  uterus, 
so  as  to  prevent  venous  regurgitation,  and  the  broad  ligament  is 
divided  half-way  down.  It  is  often  possible  and  desirable  to  pick  up 
the  divided  end  of  the  ovarian  artery  on  the  face  of  this  section  and 
secure  it  separately,  whilst  the  httle  artery  which  accompanies  the 
round  ligament  should  also  be  carefully  secured.  The  ovarian  artery 
on  the  other  side  is  next  dealt  with  in  a  similar  fashion.  A  trans- 
verse cut  is  now  made  across  the  front  of  the  uterus,  involving 
merely  the  serous  membrane,  and  connecting  the  two  ends  of  the 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  131 1 

incisions  in  the  broad  ligaments ;  the  peritoneum  below  this  trans- 
verse cut  is  detached,  together  with  the  bladder,  from  the  cervix, 
and  the  intra-ligamentary  space  is  thereby  opened  up  on  either 
side.  In  this  will  be  found  the  uterine  vessels,  and  it  may  be 
possible  to  see  and  isolate  the  uterine  artery  before  securing  it  by 
ligature.  Care  must  be  taken  in  this  part  of  the  operation  to  keep 
close  to  the  uterus,  as  the  ureter  comes  forwards  from  behind  under 
the  uterine  artery  to  reach  the  bladder,  lying  about  the  level  of  the 
OS  internum.  The  uterine  vessels  are  in  this  way  carefully  secured 
and  divided. 

The  uterus  is  now  merely  held  by  the  connection  between  the 
vagina  and  cervix,  and  the  peritoneal  reflection  in  Douglas's  pouch. 
If  a  supra- vaginal  operation  will  suffice,  the  surgeon  cuts  across  the 
neck  of  the  uterus  in  such  a  way  as  to  fashion  two  flaps,  and 
finally  the  peritoneum  behind  is  also  divided.  A  few  small  vessels 
will  probably  need  to  be  secured  on  the  face  of  the  uterine  stump. 
This  having  been  effected,  the  uterine  flaps  are  stitched  carefully 
together  so  as  to  bury  the  open  cervical  canal ;  the  uterine  stump  is 
then  covered  in  by  uniting  the  divided  portions  of  peritoneum.  This 
line  of  sutures  is  carried  up  on  either  side  so  as  to  secure  the  two 
layers  of  the  broad  ligament ;  the  final  result  is  that  the  pelvic  floor 
is  covered  in  by  a  continiious  layer  of  peritoneum,  showing  a  sutured 
incision  which  runs  transversely  from  one  side  to  the  other.  The 
usual  peritoneal  toilette  follows,  and  the  abdomen  is  generally  closed 
entirely,  no  drainage  being  required. 
.  When  the  fibroid  tumours  involve  the  cervix,  it  may  be  necessary 
to  perform  pan-hysterectomy.  The  operation  follows  along  the  lines 
indicated  above,  up  to  the  securing  of  the  uterine  vessels.  It  is  then 
advisable  to  open  into  the  posterior  vaginal  cul-de-sac,  and  enucleate 
the  cervix  from  its  surroundings  from  behind  forwards,  keeping  very 
near  to  the  uterus  at  the  sides  so  as  to  avoid  the  ureters,  and  keeping 
clear  of  the  bladder  in  front.  Several  vessels  derived  from  the 
vaginal  arteries  will  require  to  be  secured  in  this  proceeding.  The 
wound  in  the  pelvic  floor  is  closed  much  in  the  same  way  as  before, 
but  not  so  completely  as  regards  the  vaginal  walls,  a  small  lamp- 
wick  drain  of  iodoform  gauze  being  introduced  between  them.  The 
peritoneum  is  sutured  continuously  over  the  gauze,  and  up  on  either 
side  to  the  upper  extremity  of  the  broad  ligament. 

In  both  cases  a  pad  of  antiseptic  dressing  is  maintained  over  the 
vulva  for  a  time,  and  in  pan-hysterectomy  it  is  advisable  to  douche 
the  vagina  daily.  The  gauze  packing  is  removed  on  the  third  day, 
and  another  strip  introduced.  The  results  of  this  operation  are  most 
satisfactory,  and  the  death-rate  comparatively  small. 

(3)  Double  Salpingo -oophorectomy  (removal  of  ovaries  and  tubes) 
was  at  one  time  much  practised  in  the  treatment  of  uterine  fibroids, 
and  certainly  had  the  effect  of  checking  haemorrhage  and  diminishing 
their  growth  by  determining  an  artificial  menopause.  At  the  same 
time,  the  patient  is  not  relieved  of  the  incubus  of  the  growth,  and 
hence  the  operation  is  now  but  seldom  employed,  except  as  part  of  a 
complete  hysterectomy. 


1312  A  MANUAL  OF  SURGERY 

Sarcoma  of  the  Uterus  is  not  of  very  common  occurrence.  It  may 
be  a  secondary  development  follov^^ing  on  fibro-myomata,  or  may  be 
primary.  In  most  cases  it  occurs  as  a  solid,  firm  tumour,  consisting 
of  spindle  cells,  but  more  vascular  than  and  not  quite  so  hard  as  the 
majority  of  fibroids ;  in  others  it  is  of  a  softer  consistency,  and  may 
be  associated  with  myxomatous  development.  It  almost  always  in- 
volves the  body  of  the  organ,  the  cervix  being  unaffected  ;  and  it  may 
either  attack  the  mucous  membrane  primarily  as  a  diffuse  infiltra- 
tion, or  constitutes  a  more  localized  growth  in  the  muscular  tissue. 
Secondary  deposits  occur  in  the  vagina  and  elsewhere,  and  the  case 
runs  a  more  rapid  course  than  a  simple  fibroid,  although  the 
symptoms  are  much  of  the  same  type.  There  is,  however,  more 
discharge  from  the  vagina,  which  may  contain  debris  of  the  growth, 
and  becomes  somewhat  offensive.  Treatment  consists  in  pan- 
hysterectomy. 

Carcinoma  of  the  Uterus  is  the  most  common  form  of  cancer  in  the 
female,  accounting  for  over  30  per  cent,  of  the  deaths  from  this 
disease.  It  follows  the  usual  rule  as  to  age,  being  uncommon  under 
thirty  years,  and  most  frequently  seen  between  the  ages  of  forty 
and  fifty.  It  generally  occurs  in  multiparse,  and  is  probably 
associated  with  lacerations  of  the  cervix  and  inflammatory  erosions 
dependent  thereon.  The  site  of  origin  is  usually  the  cervix,  the 
body  being  comparatively  seldom  affected  primarily. 

Cancer  of  the  cervix  starts  (i.)  as  a  nodular  overgrowth  of  the 
glands  embedded  in  its  substance ;  (ii.)  as  an  epithelioma  of  the 
vaginal  portion,  projecting  into  that  passage  as  a  malignant  papil- 
loma ;  or  (iii.)  as  a  diffuse  affection  of  the  cervical  epithelium  and  its 
glands,  and  hence  is  most  frequently  of  a  columnar-celled  type.  In 
all  these  cervical  forms  the  vagina  is  early  affected ;  the  disease 
spreads  more  slowly  up  towards  the  body  of  the  uterus.  The 
arrangement  of  vessels  and  lymphatics  will  explain  the  fact  that 
invasion  of  the  broad  ligaments  is  early ;  these  structures  become 
infiltrated  and  rigid,  fixing  the  uterus,  and  pressure  phenomena  upon 
the  rectum,  bladder,  or  pelvic  vessels  and  nerves,  will  sooner  or  later 
be  manifested.  Destructive  ulceration  follows,  and  the  bladder  or 
rectum  may  be  laid  open,  and  empty  their  contents  into  the  vagina, 
which  in  the  worst  cases  becomes  an  evil-smelling  cloaca.  Adhesive 
inflammation  serves  to  protect  the  peritoneal  cavity,  which  is  not 
often  opened  up. 

Carcinoma  of  the  body  of  the  uterus  starts  in  the  mucous  mem- 
brane and  its  glands,  and  rapidly  disseminates  and  infiltrates  the 
whole  cavity;  it  also  is  of  a  columnar-celled  type.  The  whole 
organ  may  become  hollowed  out  by  ulceration,  constituting  a  slough- 
ing cavity  from  which  an  abundant  haemorrhagic  discharge  escapes. 

In  all  cases  lymphatic  dissemination  follows,  involving  the  pelvic 
glands  first,  and  later  on  the  iliac,  and  possibly  even  the  inguinal. 
Compression  of  the  ureters  may  cause  hydronephrosis ;  the  iliac 
vessels  may  be  compressed  and  lead  to  oedema  of  the  legs,  and  pul- 
monary embolus  secondary  to  venous  thrombosis  has  been  known 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1313 

to  cause  death.  General  dissemination  to  the  viscera  is  not 
common. 

The  chief  Symptoms  of  uterine  cancer  are  pain,  haemorrhage,  and 
an  offensive  discharge.  Pain  is  unfortunately  not  an  early  manifesta- 
tion in  most  cases,  and  hence  the  disease  has  often  gained  a  good 
hold  before  the  patient  comes  under  observation.  As  soon  as  the 
body  of  the  organ  is  attacked,  or  the  extra-uterine  cellular  tissue,  it 
begins  to  trouble  the  patient ;  it  is  of  an  aching,  gnawing,  or  boring 
character,  and  in  the  later  stages  may  be  so  appalling  in  its  severity 
as  to  necessitate  the  injection  of  huge  doses  of  morphia.  As  a  general 
rule,  it  is  most  marked  when  there  is  comparatively  little  destructive 
ulceration.  Referred  and  sympathetic  pains  in  back,  breasts,  and 
legs  are  also  much  complained  of.  The  haemorrhage  may  at  first  be 
merely  an  exaggeration  of  normal  menstrual  periods,  but  later  on  the 
loss  of  blood  is  often  continuous  and  maybe  associated  with  a  discharge 
of  horribly  offensive  muco-pus  and  cancerous  debris.  The  appearance 
of  a  haemorrhagic  discharge  after  the  menopause  should  always  deter- 
mine a  careful  local  examination  of  the  pelvic  viscera.  Loss  of  flesh, 
debility,  and  the  ordinary  phenomena  of  a  cancerous  cachexia,  are 
gradually  developed,  and  to  these  may  be  added  special  symptoms 
due  to  implication  of  the  bladder  and  bowel. 

On  vaginal  examination  the  physical  signs  corresponding  to  the 
type  of  disease  make  themselves  evident.  There  may  be  merely  a 
nodular  thickening  of  the  cervix ;  or  an  ulcerating  papillomatous 
mass,  like  a  cauliflower,  may  project  into  the  vagina,  invading  the 
wall  of  this  tube ;  or  the  finger  may  pass  through  the  open  os  into 
a  ragged  hollow  cavity  lined  by  an  ulcerating  mass  of  new  growth. 
The  most  careful  attention  must  be  given  as  to  the  lateral  extension 
of  the  growth  into  the  broad  ligament,  whether  the  uterus  is  mobile 
or  fixed,  and  whether  the  vaginal  wall  is  much  involved,  as  it  is 
upon  these  facts  that  the  possibility  or  not  of  operation  depends. 
It  is  useless  to  attempt  removal  when  the  broad  ligaments  are 
badly  invaded,  or  if  the  vaginal  wall  is  extensively  implicated,  or 
the  uterus  firmly  fixed  to  bladder  or  rectum. 

In  early  doubtful  cases  where  the  os  is  ulcerated  to  a  slight  extent, 
a  portion  of  the  growth  should  be  snipped  away,  and  submitted  to 
microscopical  examination. 

Radical  Treatment  is  only  practicable  v/hen  the  disease  has  not 
extended  too  far.  Formerly  gynaecologists  used  to  practise  amputa- 
tion of  the  cervix  when  the  disease  was  apparently  limited  to  this 
region.  In  the  light  of  modern  pathology  such  a  procedure  is  un- 
scientific and  insufficient,  and  clinical  experience  has  shown  that  the 
only  operation  which  should  be  considered  is  complete  hysterectomy. 

Hysterectomy  for  carcinoma  uteri  may  be  performed  by  the  vaginal 
route  or  through  the  abdomen,  (i)  The  vaginal  operation  is  possibly 
a  little  safer,  but  has  the  objections  that  the  broad  ligaments  cannot 
be  dealt  with  quite  so  satisfactorily,  and  that  should  adhesions  exist 
It  will  be  difficult  or  impossible  to  deal  with  them.  However,  in 
simple  early  cases  it  will  suffice,  and,  indeed,  when  the  disease  is  so 

83 


I3I4  A  MANUAL  OF  SURGERY 

extensive  as  to  need  more  than  a  vaginal  procedure,  it  has  probably 
gone  so  far  as  to  be  practically  inoperable.  For  details  of  this  opera- 
tion, gynaecological  text-books  must  be  consulted.  (2)  Abdominal 
hysterectomy  is  the  more  scientific  procedure,  and  should  always  be 
performed  where  the  local  and  general  conditions  of  the  patient  are 
satisfactory.  Wertheim's  pan-hysterectomy  is  the  operation  generally 
adopted,  if  it  be  practicable  ;  it  involves  the  removal  of  the  complete 
uterus,  together  with  the  upper  part  of  the  vagina,  the  whole  of  the 
broad  ligaments,  and  the  cellular  tissue  and  glands  along  the  iliac 
vessels.  An  important  preliminary  consists  in  a  thorough  scraping, 
cauterization,  and  disinfection  of  the  diseased  cervix.  The  operation 
itself  is  conducted  in  the  Trendelenburg  position  through  a  median 
subumbilical  incision,  the  intestines  being  carefully  packed  off  from 
the  pelvis  by  suitable  gauze  swabs.  The  local  condition  of  affairs 
having  been  fully  investigated,  the  ureters  are  exposed  by  an  incision 
along  the  posterior  pelvic  wall  just  behind  the  base  of  the  broad 
ligament  on  each  side.  Each  ureter  is  traced  forwards  to  the  bladder, 
and  if  this  be  done  carefully  the  blood-supply  is  not  impaired,  and 
although  the  ureters  are  isolated  they  will  not  slough.  In  this  dis- 
section the  origin  of  the  uterine  artery  is  laid  bare,  and  divided 
between  ligatures,  whilst  the  broad  ligament  is  also  divided  as  close 
to  the  pelvic  wall  as  possible  after  ligaturing  the  vessels  entering  it. 
The  peritoneum  in  front  of  the  uterus  is  next  divided,  and  the 
bladder  dissected  forwards  as  far  as  the  anterior  fornix  of  the  vagina  ; 
a  similar  dissection  frees  the  rectum  from  the  back  of  the  uterus, 
which  is  now  merely  held  in  position  by  its  vaginal  attachments. 
This  latter  tube  is  then  secured  by  two  suitable  right-angled  clamps, 
and  divided  between  them.  Finally,  if  the  patient's  condition  warrants 
it,  the  peritoneum  is  divided  upwards  over  the  iliac  vessels,  and  the 
cellular  tissue  and  all  enlarged  glands  removed  as  high  as  the  bifurca- 
tion of  the  aorta.  The  cavity  left  is  carefully  packed  with  iodoform 
gauze  projecting  into  the  vagina,  and  the  peritoneum  accurately 
sutured  transversely  over  it.  The  mortality  of  this  procedure  is  high 
(20  per  cent.),  but  with  improved  technique  this  is  diminishing.  The 
chief  risks  are  infection  of  the  peritoneal  cavity,  cancerous  dissemina- 
tion, or  injury  to  the  ureters. 

Palliative  Treatment  in  inoperable  cases  consists  in  staying  the 
haemorrhage,  keeping  the  parts  as  free  from  sepsis  as  possible,  and 
combating  pain  by  morphia.  In  some  cases  it  may  be  permissible 
to  curette  the  diseased  structures,  thereby  removing  protuberant 
masses  which  interfere  with  the  escape  of  the  discharge. 

Finally,  a  word  must  be  added  to  emphasize  the  fact  that  the 
constant  association  of  this  disease  with  a  torn  and  eroded  os  suggests 
the  possibility  of  prevention  by  attending  to  such  lesions  and  not 
allowing  them  to  persist  indefinitely  without  treatment. 

Chorio-epithelioma  {Syn.  :  Deciduoma  malignum,  Syncytioma  maligna,  etc.)  is 
an  interesting  condition  to  which  considerable  attention  has  been  directed  of 
late.  It  consists  of  an  overgrowth  of  the  chorionic  villi,  which  constitute  a  soft 
bleeding  tumour,  invading  and  thinning  the  uterine  wall,  and  insinuating  itself 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  131 5 

tion  the  venous  channels,  so  that  general  dissemination  of  the  growth  is  an  early- 
manifestation,  the  lungs  being  usually  involved  first.  The  growth  is  a  soft, 
succulent  papillomatous-looking  mass,  involving  the  body  of  the  uterus,  and 
not  unfrequently  the  fundus,  and  bearing  a  close  resemblance  in  structure  and 
physical  characters  to  a  vesicular  mole  ;  in  fact,  it  may  be  looked  on  as  a  malig- 
nant form  of  this  structure,  The  characteristic  histological  feature  is  the  presence 
of  large- syncytial  cells  derived  from  the  outer  layers  of  the  chorionic  villi,  which 
appear  as  masses  of  protoplasm,  containing  many  dark  nuclei ;  in  addition  to 
these  are  many  smaller  cells,  irregular  in  shape,  unusually  rich  in  glycogen,  and 
in  which  division  by  karyokinesis  is  the  rule.  It  is  unusual  to  be  able  to  demon- 
strate typical  chorionic  villi  in  the  mass,  but  the  peculiar  cells  are  exactly  similar 
in  nature  to  those  which  occur  in  the  villi.  Ovarian  changes  are  not  unfrequently 
observed,  in  the  shape  of  multiple  cysts,  due  to  degeneration  of  the  corpora  lutea. 
The  clinical  features  of  a  chorio-epithelioma  are  tolerably  characteristic.  Occa- 
sionally the  disease  follows  a  normal  pregnancy,  and  is  apparently  due  to  the 
persistence  of  a  portion  of  the  placental  tissue,  which  takes  on  malignant  action 
of  this  peculiar  type.  In  the  great  majority  of  cases,  however,  it  is  preceded  by 
a  miscarriage  at  a  fairly  early  date,  and  perhaps  a  vesicular  mole  of  some  size  is 
removed.  The  hasmorrhagic  discharge  does  not  cease,  but  continues  and  may 
become  exaggerated.  Retention  of  placental  tissue  is  usually  diagnosed,  and  as 
a  rule  the  uterus  is  curetted  ;  if  on  microscopic  examination  of  the  scrapings  the 
characteristic  cells  of  a  chorio-epithelioma  are  found,  no  delay  is  permissible,  but 
the  uterus  must  be  removed  at  once.  Should  the  case  be  left,  the  hsemorrhagic 
discharge  increases,  the  uterus  becomes  enlarged,  and  evidences  of  secondary 
deposits  appear,  especially  in  the  lungs.  The  nature  of  this  growth  is  very 
malignant,  and  the  patient  quickly  succumbs.  Treatment  consists  in  abdominal 
hysterectomy,  which  should  include  the  ovaries,  and  if  the  case  is  taken  before' 
dissemination  has  occurred,  there  is  good  hope  of  success. 

Affections  of  the  Fallopian  Tubes. 

Pyosalpinx,  or  an  accumulation  of  pus  m  the  Fallopian  tube,  is 
the  result  of  an  inflammation  of  its  lining  walls  (salpingitis),  due  to 
infection  either  with  gonococci  (the  commonest  cause),  or  with 
pyogenic  organisms  spreading  from  an  infected  uterus  after  a  mis- 
carriage or  confinement,  or  occasionally  with  the  tubercle  bacillus. 
The  process  is  usually  chronic  or  subacute ;  if  it  should  commence 
acutely,  the  symptoms  are  so  blended  with  those  of  the  accompany- 
ing uterine  or  peritoneal  inflammation  as  to  be  scarcely  distinguish- 
able. Both  tubes  are  usually  aff"ected,  and  it  is  not  uncommon  for 
suppuration  to  spread  to  and  involve  the  ovary. 

The  inflammation,  whether  acute  or  chronic,  usually  results  in 
blocking,  and  perhaps  complete  and  permanent  closure,  of  both  ends 
of  the  tube  ;  the  abdominal  ostium  may  be  closed  by  fibrin  or  by 
the  adhesion  of  the  fimbriated  extrernity  to  surrounding  viscera. 
Distension  of  the  tube  follows,  and  it  frequently  becomes  elongated 
and  tortuous  (Fig.  554)  ;  it  may  contain  a  considerable  quantity  of 
pus,  which,  though  containing  organisms  at  first,  may  in  time 
become  sterile,  the  germs  dying  out.  The  distended  tubes  gain 
adhesions  to  surrounding  parts  as  a  result  of  plastic  peritonitis,  and 
the  abscess  may  burst  either  into  the  vagina,  into  one  of  the  sur- 
rounding viscera  (bladder,  rectum,  or  small  intestine),  or  into  the 
general  peritoneal  cavity. 

Tuberculous  pyosalpinx  is  due  to  an  infection  of  the  mucous  mem- 
brane of  the  tube,  which  may  be  primary,  the  organisms  reaching  the 


I3i6  A  MANUAL  OF  SURGERY 

part  through  the  blood-stream,  or  secondary  to  uterine  or  peritonea) 
tuberculosis ;  the  latter  is  the  more  common.  Both  tubes  are 
generally  affected,  and  either  become  distended  with  curdy  pus,  which 
may  undergo  caseation  or  calcification,  or  constitute  solid  fibroid 
masses  with  encapsuled  caseous  foci,  embedded  in  a  dense  mass  of 
adhesions.  If  the  disease  is  primary,  it  may  spread  outwards  through 
the  abdominal  ostium  to  the  peritoneal  cavity,  and  give  rise  to  a 
tuberculous  peritonitis  which  commences  as  a  pelvic  affection  and 
may  be  shut  off  by  adhesions  from  the  general  cavity. 

Clinical  Histoiy. — In  the  acute  stage,  which  is  generally  seen  in 
gonorrhoeal  and  septic  cases,  the  symptoms  are  practically  those  of 


Fig.  554,-  Pyosalpimx,  showing  the  Fallopian  Tube  bent  over  on 
Itself.     (King's  College  Hospital  Museum.) 

I,  Ovary  ;  2,  uterine  end  of  tube. 

pelvic  peritonitis.  The  patient  lies  in  bed  with  the  knees  drawn  up  ; 
the  temperature  is  raised,  and  there  may  be  one  or  more  rigors ;  the 
lower  part  of  the  abdomen  is  intensely  tender,  and  vaginal  examina- 
tion reveals  little  but  a  generalized  painful  rigidity  and  infiltration 
of  all  the  parts.  This  condition  may  persist  and  pelvic  suppuration 
result,  an  abscess- developing  either  within  the  peritoneal  cavity,  or  in 
and  around  the  broad  ligament,  and  bursting  either  externally  or  into 
one  of  the  viscera.  More  frequently  the  acute  phenomena  gradually 
subside,  and  the  patient  then  begins  to  manifest  the  signs  of  a  chronic 
salpingitis,  which  in  the  majority  of  cases  constitute  the  initial 
symptoms.  Pain  is  perhaps  the  chief  manifestation,  and  this  is 
sometimes  of  a  continuous  dragging  type,  referred  to  the  back  and 
increased  on  any  exertion,  or  it  may  only  be  noticed  to  any  extent 
at  the  periods.  Not  unfrequently  the  patient  is  laid  up  for  a  week  or 
ten  days  at  a  time  with  these  phenomena.  If  many  adhesions  are 
present,  micturition  and  defsecation  may  also  be  very  painful.  The 
patient  is  unable  to  take  much  exercise,  and  may  walk  in  a  peculiarly 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1317 

cautious  manner,  bending  forwards  so  as  to  relax  the  abdominal 
muscles,  and  possibly  guarding  the  lower  abdomen  with  her  hands. 
All  these  symptoms  are  increased  at  the  menstrual  periods,  which 
are  profuse  and  prolonged,  and  accompanied  by  some  rise  of  tem- 
perature. When  a  well-marked  collection  of  pus  is  present,  a  hectic 
type  of  temperature  may  persist,  and  the  patient  shows  signs  of 
toxaemia.  The  bursting  of  the  abscess  into  the  vagina  or  one  of  the 
viscera  may  cure  the  case,  if  a  sufficient  exit  to  the  pus  is  thereby 
provided.  Vaginal  examination  demonstrates  the  enlarged  and 
tender  tubes ;  the  uterus  itself  loses  some  or  all  of  its  mobility,  and 
the  vaginal  vault  may  feel  hard  and  rigid. 

Treatment  in  the  acute  cases  consists  of  rest  in  bed,  fomentations 
to  the  abdomen  and  hot  vaginal  douches,  together  with  opium,  if 
need  be,  for  the  pain.  In  the  great  majority  of  cases  the  only 
treatment  is  removal  of  the  tubes,  but  this  should  be  delayed,  if 
possible,  until  the  acute  symptoms  have  passed.  It  may  be 
a  simple  procedure,  or  an  operation  of  the  greatest  difficulty, 
according  to  the  number  and  nature  of  the  adhesions  present. 
It  must  be  remembered  that,  although  the  pus  in  an  old- 
standing  case  is  likely  to  be  sterile,  one  cannot  rely  on  this 
occurrence,  and  hence  every  precaution  must  be  taken  to  guard 
against  infection.  It  may  be  possible  in  some  cases  to  save  one 
or  both  ovaries,  and  this  is  certainly  desirable  in  order  to  protect 
the  patient  from  the  discomforts  of  an  acute  menopause.  In  a 
few  favourable  cases  the  pus  can  be  reached  through  the  vaginal 
vault,  and  an  intra-peritoneal  operation  is  thereby  avoided  ;  but  the 
indications  must  be  very  clear  and  precise  before  this  method  of 
approach  is  adopted. 

Hydrosalpinx  is  a  condition  in  which  the  Fallopian  tube  is  distended 
with  a  mucoid  secretion,  due  to  the  existence  of  a  chronic  inflamma- 
tion which  has  extended  from  the  uterus,  and  led  to  the  closure  of 
the  abdominal  and  vaginal  openings  of  the  tube.  A  collection  of  con- 
siderable size  may  result,  and  needs  to  be  dealt  with  by  laparotomy. 

Tubal  Gestation  is  a  condition  in  which  the  impregnated  ovum 
commences  to  develop  in  the  Fallopian  tube  instead  of  in  the  uterus. 
The  causes  of  this  condition  are  quite  unknown,  but  it  may  be  due 
to  a  kink  or  twist  of  the  tube,  whereby  the  onward  passage  of  the 
ovum  is  prevented.  Ectopic  gestation  also  occurs  within  the  peri- 
toneal cavity  or  in  connection  with  the  ovary,  but  these  conditions 
are  looked  on  as  always  secondary  to  a  primary  tubal  gestation,  the 
foetus  having  escaped,  from  the  tube.  Any  part  of  the  tube  may  be 
affected,  and  hence  three  forms  are  described,  viz.,  (i)  the  interstitial 
or  tubo-uterine,  where  the  growth  encroaches  on  the  uterine  wall ; 
(2)  the  true  tubal ;  and  (3)  the  tubo-ovarian  or  infundibular,  where 
the  outer  end  of  the  tube  is  affected. 

The  muscular  wall  of  the  tube  stretches  and  at  first  becomes 
hypertrophied ;  the  mucous  lining  is  turgid  and  congested,  and 
transformed  into  a  decidual  membrane.  In  time  the  muscle  fibres 
disappear  and  are  replaced  by  fibrous  tissue,  and  at  the  placental 


J3i8  A  MANUAL  OF  SURGERY 

site  atrophy  occurs,  so  that  sooner  or  later  rupture  of  the  tube 
follows,  and  then  the  ovum  either  escapes  into  the  abdomen  or  into  the 
substance  of  a  broad  ligament,  and  may  die  or  continue  its  develop- 
ment, the  placenta  in  the  latter  case  gaining  a  fresh  attachment  to 
intestines  or  other  structures.  Concurrently  with  these  changes  in 
the  tube,  the  uterus  enlarges  and  becomes  lined  by  a  decidual  mem- 
brane, but  is  relatively  much  smaller  than  usual ;  at  five  months  it 
is  a  third  smaller  than  in  an  intra-uterine  pregnancy,  and  at  full 
term  is  about  4  to  6  inches  long.  Not  unfrequently  the  rupture  of 
a  tubal  gestation  is  accompanied  by  the  discharge  of  a  complete 
cast  of  the  uterus,  from  which  a  lochial  secretion  escapes  for  a  time, 
and  which  undergoes  involution. 

The  clinical  history  of  an  ectopic  gestation  varies  very  much  in 
different  cases.  Occasionally  it  occurs  in  a  young  and  healthy 
primipara,  and  then  is  due  to  some  congenital  defect  of  the  tube  ; 
more  commonly  it  is  seen  in  women  who  have  already  borne  children 
or  have  had  some  preceding  trouble,  suggesting  the  existence  of 
pelvic  adhesions  or  of  old  salpingitis.  Not  unfrequently  there  is  a 
history  of  a  preceding  period  of  sterility,  and  then  a  period  is  missed, 
the  woman  not  suspecting  the  existence  of  pregnancy.  There  may 
be  some  amount  of  pelvic  pain  of  a  crampy  nature,  and  a  discharge 
of  a  blood-stained  character,  suggesting  the  onset  of  an  abortion.  In 
most  cases  the  general  signs  of  pregnancy  are  absent,  since  the 
patient  comes  under  observation  at  too  early  a  period  for  their 
development;  but  if  the  condition  persists,  they  may  be  noticed, 
though  somewhat  atypical; the  breasts  are  enlarged;  vomiting  may 
occur;  but  the  menses  are  not  always  completely  stopped.  Exami- 
nation in  the  early  stages  might  indicate  the  presence  of  a  well- 
defined  moveable  mass  on  one  side  of  the  uterus,  constituted  by  the 
enlarged  tube. 

In  the  early  months  the  great  danger  is  that  of  rupture  of  the  tube, 
and  possibly  death  from  haemorrhage.     Two  forms  are  described  : 

I.  Primary  Intraperitoneal  Eupture  usually  occurs  about  the  sixth  to 
the  eighth  week.  The  tube  gives  way  before  the  increasing  tension 
of  the  ovum,  and  looks  almost  as  if  torn  in  half.  Severe  haemorrhage 
follows,  and  the  patient  either  succumbs,  or  recovers  to  suffer, 
perhaps,  from  a  similar  condition  a  few  days  later.  Occasionally 
the  bleeding  is  less  severe,  the  attacks  recurring  and  being  associated 
with  faintness  ;  a  localized  pelvic  haematocele  is  likely  to  result. 
In  a  few  cases  the  ovum  regains  a  vascular  connection  in  the 
abdomen  and  continues  its  development,  but  generally  the  pregnancy 
comes  to  an  end  and  the  ovum  dies.  The  symptoms  are  alarming  in 
the  extreme.  The  patient  is  seized  with  severe  cutting  intra- 
abdominal pain  which  is  referred  to  the  pelvis,  and  becomes 
white,  faint,  and  collapsed.  The  lower  part  of  the  abdomen  is 
exquisitely  tender,  and  the  muscles  are  held  rigid  and  tense.  The 
actual  presence  of  blood  in  the  peritoneal  cavity  can  rarely  be 
demonstrated,  but  the  amount  lost  is  often  very  great.  If  the 
patient  survives,  she  is  left  in  a  feeble  condition,  and  often  suffers 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1319 

from  pyrexia  for  some  days,  whilst  the  pain  gradually  diminishes. 
A  recurrence  of  the  bleeding  may  bring  the  patient  into  the  direst 
peril ;  but  if  it  does  not  recur,  absorption  commences  and  may 
progress  uninterruptedly,  or  a  pelvic  haematocele  may  result,  and 
this  may  persist  indefinitely  or  undergo  suppurative  changes  and 
require  operation. 

2.  Primary  Extraperitoneal  Rupture  occurs  when  the  chief  develop- 
ment has  been  downwards  and  inwards  between  the  layers  of  the 
broad  hgament.  The  catastrophe  is  in  these  cases  somewhat  later 
than  in  the  former  class,  rupture  being  delayed  sometimes  till  the 
seventh  to  the  twelfth  week.  The  loss  of  blood  is  necessarily  not 
so  great,  and  the  general  symptoms  are  less  severe.  On  vaginal 
examination  the  blood  tumour  can  probably  be  detected  by  the  side  of 
the  uterus.  The  ovum  usually  dies,  and  the  blood  may  be  absorbed  ; 
but  not  uncommonly  sepsis  supervenes  and  an  abscess  forms ;  in 
other  cases  a  secondary  rupture  into  the  peritoneal  cavity  follows, 
being  associated  with  the  ordinary  symptoms  of  this  condition. 

Comparatively  few  ectopic  pregnancies  continue  after  the  fourth 
month,  but  should  the  ovum  escape  the  earlier  dangers  that  surround 
it,  its  development  may  continue  either  in  the  tube  (very  rare)  or  in  the 
abdominal  cavity.  The  usual  phenomena  of  pregnancy  are  present, 
but  with  modifications.  The  breasts  are  less  full  than  usual;  the 
movements  of  the  child  under  the  abdominal  wall  may  be  unnaturally 
obvious  to  the  naked  eye;  the  abdomen  is  asymmetrically  enlarged, 
and  the  long  axis  may  even  be  transverse ;  palpation  of  the  fcetus 
may  be  unduly  easy,  and  the  placental  souffle  exaggerated  or  mis- 
placed. At  full  term,  or  possibly  a  month  or  two  before  it,  a  form 
of  spurious  labour  occurs,  followed  usually  by  the  death  of  the  foetus. 
The  abdominal  swelling  diminishes  in  size,  and  the  uterus  undergoes 
involution  with  a  lochial  discharge.  The  foetus  becomes  encapsuled, 
and  may  be  either  mummified,  calcified  (then  constituting  a  litho- 
pedion),  or  transformed  into  adipocere;  or  suppuration  sometimes 
ensues,  and  the  disintegrated  foetus  may  find  its  way  out  through 
abscesses  which  burst  into  the  hollow  viscera  or  externally. 

Treatment  of  a  Ruptured  Tubal  Gestation. — In  these  cases  the 
danger  to  the  patient  is  that  of  haemorrhage,  and  it  is  obvious  that 
the  rules  guiding  us  elsewhere  apply  here — viz.,  that  the  bleeding 
point  should  be  exposed  and  the  torn  vessels  secured.  Owing  to  the 
fact  that  the  haemorrhage  is  concealed,  it  is  possible  for  the  patient 
to  pass  into  such  a  condition  of  collapse  as  to  render  operative  treat- 
ment almost  impracticable.  In  such  cases  it  may  be  feasible  to 
improve  her  condition  by  the  infusion  of  salt  solution,  so  as  to  justify 
operation.  In  other  cases  where  the  patient  has  had  one  attack  of 
haemorrhage  from  which  she  is  recovering,  the  question  of  operation 
is  quite  open  to  discussion  :  on  the  one  hand  are  the  facts  that  no 
further  trouble  need  arise,  and  that  the  haematocele  may  be  absorbed  ; 
on  the  other  hand  the  haemorrhage  may  recur,  or  the  haematocele  may 
suppurate.  It  is  probable  that  operation  in  all  cases  is  perfectly 
sound  advice,  especially  as  one  cannot  be  always  certain  that  the 


1320  A  MANUAL  OF  SURGERY 

ovum  is  dead  (although  the  passage  of  a  cast  of  the  uterus  Is  sug- 
gestive), and  its  continued  development  in  the  peritoneal  cavity  is 
most  undesirable.  In  careful  aseptic  hands  the  risks  of  operation 
are  very  small.  It  goes  almost  without  saying  that  if  a  diagnosis 
of  tubal  gestation  is  made  prior  to  rupture,  the  tube  should  be  at 
once' removed. 

Operation  for  intraperitoneal  rupture  must  not  be  delayed  :  possibly 
it  may  be  wise  to  commence  intravenous  infusion  before  opening  the 
abdomen,  and  to  allow  an  assistant  to  continue  the  process  during  its 
performance.  The  patient  is  placed  in  the  Trendelenburg  position  ;  a 
median  incision  is  made  above  the  pubes ;  an  abundant  escape  of 
blood  and  clots  is  likely  to  follow,  but  the  hand  is  thrust  firmly  down 
so  as  to  distinguish  the  uterus,  and  thence  passes  to  the  ruptured 
tube,  which  must  be  grasped  by  the  uterine  attachment  and  a 
haemostatic  clamp  at  once  applied;  the  other  end  is  then  sought 
for.  Both  portions  are  removed,  and  the  bases  securely  ligatured. 
The  intraperitoneal  clots  may  be  swabbed  away  or  left  according  to 
the  condition  of  the  patient,  and  the  abdomen  either  closed  entirely 
or  a  drainage-tube  inserted.  The  subsequent  treatment  is  that  for 
all  forms  of  haemorrhage. 

The  operation  for  an  extraperitoneal  rupture  is  slightly  different 
in  its  characters,  since  it  is  usually  not  undertaken  fcr  haemorrhage, 
but  in  order  to  remove  the  products  of  gestation,  to  relieve  the 
patient  from  pain,  or  to  prevent  a  long  and  tedious  convalescence 
whilst  the  hsematocele  is  absorbing.  The  possibility  that  sepsis  may 
have  already  reached  the  sac  must  not  be  lost  sight  of.  A  median 
laparotomy  is  performed  in  the  Trendelenburg  position,  and  the 
viscera  securely  walled  off  by  sterile  gauze.  Intestinal  adhesions 
may  be  present,  and  must  be  cautiously  loosened  so  as  to  expose  the 
sac  of  the  haematocele.  This  may  give  way  during  the  manipula- 
tions to  separate  the  intestine,  or  may  need  to  be  incised,  or  is  tapped 
with  a  trocar.  The  mass  is  then  isolated,  its  vessels  tied,  and  com- 
plete removal  follows ;  or  it  may  be  necessary  to  evacuate  the 
contents  and  drain  or  pack  the  cavity,  especially  when  the  blood  has 
burrowed  deeply  into  the  pelvis  between  the  layers  of  the  broad 
ligament. 

When  suppuration  has  occurred,  the  abscess  must  be  treated  on  the 
same  lines  as  are  followed  in  the  treatment  of  a  pelvic  peritonitis. 
It  may  be  possible  to  open  and  drain  from  the  vagina,  or  the  abscess 
may  have  to  be  dealt  with  from  above. 

For  the  treatment  of  ectopic  gestation  which  persists  after  the 
fourth  month,  we  must  refer  readers  to  larger  text-books. 

Primary  Cancer  of  the  Fallopian  Tube  commences  in  the  mucous 
membrane,  and  is  likely  to  run  a  rapid  course,  leading  to  early 
dissemination  of  the  disease  through  the  peritoneal  cavity  if  the 
abdominal  ostium  is  patent.  The  ovary  is  not  unfrequently  affected 
in  this  way,  and  careful  examination  may  be  required  to  demonstrate 
that  the  primary  lesion  is  in  the  tube. 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS 


1321 


Cysts  of  the  Ovary  and  Broad  Ligament. 

Many  different  forms  of  cyst  are  developed  in  this  region,  and  their 
origin  Irom  an  embryological  standpoint  has  been  already  alluded  to 
(p.  224).     The  following  classification  may,  however,  be  useful : 

I.  Cysts  directly  connected  with,  the  Ovary. 

1.  True  ovarian  cyst,  single,  multiple,  or  proliferating. 

2.  Paroophoritic  cyst  with  papillomatous  developments. 

3.  Corpus  luteum  cysts. 

4.  Ovarian  dermoid  or  teratoma. 

5.  Malignant  ovarian  cyst  (usually  carcinomatous). 

6.  Ovarian  hydrocele. 


Fig.  555. — Proliferating  Cysto-adenoma  of  the  Ovary.      (King's 

College  Hospital  Museum.) 

The  main  cyst  has  been  laid  open  to  show  the  smaller  cysts  which  project  into 

its  cavity. 

II.  Cysts  of  the  Broad  Ligament. 

1.  Parovarian  cysts. 

2.  Cysts  of  Kobelt's  tubes. 

3.  Cyst  of  Gartner's  duct 

4.  Fallopian  tube  cysts. 

5.  Lymphangiomatous  developments. 

True  Ovarian  Cysts,  or,  as  they  should  perhaps  be  better  termed, 
the  cysto-adenomata  of  the  ovary,  are  usually  multilocular  swellings, 
involving  one  or  both  ovaries  (more  commonly  the  former),  and 
arising  from  the  tubular  ingrowths  of  the  ovarian  epithelium  or  from 
the  Graafian  follicles.  As  the  swelling  increases,  the  walls  between 
the  loculi  thin  out  and  may  be  absorbed ;  but  the  usual  appearance 
is  that  shown  in  Fig.  555,  where  rounded  cyst-like  masses  are  seen 


1322  A  MANUAL  OF  SURGERY 

proiecting  within  the  larger  cyst,  which  has  been  laid  open.  The 
fluid  is  of  a  tenacious  character,  somewhat  similar  m  type  to  mucm, 
and  usually  of  a  yellowish-white  colour  ;  if  haemorrhage  has  taken 
place  into  the  cyst,  the  colour  is  of  course  modified. 

The  size  of  these  cysto-adenomata  varies  enormously  ;  they  may 
be  small  as  an  orange,  or  large  enough  to  compress  the  abdommal 
contents  and  interfere  seriously  with  respiration.  The  largest  cyst 
of  this  type  we  have  dealt  with  contained  32  pints  of  fluid  ;  the 
patient  was  65  inches  in  circumference,  and  her  legs  were  dripping 
with  dropsy  ;  she  had  been  unable  to  He  down  m  bed  for  many 
months.  The  walls  of  the  growth  vary  in  thickness  and  substance  ; 
sometimes  th"r3  is  a  considerable  mass  of  newly-formed  epithelial 


Fig.  556. — Cyst   of    Ovary  (Paroophoritic)  with    Proliferating    Papillo- 

MATOUS    InTRA-CYSTIC    GROWTHS.        (KiNG'S    COLLEGE    HOSPITAL    MuSEUM.) 

tissue,  which  in  time  would  undergo  degeneration  and  form  fresh 
cysts.  The  cyst  is  covered  externally  with  peritoneum,  and  possibly 
adhesions  to  omentum  or  intestine  may  be  present.  The  broad 
ligament  and  Fallopian  tube  become  stretched  by  the  traction  and 
weight  of  the  mass  and  constitute  a  well-marked  pedicle,  which  con- 
tains the  nutrient  vessels. 

Parobplioritic  Cysts  are  very  similar  in  character  to  the  above,  but 
contain  intracystic  papillomatous  developments  (Fig.  556),  which 
not  unfrequently  burrow  through  the  cyst  wall,  and  may  invade  the 
peritoneal  cavity,  and  hence  are  semi-malignant.  The  primary 
grov;th  may  be  uni-  or  multi-locular,  and  in  some  cases  large  thin- 
walled  cysts  develop  containing  large  cauHflower-like  excrescences, 
which  are  covered  with  columnar  epithelium. 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1323 

Corpus  Luteum  Cysts  are  usually  multiple  and  not  of  great  size, 
though  occasionally  they  may  be  found  as  large  as  a  fist.  The  fluid 
contained  within  is  more  or  less  thick,  and  dark  in  colour  from  blood 
extravasation,  and  the  lining  wall  shows  a  definite  overgrowth  of 
lutein  cells.  The  association  of  this  type  of  overgrowth  with 
deciduoma  malignum  has  been  already  mentioned. 

For  Ovarian  Dermoids  or  Teratomata,  see  p.  221.  An  ovarian 
dermoid  is  usually  unilocular ;  it  may  manifest  its  presence  at  an 
early  age,  or  not  until  middle  life  ;  it  grows  slowly,  and  is  very  liable 
to  attacks  of  partial  torsion,  which  may  finally  become  complete. 

Ovarian  Hydrocele  is  a  condition  rarely  observed,  in  which  the 
ovary  lies  in  a  pouch  in  the  broad  ligament,  the  mouth  of  which 
becomes  closed  through  the  development  of  adhesions,  so  that  a 


.^■- 


'^\  W' 

Fig.  557. — Cysts  of  Kobelt  s  Tubes.     (King's  College  Hospital  Museum.) 

I.  Fallopian  tube  ;  2,  fimbriated  extremity  of  Fallopian  tube  ;  3,  ovary  ; 
4,  Kobelt's  cysts. 

collection  of  fluid  can  occur  outside  the  ovary.  It  is  not  likely  to 
attain  great  dimensions. 

Parovarian  Cysts  result  from  distension  with  fluid  of  the  parovarium 
or  organ  of  Rosenmiiller,  which  in  reality  is  the  atrophied  remnant 
of  the  Wolffian  body,  traces  of  which  can  often  be  seen  in  the  broad 
ligament.  As  the  cyst  gradually  increases  in  size,  the  layers  of  the 
broad  ligament  are  separated,  and  the  ovary  and  tube  are  pushed  up 
and  stretched  over  the  growth,  which  usually  burrows  deeply  into 
the  pelvis  by  the  side  of  the  uterus.  The  cyst  is  generally  unilocular, 
thin-walled,  and  contains  a  clear  limpid  fluid.  Its  method  of  develop- 
ment explains  the  fact  that  it  has  no  pedicle. 

Cysts  of  Kobelt's  Tubes  (Fig.  557)  are  frequently  seen,  and  are  of 
little  significance.  It  is  quite  unusual  for  them  to  become  large 
enough  to  cause  symptoms. 

Clinical  History. — It  is  unnecessary  to  discuss  here  in  extenso  the 
symptoms  which  arise  in  the  earlier  stages  when  the  cyst  is  small 
and  intrapelvic.  Suffice  it  that  some  disturbance  of  menstruadon 
may  occur,  usually  in  the  direction  of  monorrhagia,  and  that  there 
may  be  a  sense  of  intrapelvic  pressure  or  pain,  and  possibly  some 
interference  with  the  bladder  or  rectum  ;  the  latter  may  be  more 
marked  in  the  broad  ligament  cysts  than  in  the  true  ovarian. 

The  patient  is  most  likely  to  come  under  observation  when  the 


1324 


A  MANUAL  OF  SURGERY 


growth  has  emerged  from  the  pelvis  and  become  abdominal,  and 
possibly  she  may  have  noticed  that  the  swelling  appeared  first  on  one 
side.  As  it  increases  in  size,  it  becomes  more  mesial,  and  pushes  up 
under  the  anterior  abdominal  wall,  usually  displacing  the  intestines 
backwards  and  towards  the  sides  of  the  abdomen.  Hence  on  inspec- 
tion the  projection  of  the  growth  can  often  be  seen,  and  there  is  no 
bulging  of  the  flanks  such  as  occur  in  ascites.  Percussion  elicits  a 
dull  note  over  the  swelling,  though  the  margins  may  be  overlapped 
by  intestine  and  give  a  semi-resonant  note  ;  the  flanks  are  resonant, 
whereas  in  ascites  the  anterior  abdominal  wall  is  resonant,  and  the 
flanks  and  sides  dull.  Very  little  or  no  modification  in  the  percussion 
note  occurs  on  changing  the  position  from  the  dorsal  to  the  lateral 
decubitus,  whereas  in  ascites  this  produces  a  marked  alteration.  On 
palpation  the  outline  of  the  cyst  may  be  easily  tangible,  and  it  may 
be  felt  passing  down  into  the  pelvis.  A  tap  sometimes  produces  a 
fluid  thrill,  which  is  most  marked  in  the  unilocular  parovarian  cysts, 
and  often  absent  in  the  multilocular  variety,  unless  the  front  of  the 
mass  is  constituted  by  a  single  large  loculus.  It  may  be  possible  to 
demonstrate  that  the  mass  is  mobile,  especially  on  bimanual  examina- 
tion. The  growth  is  usually  found  to  drag  the  uterus  upwards,  and 
does  not  project  down  into  the  fornices  ;  hence  the  vagina  often 
appears  to  be  very  long,  and  the  cervix  is  sometimes  difficult  to  reach. 
The  uterus  may  be  displaced  laterally. 

Pressure  symptoms  of  various  types  arise,  such  as  impaired  diges- 
tion and  constipation,  leading  to  interference  with  nutrition,  emacia- 
tion and  debility  ;  oedema  of  the  legs  is  caused  by  pressure  on  the 
vena  cava  ;  the  subcutaneous  veins  of  the  abdominal  wall  become  pro- 
minent ;  and  respiration  may  be  considerably  embarrassed.  Should 
even  a  small  ovarian  cyst  become  impacted  in  the  pelvis,  all  the 
evidences  of  pressure  may  be  at  once  exaggerated,  and  both  rectum 
and  bladder  are  irritable. 

Complications  of  various  types  ensue,  and  may  quickly  jeopardize 
the  patient's  life.  (i).  Inflammation  arises  from  a  variety  of  causes 
— e.g.,  traumatism  or  partial  torsion  ;  or  germs  may  gain  access 
from  some  neighbouring  viscus — e.g.,  the  appendix  or  Fallopian  tube. 
The  trouble  may  be  of  a  slight  and  localized  character,  and  then 
merely  a  few  adhesions  are  developed  ;  or  it  may  be  a  deep  paren- 
chymatous affection,  followed  by  suppuration.  The  usual  phenomena 
of  intra-abdominal  inflammation  are  manifested  :  the  patient  com- 
plains of  pain,  and  lies  with  the  legs  drawn  up ;  the  temperature  is 
raised  ;  vomiting  and  possibly  constipation  are  present ;  and  on  pal- 
pation the  growth  is  tender,  increased  in  size,  and  possibly  less  easily 
defined.  If  pus  forms,  it  may  escape  into  the  peritoneal  cavity  or 
one  of  the  hollow  viscera.  Even  if  recovery  follows,  extensive  adhe- 
sions may  ensue  and  lead  to  serious  consequences. 

(ii.)  Torsion  of  the  cyst  is  predisposed  to  by  the  existence  of  a 
well-marked  elongated  pedicle  and  is  most  often  seen  in  connection 
with  dermoids ;  it  is  impossible  in  the  presence  of  extensive 
adhesions.     It   is   probably    determined   by   irregular   contractions 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1325 

of  the  abdominal  muscles,  and  the  final  disturbance  may  be  caused 
by  definite  traumatism.  From  the  fact  that  in  acute  cases  the 
pedicle  is  found  twisted  on  itself  two  or  three  times,  it  is  obvious 
that  slight  attacks  must  have  preceded  the  final  outbreak  of 
symptoms,  and  many  of  the  slighter  attacks  of  inflammation  (usually 
supposed  to  be  peritonitic  in  type)  are  probably  of  this  nature. 
Finally,  the  torsion  becomes  so  severe  that  the  circulation  in  the 
cyst  ceases,  and  strangulation  ensues.  An  aseptic  peritonitis  follows, 
and  unless  relief  is  given  in  time  death  from  generalized  peritonitis 
and  intestinal  paralysis  follows.  The  cyst  becomes  enlarged  and 
engorged  with  blood ;  haemorrhage  may  occur  into  its  substance, 
and  gangrene  is  likely  to  follow.  The  symptoms  may  come  on 
suddenly  after  some  effort,  or  there  may  be  no  obvious  cause.  Pain 
of  a  severe  character  is  complained  of,  followed  by  shock  ;  the 
tumour  is  obviously  increased  in  size,  tense  and  tender  ;  vomiting 
and  constipation  suggest  the  existence  of  an  acute  intestinal  obstruc- 
tion, and  if  the  case  is  not  seen  till  late  and  there  is  no  definite  history 
of  a  cyst  to  be  obtained,  a  diagnosis  may  be  difficult  or  impossible 
apart  from  an  exploratory  operation. 

(iii.)  Rupture  of  the  cyst  may  be  spontaneous  from  gradual 
thinning  of  the  walls,  or  due  to  traumatism.  The  results  vary 
with  the  contents.  A  sudden  rupture  leads  to  severe  pain  and 
shock :  this  may  be  followed  by  inflammatory  phenomena  and  peri- 
tonitis if  the  contents  are  of  a  sticky  colloidal  character,  but,  when 
limpid  and  serous,  the  fluid  may  be  absorbed,  and  no  harm  follows. 
The  cyst  itself  collapses,  and  is  likely  to  develop  adhesions,  but  the 
secreting  substance  persists,  and  the  cavity  may  fill  up  again. 

It  is  impossible  to  discuss  fully  here  the  Diagnosis  of  ovarian 
cystomata,  and  it  must  suffice  to  point  out  that  the  passage  of  a 
catheter  eliminates  the  question  of  a  distended  bladder ;  that  careful 
attention  to  the  percussion  phenomena,  both  in  the  dorsal  and 
lateral  decubitis,  should  suffice  to  determine  the  existence  or  not 
of  ascites ;  and  that  vaginal  examination  and  the  passage  of  a  uterine 
sound  should  eliminate  uterine  conditions  that  might  be  mistaken. 
Before  the  introduction  of  a  sound  it  is  of  course  essential  to  exclude 
the  possibility  of  pregnancy.  The  absence  of  changes  in  the  cervix 
uteri  and  in  the  breasts,  the  non-existence  of  a  uterine  souffle  on 
auscultation,  or  of  a  history  of  amenorrhoea,  morning  sickness,  etc., 
should  suffice  to  determine  the  absence  of  this  latter  condition. 

Treatment  for  nearly  all  varieties  of  ovarian  cyst  is  the  operation 
of  Ovariotomy,  first  performed  in  i8og  by  Dr.  Ephraim  McDowell  in 
Danville,  Kentucky,  and  that  with  success.  The  essential  idea  of 
the  operation  is  the  removal  of  the  cyst,  and  this  may  be  accomplished 
either  with  or  without  tapping.  The  size  of  the  growth  will  to  some 
extent  determine  whether  or  not  it  should  be  tapped,  but  there  are 
some  conditions  where  it  is  unnecessary  (e.g.,  in  small  cysts),  and 
others  where  it  is  undesirable  (e.g.,  dermoid  cysts,  and  the  pro- 
liferating papillomatous  forms) ;  in  these  latter  there  may  be  active 
cells  in  the  fluid  contents,  and  the  escape  of  these  into  the  peritoneal 


1326 


A  MANUAL  OF  SURGERY 


cavity  (and  it  is  not  always  possible  to  prevent  such  escape)  may 
result  in  infection  of  the  peritoneum  with  these  cells,  and  a  new 
development  of  some  form  of  epithelial  growth  may  ensue. 

Operation. — The  patient  is  prepared  in  the  usual  way,  the 
abdominal  wail  being  purified  and  the  vulva  shaved  ;  but  unless 
there  is  some  objectionable  discharge,  there  is  no  need  to  douche  or 
pack  the  vagina.  The  Trendelenburg  position  may  be  advisably 
adopted,  as  it  enables  the  surgeon  to  get  at  the  pedicle  of  the  cyst 
more  easily.  An  incision  is  made  in  the  middle  line  above  the  pubes, 
and  the  anterior  wall  of  the  cyst  is  exposed.  The  finger  or  hand  is 
swept  round  in  order  to  ascertain  whether  or  not  there  are  any 
adhesions ;  if  present,  it  may  be  possible  to  deal  with  them  at  this 
stage,  but  more  usually  it  is  easier  to  detach  them  later  on.  A 
Spencer  Wells  trocar  is  then  thrust  into  the  cyst,  and  as  the  fluid 
escapes,  the  relaxed  wall  is  grasped  by  forceps  and  drawn  up  out  of 
the  incision  so  as  to  prevent  the  fluid  getting  into  the  peritoneal 
cavity.  This  end  is  not  always  attained,  as  the  cyst  wall  is  some- 
times so  soft  and  friable  that  it  splits  and  bursts,  and  any  attempt 
to  grasp  it  with  forceps  leads  to  an  increased  rent  in  its  substance. 
Under  these  circumstances  the  patient  can  either  be  rolled  over  on 
her  side,  and  the  contents  scooped  out  by  the  hand,  or,  possibly  better, 
the  incision  is  rapidly  increased  in  length  to  a  sufficient  extent  to 
allow  the  whole  cyst  to  be  lifted  up  out  of  the  abdomen.  Large 
secondary  cysts  may  be  opened  by  the  trocar  through  the  first  main 
cyst,  but  in  doing  this  care  must  be  taken  not  to  thrust  the  instru- 
ment through  the  posterior  or  lateral  wall  of  the  growth.  The 
pedicle  is  now  securely  tied  off,  and  any  form  of  ligature  which 
involves  its  transfixion  will  suffice.  It  is  perhaps  wise  to  divide  the 
pedicle  at  such  a  distance  from  the  hgature  that  the  main  ovarian 
vessels  can  be  recognised  on  the  stump,  and  an  ordinary  silk  or  cat- 
gut ligature  can  be  separately  applied  to  each  of  these ;  this  plan 
will  obviate  any  danger  that  might  arise  from  the  relaxation  or 
slipping  of  the  main  ligature.  The  other  ovary  is  then  examined  and 
dealt  with  according  to  circumstances.  The  peritoneal  cavity  is 
cleansed,  and  possibly  when  much  of  the  cyst  fluid  has  escaped  it 
may  be  desirable  to  wash  it  out  with  salt  solution,  and  the  abdominal 
incision  is  then  closed. 

Broad  ligament  cysts  (parovarian)  often  have  no  pedicle,  and  then 
must  be  enucleated  after  tapping.  The  layers  of  the  broad  ligament 
are  divided  in  a  suitable  manner  back  and  front ;  the  supplying 
vessels  are  secured  by  ligature  ;  and  the  cyst  wall  can  usually  be 
freed  from  its  surroundings  without  difficulty.  The  opening  in  the 
broad  ligament  is  subsequently  stitched  up,  and  probably  no  drainage 
will  be  required. 

An  ovarian  cyst  with  a  twisted  pedicle  is  treated  in  the  usual  way 
after  untwisting.  An  inflamed  or  suppurating  cystoma  must  be 
dealt  with  according  to  circumstances ;  it  may  be  possible  to  remove 
it  611  masse,  but  incision  and  drainage  without  removal  may  have  to 
be  resorted  to. 


SURGERY  OF  THE  FEMALE  GENITAL  ORGANS  1327 

An  uncomplicated  ovariotomy  is  one  of  the  most  successful  major 
operations  in  surgery,  and  the  death-rate  is  now  phenomenally  small. 
The  presence  of  adhesions  and  other  complications  of  course  adds  to 
the  gravity,  and  increases  the  death-rate. 

Solid  Tumours  of  the  Ovary  are  not  very  common,  and  consist 
of  carcinoma,  sarcoma,  or  myo-fibroma.  Cavcinomata  are  solid  or 
cystic ;  they  grow  rapidly,  and  early  involve  surrounding  parts, 
producing  a  generalized  carcinomatous  infection  of  the  peritoneal 
cavity  with  ascites.  Bland-Sutton*  has  pointed  out  that  in  the 
majority  of  cases  cancer  of  the  ovary  is  secondary  rather  than 
primary,  and  that  the  causative  lesion  may  be  found  in  the  intestine, 
Fallopian  tube,  or  breast.  Sarcomata  are  usually  more  orless  firm, 
and  of  the  spindle-celled  type,  thereby  closely  simulating  the  myo- 
fihyomata ;  in  the  former,  however,  the  growth  is  more  rapid,  and 
ascites  is  more  likely  to  be  present.  In  all  these  cases  extirpation 
should  be  practised,  if  possible. 

Salpingo-oophorectomy,  or  removal  of  the  ovary  and  its  tube,  is 
required  in  many  conditions — e.g.,  small  solidj  or  cystic  tumours, 
hydro-  or  pyo-salpinx,  and  sometimes  for  dealing  indirectly  with 
inoperable  carcinoma  mammae.  The  operation  may  be  simple  in  the 
extreme,  or  one  of  the  greatest  difficulty  if  many  adhesions  are 
present.  The  Trendelenburg  position  is  adopted ;  the  usual  mesial 
incision  is  made  •  the  ovary  is  secured,  and  silk  ligatures  are  carried 
through  the  broad  ligament  and  tied  above  and  below  to  secure  the 
ovarian  vessels.  After  removal  of  the  tube  and  ovary,  it  is  advisable 
to  secure  separately  the  chief  vessels  on  the  face  of  the  stump. 
Adhesions  are  dealt  with  as  may  be  required. 

*  British  Medical  Journal,  January  4,  igo8. 


CHAPTER  XLIII. 
AMPUTATIONS.. 

By  the  term  Amputation  is  meant  the  removal  of  some  portion  of  the  body 
which  is  injured  or  diseased  to  such  a  degree  as  to  endanger  the  patient's  life, 
or  to  preclude  any  hopes  of  its  restoration  to  a  normal,  or  even  useful,  condition. 
In  this  chapter  we  shall  merely  deal  with  the  operation  as  applied  to  the 
extremities,  amputations  of  organs  such  as  the  breast  and  penis  having  been 
described  elsewhere.  Necessary  limitations  of  space  force  us  to  treat  the  subject 
somewhat  briefly. 

Methods  of  Amputation. — Since  the  introduction  of  anesthesia,  the  methods 
employed  for  the  purpose  of  removing  limbs  have  been  almost  revolutionized  ; 
there  is  now  no  necessity  to  hurry  through  the  operation,  and  hence  many  new 
proceedings,  and  these   sometiincs  of  a  most  complicated   nature,  have   been 


Fi6.  558. — Circular  Amputation  for  the  Arm, 
SHOWING  Flap  of  Skin  turned  back,  and 
Knife  applied  for  Division  of  the  Muscles. 


Fig.  559.  —  Section  of 
Parts  after  Circular 
Amputation. 

A,  Skin  and  subcutaneous 
fat ;  B,  muscles ;  C,  bone. 


devised.    They  are  in  the  main  merely  modifications  of  three  cardinal  operatior^s 
the  circular,  the  racquet-shaped,  and  the  flap. 

The  Circular  Amputation  (Fig.  558),  although  formerly  much  employed,  is  now 
but  little  used  ;  in  it  the  skin  and  subcutaneous  tissues  are  divided  around  the 
whole  circumference  of  the  limb  by  a  circular  sweep  of  the  knife.  These  are 
then  retracted  or  dissected  back  like  a  cuff,  and  the  superficial  muscles  divided 
in  a  similar  manner.  The  soft  parts  are  again  further  retracted,  and  the  deeper 
muscles  divided,  allowing  the  bone  to  be  cleared  and  sawn  through  at  a  sbll 
higher  level.  The  end  of  the  bone  is  thus  placed  at  the  apex  of  a  conical  hollow 
(Fig.  559),  and  can  be  completely  covered  over;  the  vessels,  moreover,  are 
divided  transversely.     The  stump  is  not  very  shapely,  and  after  a  time,  owing  to 

1328 


AMPUTATIONS 


1329 


the  shrinking  of  the  soft  parts,  the  cicatrix  is  likely  to  become  attached  to  the 
bone.  The  arm  is  almost  the  only  situation  in  which  a  pure  circular  operation  is 
ever  undertaken  at  the  present  day ;  but  a  modified  form,  is  still  occasionally 
utilized  elsewhere.  Thus,  one  or  two  vertical  incisions  may  be  associated  with 
the  circular  cut,  in  order  to  facilitate  the  removal  of  the  bone  at  a  higher  level,  as 
in  disarticulation  of  the  hip-joint  by  Furneaux  Jordan's  method  (p.  1344)- 

The  Racquet-shaped  Method  (Fig.  564.  A  and  C)  is  very  similar  to  the  last- 
described  modification  of  the  circular.  In  it  an  oval  incision  is  made  around  the 
limb  with  one  end  pointed,  and  if  necessary  prolonged  upwards  to  form.as  it 
were,  the  handle  of  the  racquet.  This  method  is  useful  for  removing  fingers  and 
toes,  and  is  also  employed  at  the  hip  and  shoulder  joints. 

A  somewhat  similar  operation  is  known  as  the  Elliptical  or  Oval  Method.    In 


Fig.  560.— Amputation  of  the  Thigh  by      Fig.   561.— Lateral  View  of  the 
Lister's  Flap  AND  Circular  Method.  Same     Operation     with      the 

Skin  Flaps  Dissected  Back. 
A   indicates    the   anterior    flap  ;    B,   the 
posterior,  which  is  half  the  length  of  C  again  indicates  the  line  of 

the   anterior  ;    C,  the  line  of   division  ^    division  of  the  muscles, 

of  the  muscles,  which  is  performed  by 
circular  sweeps  of  the  knife. 

it  an  oval  incision  is  made  around  the  limb  ;  the  lower  or  distal  portion  is  then 
dissected  up  so  as  to  enable  the  amputation  or  disarticulation  to  be  completed  at 
a  level  a  little  below  the  proximal  end.  The  free  convex  border  of  the  flap  is  then 
turned  over,  and  fitted  into  the  concavity  of  the  wound. 

The  Flap  Method  is  that  chiefly  made  use  of  at  the  present  day  in  amputating 
through  the  shafts  of  the  long  bones.  It  was  formerly  performed  by  transfixion 
in  order  to  save  time  ;  but  the  bulk  of  muscles  included  in  the  flaps,  and  the  fact 
that  the  vessels  and  nerves  are  often  sliced  longitudinally,  render  this  an 
undesirable  proceeding.  Hence  it  has  been  discarded,  and  the  flaps  are  now 
usually  marked  out  superficially,  and  then  raised  by  dissection.    As  a  rule,  they 

84 


I330 


A  MANUAL  OF  SURGERY 


consist  merely  of  skin,  subcutaneous  tissue  and  deep  fascia,  a  little  muscle  being 
perhaps  included  towards  the  base. 

The  best  method  of  amputating  in  muscular  parts,  such  as  the  thigh,  is  that 
known  as  the  Modified  Flap  and  Circular  (Figs.  560  and  561),  which  was  originally 
suggested  by  Lord  Lister.  In  this  two  rectangular  flaps  with  the  corners 
rounded  off  are  raised  on  opposite  sides  of  the  limb,  the  length  of  the  anterior 
being  two-thirds  of  the  diameter  of  the  limb  at  the  point  at  which  it  is  proposed 
to  divide  the  bone  and  the  posterior  flap  half  the  length  of  the  anterior.  These, 
consisting  merely  of  skin  and  subcutaneous  tissues,  are  dissected  up  ;  the  muscles 
are  then  divided  circularly,  being  retracted  for  another  half-diameter.  The 
advantages  of  the  flap  and  circular  methods  are  thus  combined.  In  cutting  the 
flaps  it  is  most  essential  that  they  should  not  taper,  but  should  remain  the  same 
breadth  throughout,  the  corners  being  merely  rounded  off. 

General  Remarks  on  Amputations. 

Certain  important  details  must  always  be  attended  to  by  the  operator  when 
selecting  an  amputation  suitable  for  any  particular  case. 

I.  A  Sufla.cient  Covering  is  necessary  in  order  to  protect  the  end  of  the  bone 

from  injurious  pressure. 
If  the  skin  were  not  con- 
tractile, and  if  the  muscles 
did  not  retract,  it  would 
suffice  to  provide  two 
flaps,  each  equal  to  half 
the  diameter  of  the  limb 
at  the  point  of  section  of 
the  bone  ;  but  owing  to 
the  contractility  and  re- 
traction of  living  tissues, 
it  is  essential  to  allow  at 
least  a  diameter  and  a 
half,  and  sometimes  two 
diameters  ;  in  non-mus- 
cular parts  the  former 
may  suffice,  but  in  fleshy 
parts,  especially  when 
amputating  low  down  in 
the  thigh,  where  the 
range  of  muscular  con- 
traction is  much  greater, 
the  latter.  It  is  usually 
a  matter  of  some  signi- 
ficance whence  the  flaps 
are  derived  ;  thus,  a 
single  flap,  e.g.,  a  long 
anterior  or  posterior,  is 
not  to  be  recommended 
owing  to  the  difficulty  of 
maintaining  its  nutrition. 
Equal  flaps  are  used  in 

Fig.  562.-Teale's  Amputation.     (Treves'  fu'^^^'^^^^u^T'  '""^^'u 

'  Operative  Surgery.  ')  ^^^,  ^"^^  °^  *^  ^.^T^  ^^^ 

'  not  be  exposed  to  pres- 

The  smaller  block  indicates  how  the  flaps  are  brought   sure.      Generally,    how- 
together,  ever,  the  anterior  flap  is 

cut  longer  than  the  pos- 
terior, as  in  the  case  of  the  modified  flap  and  circular,  or  sometimes  vice  versa  ; 
in  the  former,  owing  to  the  additional  retraction  of  the  rnuscles,  a  covering  equal 
to  two  diameters  of  the  limb  is  provided.  Teale's  amputation  (Fig.  562)  consists 
in  raising  a  long  square  anterior  flap,  equal  in  breadth  and  length  to  half  the 


AMPUTATIONS  1331 

circumference  of  the  limb  at  the  point  of  section  of  the  bone,  and  including 
everything  down  to  the  bone.  The  posterior  flap  is  similar  in  nature  to  the 
anterior,  but  only  a  quarter  of  its  length.  The  free  end  of  the  anterior  flap 
is  doubled  over,  and  accurately  stitched  to  the  posterior.  The  advantages 
claimed  for  this  operation  are  that  the  vessels  are  cut  long,  and  thus  the  nutrition 
of  the  flaps  is  secured,  whilst  a  covering  nearly  equal  to  two  diameters  of  the 
limb  is  provided.  The  great  objection  to  the  method  consists  in  the  amount  of 
the  limb  which  has  to  be  sacrificed  on  account  of  the  length  of  the  anterior  flap, 
and  hence  it  is  rarely  employed.  Occasionally  the  covering  is  derived  from  the 
sides  of  the  limb  (amputation  by  lateral  flaps). 

2.  The  Cicatrix  should  be  situated  away  from  the  end  of  the  bone,  especially 
in  the  lower  extremity,  where  the  weight  of  the  body  has  to  rest  upon  the 
stump. 

3.  A  Dependent  Opening  is  desirable  for  purposes  of  drainage,  and  to  ensure 
this  the  anterior  flap  is  often  made  longer  than  the  posterior.  This,  however,  is 
not  such  an  important  matter  since  the  introduction  of  antiseptic  methods. 

4.  All  these  objects  should  be  attained  with  as  little  sacrifice  of  the  limb  as 
possible,  since  the  higher  the  operation,  the  greater  the  shock  to  the  patient. 

As  to  the  operation  itself,  the  greatest  care  must  be  taken  to  maintain  Asepsis, 
since  muscular  and  fascial  planes  have  been  freely  opened,  and  possibly  the 
medullary  cavity  of  the  bone  exposed  ;  the  dangers  of  infection  under  such 
circuinstances  are  obvious.  Hsemorrliage  is  prevented  by  previous  exsanguina- 
tion  of  the  limb  by  elevating  it  for  two  or  three  minutes,  and  then  applying 
an  elastic  tourniquet.  In  the  leg  a  piece  of  rubber  tubing  may  be  employed, 
Samway's  tourniquet  being  perhaps  the  best.  In  the  arm,  however,  paralytic 
symptoms,  usually  involving  the  musculo-spiral  nerve,  have  followed  the  use  of 
such  appliances,  especially  vi^hen  made  of  solid  rubber  ;  a  flat  elastic  bandage 
carried  several  times  around  the  limb,  and  secured  by  a  knot  or  with  a  safety-pin, 
is  all  that  is  needed.  Should  the  tourniquet  have  to  be  applied  close  to  the  area 
of  operation,  it  must,  of  course,  be  first  sterilized  ;  it  is  also  advisable  to  protect 
the  skin  over  which  it  is  placed  by  a  few  layers  of  gauze.  After  the  limb  has  been 
removed,  the  main  vessels  are  at  once  ligatured,  both  artery  and  vein  being 
separately  tied.  It  is  well  to  isolate  and  draw  them  down  for  a  little  distance, 
so  as  to  make  sure  that  they  have  not  been  buttonholed.  Any  other  vessels 
which  can  be  seen  are  tied  before  the  tourniquet  is  removed.  An  assistant  should 
for  a  time  be  ready  to  control  the  main  trunk  after  releasing  it  from  the  tourni- 
quet. In  some  cases  it  may  be  impracticable  or  undesirable  to  apply  a  tourniquet, 
and  then  the  main  vessels  may  be  temporarily  controlled  by  digital  compression 
at  some  suitable  spot  whilst  the  amputation  is  completed.  Any  bleeding-points 
are  rapidly  secured  by  pressure  forceps  and  subsequently  tied,  and  the  main 
trunks  isolated,  and  clamped  or  ligatured  before  division. 

For  special  methods  of  controlling  the  hsemorrhage  in  amputation  through  the 
hip-joint,  see  p.  1344. 

Attention  has  already  been  drawn  to  the  necessity  of  not  tapering  the  flaps, 
but  of  cutting  them  square,  the  corners  alone  being  rounded.  In  dissecting 
them  up,  the  deep  fascia  should  be  included  with  the  flap,  and  the  blade  of  the 
knife  always  turned  towards  the  part  which  is  to  be  removed,  so  that  the  under 
surface  of  the  flap,  and  with  it  the  nutrient  vessels,  shall  not  be  scored.  Whilst 
dividing  the  muscles,  the  flaps  must  be  carefully  guarded  by  the  hands  of  assistants. 
Before  sawing  the  bone,  it  is  recommended  that  the  periosteum  should  be  retracted 
for  some  distance,  so  as  more  efficiently  to  provide  for  its  nutrition  ;  this  plan 
should  certainly  be  adopted  for  the  humerus  and  femur.  Any  irregular  bony 
spicules  left  after  sawing  should  be  trimmed  off  with  cutting  pliers.  Attention 
must  next  be  directed  to  the  main  nerves  and  to  any  tendons  which  lie  exposed 
in  the  wound,  all  such  structures  being  cut  short,  the  nerves  as  high  as  possible. 
It  is  always  well  to  cover  in  the  end  of  the  bone  by  stitching  the  muscles  together 
over  it,  and  the  little  extra  time  expended  in  the  introduction  of  these  buried 
stitches  will  be  well  repaid  in  the  increased  shapeliness  of  the  stump.  The 
incision  in  the  skin  is  usually  closed  by  a  continuous  suture,  and  provision  made 
for  drainage  from  one  of  the  angles  of  the  incision.  The  dressing  is  applied  in 
such  a  way  as  to  draw  the  flaps  down  over  the  end  of  the  bone,  and  a  splint  is 


1332  A  MANUAL  OF  SURGERY 

generally  necessary  in  order  to  control  the  upper  ends  of  the  divided  muscles 
and  to  keep  them  from  spasmodic  contractions. 

The  chief  Complications  likely  to  arise  in  the  subsequent  course  of  the  case 
are  shock,  reactionary  haemorrhage,  and  those  which  result  from  sepsis  ;  these 
conditions  and  their  treatment  have  been  described  elsewhere. 

In  a  Healthy  Stump  the  end  of  the  bone  is  rounded,  and  the  medullary  cavity 
closed  by  a  layer  of  compact  tissue.  The  divided  muscles  and  tendons  are  either 
incorporated  in  the  cicatrix,  or  gain  fresh  adhesions  to  the  bones.  The  vessels 
are  obliterated  as  far  as  the  next  patent  branches,  whilst  the  nerve-ends  usually 
become  bulbous  (Fig.  121,  P- 375),  but,  if  suitably  shortened,  do  not  adhere  either 
to  the  end  of  the  bone  or  to  the  cicatrix,  and  hence  give  rise  to  no  trouble.  A 
sufficient  covering  of  non-adherent  skin  and  subcutaneous  tissue  should  form  a 
pad  for  the  protection  of  the  bones. 

Aifections  of  Stumps. — (a)  Necrosis  of  the  end  of  the  bone  is  sometimes  the 
result  of  carelessness  on  the  part  of  assistants,  who  can  readily  denude  it  of  its 
periosteum  by  rough  sponging,  etc.  ;  it  rarely  follows  if  the  periosteum  has  been 
tirst  retracted  before  the  bone  is  divided,  and  practically  never  apart  from  sepsis. 
A  small  annular  sequestrum  is  usually  all  that  separates,  but  should  the  inflam- 
mation spread  up  the  medullary  cavity  (septic  osteomyelitis),  a  more  extensive 
destruction  of  bone  tissue  follows  (for  symptoms  and  treatment  of  which  see 
p.  575).     (b)  Sloughiyig  of  the  ends  of  the  flaps  occurs  in  debilitated  individuals, 

especially  if  thin  skin  flaps  have  been  employed, 
or  if  their  nutrition  has  been  impaired  by 
trauma,  or  if  unhealthy  tissue  has  been  incor- 
porated in  their  substance  by  amputating  too 
close  to  the  seat  of  disease  or  injury.  The 
process  is  usually  limited  in  extent,  and  rarely 
calls  for  treatment  other  than  keeping  the  part 
dry  and  aseptic,  the  slough  being  then  slowly 
absorbed  ;  if  sepsis  is  present,  the  consequences 
may  be  very  serious,  even  necessitating  re- 
amputation  at  a  higher  level,  (c)  A  conical 
stump  results  either  from  the  flaps  being  cut 
too  short,  or  from  the  parts  shrinking  as  a  result 
of  septic  inflammation,  or  in  j'oung  people  from 
continued  growth  of  the  upper  epiphyseal  car- 
tilage  of  the  divided  bone.  In  bad  cases  the 
Fig.  563.  Incisions  for  bone  may  even  project  through  the  integu- 
Ampdtation  of  Terminal  ^^^^^  and  necrose  ;  re-amputation  is  the  only 
Phalanx  of  Finger.  treatment,     [d]  A  painful  stump  is  usually  due 

to  the  adhesion  of  a  bulbous  nerve-end  to  the 
cicatrix  or  bone,  so  that  it  is  dragged  upon  at  each  movement  of  the  limb.  The 
pain  is  of  a  severe  neuralgic  nature,  and  is  treated  by  excising  the  bulb,  or 
re-amputation,  (e)  A  spasmodic  stump  sometimes  occurs,  being  due  either  to 
irritation  of  the  enlarged  nerve-ends,  or  to  some  central  cause.  In  the  former 
instance,  excision  of  the  bulbs  or  re-amputation  will  cure  the  case  ;  in  the  latter, 
the  trouble  will  persist  in  spite  of  treatment,  affecting  fresh  groups  of  muscles 
after  re-amputation. 

Special  Amputations. 

Amputation  of  the  Fingers  is  frequently  required  after  machine  accidents  and 
similar  injuries,  or  in  necrosis  following  a  whitlow.  In  these  cases  it  is  often 
impossible  to  follow  any  regular  routine,  the  flaps  being  obtained  from  any 
portion  of  sound  tissue  present.  The  following,  however,  are  the  chief  plans 
adopted  : 

Amputation  of  the  Terminal  Phalanx  is  usually  conducted  by  opening  the 
joint  on  the  dorsal  aspect,  and  cutting  a  palmar  flap  from  the  pulp  of  the  finger 

(Fig.  563)- 

No  useful  result  follows  amputation  through  the  first  inter-phalangeal  articula- 
tion, since  the  portion  left  is  practically  fixed   and  useless,  no  tendons  being 


AMPUTATIONS 


1333 


inserted  to  govern  it.  An  operation  which  is  sometimes  advantageous  consists  in 
amputating  through  the  middle  of  the  second  phalanx,  so  as  to  leave  the  insertion 
of  the  flexor  sublimis  tendon,  the  flaps  for  such  an  operation  being  derived  from 
any  part  of  the  finger,  and  the  bone  divided  by  cutting  pliers. 

Removal  of  a  finger  at  the  Metacarpo-phalangeal  Joint  is  an  operation 
frequently  necessary.  It  is  best  conducted  by  means  of  a  racquet-shaped 
incision  (Fig.  564,  A),  which  starts  over  the  knuckle,  extends  between  it  and  the 
next  finger,  curves  round  to  the  palmar  aspect  so  as  to  be  placed  a  little  below 
the  crease  in  the  skin  at  the  root  of  the  finger  (Fig.  565,  A),  and  returns  in  the 
same  way  to  the  back  of  the  knuckle.  This  incision  can  be  made  with  one  sweep 
of  the  knife,  but  there  is  no  real  advantage  in  such  a  procedure.  The  articulation 
is  then  opened   from   behind  ;  the  structures  on  either  side   are  successively 


C3\   \-^A    \-A 


\       \    \    -  \     i<r 


r\  n  .0 


Figs.  564  and  565. — Dorsal  and  Palmar  Views  of  Hand  with 
Incisions  for  Various  Amputations, 

A,  incision  for  amputation  of  finger  by  racquet  method  ;  B,  Faraboeuf's  method 
of  amputation,  as  applied  for  index-finger  ;  C,  racquet-shaped  incision  for 
disarticulation  of  thumb  at  carpo-metacarpal  joint ;  D,  amputation  through 
the  wrist  by  a  long  palmar  flap.  In  all  of  these  the  continuous  black  lines 
indicate  the  portions  of  the  incisions  visible  from  the  dorsal  or  palmar  aspects 
respectively  ;  the  interrupted  lines,  the  portions  that  are  hidden. 


divided,  making  them  tense  by  rotation  of  the  finger,  and  the  flexor  tendons 
finally  cut  across.  Bleeding  points  (usually  one  on  each  side)  are  secured,  and 
the  wound  closed. 

The  question  of  removing  the  head  of  the  metacarpal  bone  is  one  which  must 
be  decided  by  the  occupation  of  the  patient  ;  if  he  is  a  working  man,  or  needs 
strength  of  hand,  it  should  be  left,  as  its  removal  always  causes  weakness.  In 
ladies  and  those  where  smallness  and  elegance  of  the  hand  are  required  rather 
than  strength,  it  can  be  taken  away  by  sHghtly  prolonging  the  incision  upwards, 
clearing  the  bone  on  either  side,  and  applying  cutting  pHers.  The  gap  between 
the  adjoining  fingers  can  in  this  way  be  almost  obliterated.  It  is  especially 
advisable  to  do  this  in  the  case  of  the  index-finger,  since  the  head  of  the  second 
metacarpal  bone  forms  an  unsightly  projection,  and  is  very  exposed  to  injury. 
For  this  finger,  Faraboeuf's  method  (Figs.  564,  B,  and  565,  B)  is  often  used. 


1334 


A  MANUAL  OF  SURGERY 


Occasionally  the  four  fingers  and  their  attached  metacarpal  bones  have  to  be 
removed  en  bloc.  Short  equal  flaps  may  then  be  cut  from  the  front  and  back  ot 
the  hand,  and  the  disarticulation  effected.  The  stump  that  remains,  although 
consisting  merely  of  the  carpus  and  thumb,  is  very  serviceable. 

Amputation  of  the  Thumb  should  never  be  undertaken  unless  absolutely  neces- 
sary, since  its  removal  seriously  impairs  the  functional  utility  of  the  hand  ;  as 
large  a  portion  must  be  saved  as  practicable,  so  as  to  assist  the  patient  in  grasp- 
ing. The  phalanges  may  be  removed  by  any  method  which  enables  the  bone  to 
be  covered  with  the  least  possible  sacrifice. 

When  it  is  also  necessary  to  take  away  the  metacarpal  bone,  one  of  the  two 
following  plans  should  be  adopted  : 

I.  The  racquet  method  {Figs.  564 ,  C,  and  565,  C).  In  this  an  incision  commences 
in  the  intertendinous  hollow  known  as  the  tabatiere,  and  extends  along  the 
dorsum  of  the  thumb  to  the  head  of  the  metacarpal  bone,  the  oval  portion  sweep- 
ing round  it  at  the  level  of  the  vs/eb  when  the  thumb  is  abducted,  and  on  the 
palmar  aspect  corresponding  to  the  oblique  crease  at  its  root.     The  remainder 

of  the  operation  resembles  that  for  re- 
moval of  a  finger.  Care  must  be  taken 
not  to  wound  the  trunk  of  the  radial 
artery  as  it  passes  through  the  base  of 
the  interosseous  space  ;  the  blade  of  the 
knife  is  therefore  kept  closely  applied 
to  the  bone. 

2.  By  a  palmar  ftaf.  In  this  the  knife 
is  first  carried  across  the  dorsal  aspect 
of  the  thumb,  from  the  centre  of  the 
web  between  it  and  the  index-finger, 
to  a  point  on  the  palmar  surface  of  the 
wrist  just  above  the  thenar  eminence. 
The  knife  is  then  rotated  so  that  its 
cutting-edge  looks  outwards,  and  in- 
serted deeply  through  the  ball  of  the 
thumb,  transfixing  it,  so  as  to  emerge 
at  the  same  spot  in  the  centre  of  the 
web  as  that  at  which  the  incision  com- 
menced. A  muscular  flap  with  a  well- 
rounded  border  is  readily  fashioned  by 
cutting  outwards.  The  remaining  soft 
parts  are  then  divided,  and  disarticula- 
tion completed  by  opening  the  joint.  It 
is  a  prettier  and  more  showy  operation 
than  the  former,  but  otherwise  has  no 
advantages. 
Amputation  through  the  Wrist-Joint  is  seldom  performed  except  for  injuries, 
and  then  the  flaps  must  be  derived  as  best  they  can  from  healthy  tissues.  Three 
chief  methods  are,  however,  described  :  (a)  In  the  elliptical  (Fig.  566),  the  in- 
cision takes  the  form  of  an  ellipse,  the  highest  point  being  on  the  dorsum  \  inch 
below  the  level  of  the  wrist-joint,  and  the  lowest  in  the  centre  of  the  palm 
2  inches  below  the  former.  On  the  ulnar  side,  the  incision  passes  betvi^een  the 
pisiform  bone  and  the  base  of  the  lifth  metacarpal,  whilst  on  the  radial  side  it 
crosses  the  carpo-metacarpal  articulation.  After  dividing  the  cellular  tissue,  and 
dissecting  up  the  palmar  flap,  the  joint  is  opened  from  the  posterior  aspect,  and 
the  disarticulation  completed.  The  convex  end  of  the  palmar  flap  is  fitted  into 
the  concavity  of  the  dorsum,  and  the  cicatrix  thus  forms  a  curved  line  on  the 
back  of  the  stump.  (6)  A  long  palmar  flap  (Fig.  565,  D)  is  sometimes  utilized, 
extending  from  just  below  either  styloid  process  down  to  about  the  middle  of  the 
metacarpal  bones,  the  sides  of  this  flap  being  parallel  to  each  other.  The  dorsal 
incision  crosses  the  carpus  horizontally  between  the  two  extremities  of  the 
former  wound  (Fig.  564 ,  D).  The  palmar  flap  is  then  dissected  up  so  as  to 
include  only  skin  and  subcutaneous  tissue,  with  perhaps  a  little  muscular  tissue 
from  the  thenar  and  hypothenar  eminences.     The  wrist-joint  is  opened  from  the 


Fig, 


565. — Amputation  of  the  Wrist 
BY  Elliptical  Method, 


The  dark  line  indicates  the  palmar  flap, 
the  dotted  line  the  dorsal  incision. 


AMPUTATIONS 


1335 


dorsum,  and  the  amputation  completed  by  the  division  of  the  flexor  tendons, 
(c)  In  a  few  cases,  amputation  by  an  external  flap  may  be  desirable  (Dubreuil's 
method).  The  incision  commences  at  the  junction  of  the  middle  and  outer 
thirds  of  the  back  of  the  wrist,  reaches  down  to  the  head  of  the  metacarpal  bone 
of  the  thumb,  terminating  at  a  point  in  the  palm  immediately  opposite  its  com- 
mencement. This  flap  is  dissected  up,  and  should  contain  a  certain  airiount 
of  muscular  substance  from  the  thenar  eminence.  The  skin  and  subcutaneous 
tissues  on  the  ulnar  aspect  are  now  divided  by  a  circular  sweep  of  the  knife 
around  the  inner  side  of  the  limb.  Disarticulation  follows,  and  the  external  flap 
is  carried  inwards,  and  sutured  so  as  to  close  the  wound. 

Amputation  through  the  Forearm  is  usually  conducted  by  means  of  a  flap 
operation,  the  flaps  being  either  equal  in  length  or  one  a  little  longer  than  the 
other.  The  muscles  are  divided  circularly,  and  the  bones  should  be  thoroughly 
cleared  before  division. 

Disarticulation  at  the  Elbow-joint  is  an  operation  very  rarely  seen,  and  is 
either  undertaken  by  the  elliptical  method  or  with  a  long  anterior  flap. 

Amputation  through  the  Arm  may  be  carried  out  by 
any  of  the  methods  described,  e.g.,  the  flap,  circular,  or 
modified  flap  and  circular,  the  choice  in  any  particular 
instance  being  determined  by  the  requirements  of  the 
case. 

Disarticulation  at  the  Shoulder -joint. — Three  chief 
methods  are  practised  for  the  performance  of  this  opera- 
tion, viz.,  Spence's,  Larrey's,  or  that  by  means  of  an 
external  or  deltoid  flap.  In  all,  the  third  part  of  the  sub- 
clavian artery  may  be  controlled  by  digital  compression, 
the  surgeon  endeavouring  to  leave  the  division  of  the  main 
vessels  until  the  last  stage  of  the  proceedings  ;  but  it  is 
perhaps  better  to  clamp  all  the  smaller  vessels  as  soon  as 
they  are  cut,  and  to  isolate  and  tie  the  main  trunks  before 
their  division. 

(a)  Spence's  operation  (Fig.  567). — A  preliminary  incision 
similar  to  that  for  excision  of  the  shoulder  is  first  made, 
extending  downwards  and  outwards  through  the  fibres  of 
the  deltoid,  from  a  point  midway  between  the  coracoid 
and  acromion  processes.  This  passes  directly  down  to 
the  bone,  and,  if  necessary,  the  joint  is  at  once  opened  and 
examined  prior  to  any  further  steps  being  taken.  The 
surgeon,  standing  on  the  outer  side  of  the  limb,  then 
carries  his  knife  from  the  lower  part  of  the  incision  down- 
wards and  inwards  across  the  axillary  folds  around  the 
limb  to  the  point  from  which  it  first  started,  thus  making  the 
incision  racquet-shaped.  The  skin  is  first  dissected  up  all  round  for  an  inch  or  so, 
and  then  the  muscles  on  the  inner  side,  the  deltoid  in  part,  the  pectoralis  major, 
the  coraco-brachialis  and  biceps,  are  divided  on  the  slant,  thereby  exposing  the 
main  vessels  and  nerves.  The  vessels  may  now  be  secured  and  divided,  and  the 
nerves  isolated,  pulled  down  and  cut  short,  or  they  may  be  left  intact  for  a  time. 
The  soft  structures  on  the  outer  side  of  the  vertical  incision  are  next  separated 
from  the  bone,  and  then  the  outer  half  of  the  capsule,  together  with  the  muscles 
inserted  into  the  greater  tuberosity  of  the  humerus,  and  the  long  tendon  of  the 
biceps,  are  divided.  The  inner  half  of  the  capsule  and  the  subscapularis  are  then 
cut  through  so  as  to  free  the  head  of  the  bone.  By  retracting  the  external  flap 
and  protruding  the  head  from  its  socket,  the  posterior  part  of  the  capsule  can  be 
severed,  and  then  the  knife,  travelling  downwards  between  the  humerus  and  the 
axillary  vessels,  is  made  to  cut  its  way  out,  thus  completing  the  disarticulation, 
the  vessels  and  nerves,  if  not  already  dealt  with,  being  divided  as  the  last  step  in 
the  proceeding.  If  the  knife  is  kept  close  to  the  bone,  the  trunk  of  the  posterior 
circumflex  artery  is  not  interfered  with. 

(6)  Larrey's  operation  (Fig.  568)  is  very  similar  to  the  above,  except  that  the 
vertical  incision  is  made  on  the  outer  aspect  of  the  joint,  reaching  downwards 
from  the  prominence  of  the  acromion  for  a  distance  of  about  6  inches,  the  oval 


Fig.  567. — Spence's 
Amputation  at 
THE  Shoulder 
BY  Anterior  Rac- 
quet. (Treves' 
'  Operative  Sur- 
gery.') 


1336 


A  MANUAL  OF  SURGERY 


portion  starting  from  its  centre,  and  being  directed  obliquely  downwards  and 
inwards.  The  tissues  are  reflected  on  either  side  of  the  humerus  ;  the  jomt  is 
opened  by  a  transverse  cut  over  the  great  tuberosity,  which  also  divides  the 
muscles  inserted  into  it.  The  knife  is  finally  carried  down  on  the  inner  side  of 
the  humerus  so  as  to  sever  the  vessels  last,  if  considered  desirable. 

(c)  Amputation  by  the  external  or  deltoid  flap  is  but  little  practised  at  the 
present  time.  The  flap  is  either  cut  by  transfixion,  or  dissected  up.  It  is 
U-shaped,  its  base  extending  from  the  coracoid  process  in  front  to  the  root  of 
the  acromion  behind.  A  skin  incision  is  now  made  across  the  inner  aspect  of 
the  limb,  joining  the  ends  of  the  former  incision,  and  extending  about  2  inches 
below  the  axilla.  Disarticulation  is  then  carried  out  in  the  same  way  as  in  the 
previous  methods. 

Occasionally  it  is  necessary  to  remove  the  whole  of  the  upper  limb  together 
with  the  scapula  and  outer  third  of  the  clavicle,  for  new  growths,  usually  of  a 
sarcomatous  nature,  or  for  injury.  This  so-called  Interscapulo-thoracic  Amputa- 
tion is  best  performed  according  to  Berger's  method.  An  incision  is  made  along 
the  clavicle,  and  the  middle  portion  of  this  bone  is  then  removed  so  as  to  enable 
the  surgeon  to  divide  between  ligatures  the  subclavian  artery  and  vein  on  a  level 


Fig.  568. — Larrey's    Amputation 

THROUGH     THE      SHOULDER-JOINT 

BY     External     Racquet. 
(Treves'  'Operative  Surgery.') 


Fig.  560. — Incisions  for  the 
Interscapdlo-thoracic  Am- 
putation. 


with  the  lower  border  of  the  first  rib.  The  anterior  flap  is  then  formed  by  an 
incision  (Fig.  569)  reaching  from  the  centre  of  the  former  and  extending  down- 
wards and  outwards  over  the  shoulder,  across  the  anterior  fold  of  the  axilla,  and 
as  far  as  the  lower  angle  of  the  scapula.  The  pectorales  major  and  minor  are 
divided  along  this  line,  thereby  exposing  the  brachial  plexus,  the  constituent 
nerves  of  which  are  severed  on  a  level  with  the  section  of  the  vessels.  The 
axillary  space  can  now  be  opened  up  along  the  outer  surface  of  the  serratus 
magnus.  The  limb  is  then  rotated  inwards  and  adducted  across  the  trunk,  and 
the  patient  drawn  well  to  the  edge  of  the  table  so  as  to  enable  the  posterior 
incision,  which  unites  the  outer  ends  of  the  two  former,  to  be  made.  The  flap 
thus  marked  out  is  dissected  up,  and  the  different  muscles  retaining  the  scapula 
in  connection  with  the  body  are  divided  one  after  the  other,  including  the 
trapezius,  omo-hyoid,  levator  anguli  scapulas,  rhomboids,  and  serratus  magnus. 
These  may  be  incised  as  near  to  the  bone  as  is  thought  compatible  with  the 
total  removal  of  the  growth.  Any  remaining  fibres  are  cut  across,  and  the  limb 
is  thus  detached.  In  cases  of  new  growth  there  may  be  a  large  number  of 
vessels,  both  arteries  and  veins  requiring  ligature ;  but  in  a  healthy  limb  removed 
for  injury,  none   but  the  posterior  scapular  and  supra-scapular  will  give  any 


AMPUTATIONS 


1337 


trouble.     Naturally,  such  an  operation  is  accompanied  by  some  amount  of  shock, 
but  the  results  hitherto  obtained  have  been  very  gratifying. 

Amputations  of  the  Lower  Extremity. 

Amputation  of  the  Toes  at  the  metatarso-phalangeal  articulations  is  precisely 
similar  to  the  analogous  operation  on  the  fingers.  It  must  be  remembered  that 
the  joint  lies  as  far  behind  the  web  as  the  apex  of  the  toe  is  in  front  of  it,  and 
hence  the  incision  must  start  farther  back  than  might  be  expected. 

For  the  removal  of  the  great  toe  from  the  metatarsal  bone,  Farabceiif's  operation 
is  the  best.  The  incision  (Fig.  570)  commences  over  the  head  of  the  latter  bone, 
and  well  to  the  inner  side  of  the  extensor  tendon  ;  it  extends  downwards  nearly 
as  far  as  the  interphalangeal  articulation,  and  then  crosses  the  plantar  surface  of 
the  toe  so  as  to  reach  the  centre  of  the  web  between  it  and  the  second  toe  ;  thence 


Fig.  570. — Farabceuf's  Ampu- 
tation OF  THE  Great  Toe. 
(Treves'   '  Operative   Sur- 

GERY.') 


Fig.  571. — Incisions  for  Lisfranc's  Amputa- 
tion.    (Treves'  '  Operative  Surgery.') 

the  knife  is  carried  straight  back  to  the  commencement  of  the  incision.  These 
cuts  are  deepened,  the  tendons  divided,  the  joint  opened,  and  the  toe  removed. 
It  will  then  be  found  that  an  internal  flap  remains,  which  can  be  brought  across 
the  head  of  the  metatarsal  bone,  and  covers  it  in  so  that  the  L-shaped  cicatrix  is 
not  exposed  to  pressure. 

Amputation  of  the  great  toe  at  the  tarso-metatarsal  articulation  is  conducted 
either  by  a  racquet-shaped  incision,  or  by  dissecting  up  a  flap  from  the  inner  side. 
It  is  a  bad  operation,  leaving  a  terribly  mutilated  foot,  and  should,  if  possible, 
never  be  undertaken. 

Amputation  of  the  foot  at  the  Tarso-metataxsal  Articulation  is  performed 
either  by  Lisfranc's  or  Hey's  operation. 

Lisfranc's  amputation  (Fig.  571)  consists  really  of  a  disarticulation,  no  bone 
being  sawn  across.  The  patient  lies  on  the  back  with  the  foot  elevated,  and 
extending  beyond  the  end  of  the  table.  On  the  right  foot  a  slightly  convex 
dorsal  incision  extending  down  to  the  bones  is  made  from  the  tip  of  the  fifth 


1338 


A  MANUAL  OF  SURGERY 


metatarsal  bone  on  the  outer  side  to  the  base  of  the  first  on  the  inner.  The 
plantar  flap  is  then  marked  out,  reaching  from  the  terminations  of  the  former 
incision  forwards  as  far  as  the  roots  of  the  toes,  and  being  necessarily  longer  on 
the  inner  than  the  outside  side.  On  the  left  foot  the  incisions  are  made  in  the 
opposite  direction.  This  latter  flap  is  dissected  up,  the  toes  being  fully  extended 
by  an  assistant ;  only  the  skin  and  subcutaneous  tissues  are  raised  for  the  first 
inch,  but  further  back  all  the  structures  in  the  sole  of  the  foot  are  included.  The 
appearance  of  the  peroneus  longus  tendon  will  indicate  that  the  dissection  has 
been  carried  back  far  enough.  Disarticulation  is  now  performed  from  the  dorsal 
aspect,  the  line  of  the  joints  (Fig.  572)  being  kept  in  mind.  The  knife  is  entered 
behind  the  spur  of  the  fifth  metatarsal  bone,  and  is  at  first  directed  forwards  and 
inwards  towards  the  head  of  the  first  metatarsal  bone.   The  line  of  the  articulation 

is  then  followjed  as  far  as  the  base  of  the  second 
metatarsal,  which  projects  backwards  between  the 
internal  and  external  cuneiform  bones.  The  joint 
between  the  first  metatarsal  and  the  internal 
cuneiform  is  now  opened  transversely  on  the 
inner  side,  and  the  dorsal  ligament  between  the 
second  metatarsal  and  the  middle  cuneiform 
divided.  The  strong  interosseous  ligament  pass- 
ing between  the  internal  cuneiform  and  the  base 
of  the  second  metatarsal  is  next  severed  by  in- 
serting the  point  of  a  knife  downwards  between 
the  first  and  the  second  metatarsal  bones,  and 
cutting  backwards  towards  the  ankle,  elevating 
the  handle  of  the  knife  in  order  to  do  so.  By 
grasping  the  toes  in  the  left  hand,  and  forcibly 
depressing  them,  the  remaining  ligaments  on  the 
dorsal  aspect  are  divided,  and  the  disarticulation 
can  then  be  completed. 

The  plantar  flap  is  sometimes  formed  as  the 
last  stage  of  the  operation,  having  merely  been 
mapped  out  in  the  first  instance.  In  such  a  case 
the  dorsal  incision  is  first  made,  the  metatarsus 
disarticulated,  and  the  plantar  flap  cut  from  within 
outwards. 

Hey's  operation  is  essentially  similar  to  the  above, 
with  the  exception  that  the  projection  of  the 
internal  cuneiform  is  sawn  across  (Fig.  572),  leaving 
a  more  even  surface  of  bone.  It  is  certamly  to  be 
preferred  to  a  simple  disarticulation.  Skey  advised 
that  the  three  outer  joints  should  be  opened  as 
above,  and  that  then  the  saw  should  be  applied 
so  as  to  leave  in  its  mortice  the  base  of  the  second  metatarsal,  whilst  the  projec- 
tion of  the  internal  cuneiform  is  removed. 

Amputation  at  the  Mid-tarsal  Joint  {Choparfs  amputation,  Fig.  572)  is  con- 
ducted in  a  very  similar  manner  to  Lisfranc's.  A  plantar  flap  with  convex  end  is 
marked  out,  reaching  on  the  inner  side  of  the  foot  from  a  point  immediately 
behind  the  tubercle  of  the  scaphoid  forwards  to  within  i  inch  of  the  root  of  the 
toes,  and  terminating  on  the  outer  side  on  a  level  with  the  calcaneo-cuboid 
articulation,  i.e.,  midway  between  an  external  malleolus  and  the  spur  of  the  fifth 
metatarsal.  It  should  be  i  inch  longer  on  the  inner  than  on  the  outer  side. 
This  plantar  flap  is  first  dissected  up,  including  everything  down  to  the  bones, 
and  then  a  dorsal  incision  is  made  with  a  slightly  convex  border.  The  joints 
between  the  astragalus  and  scaphoid  on  the  inner  side,  and  between  the  os 
calcis  and  cuboid  on  the  outer,  are  opened  from  above.  Disarticulation  is 
completed  by  a  few  touches  of  the  knife,  and  after  all  haemorrhage  has  been 
arrested,  the  plantar  flap  is  drawn  up,  and  united  by  sutures  to  the  dorsal. 
Some  surgeons  prefer  to  fashion  the  plantar  flap  after  opening  the  joints  from 
the  dorsum. 
Chopart's  amputation  is  not.  on  the  whole,  a  very  satisfactory  proceeding, 


Fio.  572. —  Skeleton  and 
Outline  of  Foot,  show- 
ing Level  of  Various 
Amputations. 


AMPUTATIONS  1339 

since  it  consists  in  the  removal  of  the  anterior  segment  of  the  arch  of  the  foot, 
the  posterior  half  being  left  without  support.  The  natural  result  of  this  is  that 
the  head  of  the  astragalus  travels  downwards,  and  presses  upon  the  anterior 
portion  of  the  stump,  causing  a  good  deal  of  pain  and  discomfort,  whilst  the  os 
calcis  is  drawn  upwards  by  the  traction  of  the  tendo  Achillis.  Formerly  it  was 
considered  that  the  resulting  deformity  was  purely  due  to  unbalanced  muscular 
traction,  and  hence  attempts  to  prevent  it  were  made  by  dividing  the  tendo 
Achillis,  or  by  stitching  the  extensor  tendons  to  the  under  surface  of  the  os  calcis. 
Seeing,  however,  that  the  trouble  is  mainly  mechanical,  and  hence  unavoidable, 
it  would  perhaps  be  wiser  to  avoid  the  operation  entirely,  substituting  for  it  a 
subastragaloid  amputation,  or  modifying  it  by  removing  the  astragalus  after  the 
foot  has  been  taken  away.  Tripier's  amputation  has  also  been  utilized  to  prevent 
such  displacement ;  in  it  an  oblique  external  racquet  is  made,  reaching  back- 
wards to  the  anterior  border  of  the  tendo  Achillis  ;  disarticulation  follows  at  the 
mid-tarsal  joint,  and  then  the  os  calcis  is  sawn  across  horizontally  on  a  level  with 
the  sustentaculum  tali,  so  as  to  leave  a  broad  base  of  support,  which  is  not  so 
likely  to  become  tilted  forwards.  It  is  but 
fair  to  say,  however,  that  in  not  a  few 
cases  of  Chopart's  amputation  an  excellent 
stump  remains  without  any  of  these  incor- 
veniences. 

A  still  better  modification,*  where  prac- 
ticable, is  to  remove  the  foot  on  a  slightly 
anterior  plane,  i.e.,  to  leave  the  scaphoid 
on  the  inner  side,  and  to  divide  the  cuboid 
on  a  level  with  its  anterior  border  with  a 
saw.  The  skin  incisions  can  be  made  as 
for  a  Chopart.  The  stump  left  is  longer, 
and  therefore  controlled  more  easily,  whilst     „  _  . 

the  attachment  of  the  tibialis   posticus  is     ^'l'  573.-Racqdet  Incision  for 
maintained,   and    it    is  easy   to    give   the         Subastragaloid  Amputation. 
peroneus  longus  an  insertion,  so  that  the 
lateral  movements  of  the  foot  are  in  great  part  preserved. 

Subastragaloid  Amputation  of  the  foot  is  occasionally  possible  in  cases  of 
injury,  where  the  astragalus  remains  uninjured.  The  best  plan  to  adopt  is  that 
known  as  Maurice  Perrin's  oval  operation.  A  racquet-shaped  incision  (Fig.  573) 
is  made,  commencing  at  the  insertion  of  the  tendo  Achillis,  and  extending  along 
the  outer  border  of  the  foot  to  a  point  immediately  behind  and  a  little  above  the 
spur  of  the  fifth  metatarsal,  from  which  it  sweeps  over  the  dorsum,  along  the 
instep,  and  after  crossing  the  sole  returns  to  the  same  spot.  The  dorsal  part  of 
the  flap  is  then  dissected  up,  the  astragalo-scaphoid  joint  opened,  the  tendo 
Achillis  divided,  and  by  twisting  the  foot  inwards  the  joints  between  the 
astragalus  and  os  calcis  can  be  entered,  and  the  interosseous  ligament  severed. 
By  still  further  inverting  the  foot  until  it  assumes  a  position  of  extreme  varus,  the 
structures  on  the  inner  side  of  the  os  calcis  can  be  detached,  and  by  continuing 
the  same  torsion,  the  inner  surface  of  the  bone  is  finally  cleared,  the  dorsal 
.aspect  of  the  foot  looking  downwards.  When  the  foot  has  been  removed, 
bleeding-points  are  secured,  tendons  and  nerves  cut  short,  and  the  wound,  which 
now  lies  horizontally,  is  secured  by  sutures.  A  very  firm  basis  of  support  is 
provided  by  this  operation,  and  the  stump  is  covered  by  the  skin  of  the  heel, 
which  is  accustomed  to  pressure. 

Amputation  of  the  Foot. — Syme's  amputation  consists  of  a  disarticulation  at  the 
ankle-jomt,  together  with  removal  of  the  two  malleoli  and  the  articular  surface  of 
the  tibia.  The  patient  lies  on  the  back  with  the  leg  well  elevated  and  projecting 
over  the  end  of  the  table,  the  surgeon  standing  either  below  or  a  little  to  the  right 
of  the  patient.  Having  exsanguinated  the  limb,  the  operation  is,  on  the  right 
foot,  commenced  by  making  an  incision  from  the  tip  of  the  external  malleolus 
down  to  the  heel,  and  extending  up  to  a  point  ^  inch  below  and  behind  the 
internal  malleolus  (Fig.  574,  k).     On  the  left  side  the  incision  is  made  in  the 

*  Gaz.  des  Hopitaiix,  January  21,  1902. 


1340 


A  MANUAL  OF  SURGERY 


opposite  direction.  For  this  purpose  a  short-handled  strong-bladed  knife  should 
be  employed  (an  ankle-knife).  The  incision  is  directed  slightly  backwards, 
otherwise  a  bucket-shaped  heel  flap  is  formed,  in  which  discharges  may  collect. 
The  knife  is  carried  down  to  the  bone  at  the  first  cut,  and  the  surgeon  then 
proceeds  to  dissect  up  the  heel  flap  thus  marked  out  by  inserting  his  thumb  into 
the  wound,  and  partly  peeling,  partly  cutting,  the  soft  tissues  from  the  back  of 
the  OS  calcis.  This  is  sometimes  a  tedious  and  tiring  proceeding,  since  it  is  most 
important  to  keep  close  to  the  bone  for  fear  of  dividing  the  nutrient  vessels  of  the 
flap  (external  and  internal  calcanean).  The  dorsal  incision  (A^)  is  then  made, 
uniting  the  ends  of  the  former  wound,  and  carried  slightly  forwards  so  as 
to  mark  out  a  short  convex  flap.  This  is  dissected  up,  and  the  ankle-joint 
opened,  the  line  of  the  articulation  being  placed  ^  inch  above  the  tip  of  the 
internal  malleolus.  By  division  of  the  lateral  and  posterior  ligaments,  of  the 
tendo  Achillis,  and  of  the  few  remaining  fibrous  connections  along  the  top  of  the 
OS  calcis,  the  foot  is  removed.  The  lower  ends  of  the  tibia  and  fibula  are  then 
cleared  and  sawn  off  (S),  the  ends  of  the  dorsal  flap  being  meanwhile  held  out 


Fig.  574. 


-Lines  of  Incision  in  Bones  and  Soft  Parts  in  Syme's  and 
Pirogoff's  Amputations. 


A,  A\  Incisions  for  Syme's  amputation  ;  B,  B^,  incisions  for  Pirogoff's  amputa- 
tion (these  should  really  start  from  the  same  point  as  in  Syme's  operation, 
viz.,  the  tip  of  the  external  malleolus,  but  to  avoid  confusion  they  have  been 
placed  a  little  behind  it)  ;  8,  section  of  tibia  and  fibula  in  Syme's  amputation  ; 
P,  section  of  tibia  and  fibula  in  Pirogoff's  amputation  ;  P^,  line  of  section  of 
the  OS  calcis  in  Pirogoff's  amputation. 

of  harm's  way.  The  main  vessels  are  tied,  as  also  any  other  bleeding- 
points  ;  the  tendons  and  chief  nerves  are  drawn  down  and  cut  short,  and  the 
wound  closed  by  sutures,  provision  being  made  for  drainage  through  one  of 
the  angles. 

A  much  quicker  and  prettier  method  of  performing  this  operation  consists  in 
opening  the  joint,  and  disarticulating  immediately  after  the  incisions  have  been 
made,  whilst  the  os  calcis  is  subsequently  dissected  out  of  the  heel  flap  from 
above,  keeping  the  knife  close  to  the  bone. 

Syme's  amputation  gives  excellent  results  with  only  slight  shortening,  and  the 
patient  is  able  to  walk  on  skin  which  is  already  accustomed  to  pressure.  It  is 
specially  useful  where  amputation  is  required  for  tarsal  disease,  inasmuch  as  it  is 
then  rarely  safe  to  undertake  any  of  the  partial  or  more  conservative  methods  of 
operating. 

Pirogoff's  operation  is  one  in  which  the  posterior  portion  of  the  os  calcis  is  sawn 
off,  and  applied  to  the  under  surface  of  the  previously  sawn  ends  of  the  tibia  and 
fibula.    The  operation  here  described  is  not  strictly  that  of  Pirogoff,  but  rather 


AMPUTATIONS 


1341 


the  modification  suggested  by  Sedillot.  The  patient  and  surgeon  being  relatively 
placed  as  for  Syme's  operation,  an  incision  is  made  extending  from  the  same  points, 
viz.,  betvi/een  the  tip  of  the  external  malleolus  and  a  point  |  inch  below  and  behind 
the  inner  malleolus,  but  instead  of  passing  directly  downwards  it  is  carried 
obliquely  forwards  (Fig.  574,  B).  Everything  is  divided  at  once  down  to  the  bone, 
and  the  dorsal  incision  is  then  made,  being  placed  at  right  angles  to  the  plantar 
(Bi).  The  ankle-joint  is  opened  from  above,  and  disarticulation  completed  ;  the 
structures  to  the  side  of  and  behind  the  joint  are  then  divided,  so  that  a  saw  can 
be  applied  to  the  exposed  surface  of  the  os  calcis,  and  the  bone  cut  in  a  direction 
more  or  less  parallel  to  that  of  the  plantar  flap  (pi).  The  lower  ends  of  the  tibia 
and  fibula  are  now  cleared,  and  the  malleolus  and  articular  surface  sawn  off 
obliquely,  the  saw  -  cut  being  as 
nearly  as  possible  parallel  to  that 
made  through  the  os  calcis  (P).  The 
object  of  this  obliquity  is  to  enable 
the  sawn  end  of  the  posterior  part 
of  the  OS  calcis  to  be  brought  into 
apposition  with  the  similarly  treated 
ends  of  the  bones  of  the  leg,'  and 
wired  to  them  without  any  traction 
on  the  tendo  Achillis.  By  this  opera- 
tion a  somewhat  longer  stump  is 
obtained  than  in  Syme's,  and  the 
patient  is  able  to  walk  on  the  pos- 
terior part  of  the  os  calcis  instead 
of  on  the  sawn  ends  of  the  tibia  and 
fibula.  The  operation  is  more  useful 
in  cases  of  injury  than  for  disease. 

Amputations  of  the  Leg  may  be 
undertaken  either  immediately 
above  the  malleoli  (supramalleolar) 
or  in  the  middle  third,  or  a  hand's- 
breadth  below  the  knee  (site  of  elec- 
tion). In  the  two  former  positions 
almost  any  operation  may  be  prac- 
tised according  to  the  needs  of  the 
case,  but  perhaps  the  most  satisfac- 
tory is  that  by  means  of  equal  lateral 
flaps,  each  of  which  is  equal  in 
length  to  one  diameter  of  the  limb, 
and  consists  below  of  skin,  fat,  and 
deep  fascia,  but  for  the  upper  half 
the  muscles  are  also  included  (Fig.  576,  i).  In  dividmg  the  bones,  care  must  be 
taken  not  to  leave  a  sharp  projecting  edge  on  the  front  of  the  tibia.  This  is 
best  prevented  by  partially  sawing  through  the  bone  in  an  oblique  direction 
from  above  downwards,  and  when  this  has  reached  a  little  beyond  its  centre, 
the  saw  is  withdrawn,  and  a  horizontal  section  made,  cutting  across  the  oblique 
incision  in  such  a  way  as  to  remove  a  wedge  of  bone  from  the  front  of  the 
tibia,  which  thus  becomes  suitably  bevelled.  The  fibula  should  always  be  divided 
before  completing  the  section  of  the  tibia. 

In  the  lower  third  of  the  leg,  Teale's  amputation  (Fig.  562)  is  sometimes 
recommended,  and  gives  good  results. 

Amputation  of  the  Leg  at  the  Site  of  Election  may  be  performed  either  by  the 
modified  flap  and  circular  operation,  or  by  a  large  external  flap  {Farabceufs 
operation).  In  the  latter,  the  external  flap  (Fig.  575,  A,  C),  which  is  U-shaped,  is 
first  marked  out  with  the  knife,  extending  ij  inches  higher  in  front  than  behind, 
and  its  length  being  equal  to  the  diameter  of  the  limb  at  the  point  at  which  the 
bones  are  to  be  divided.  The  incision  on  the  inner  side  is  then  made,  extending 
directly  across  the  limb  from  a  point  1^  inches  below  the  upper  end  of  the 
anterior  horn  of  the  former  incision  to  its   posterior   extremity  (B,   C).     The 


Fig.  575. — Farabcedf's  Ampdtation  at 
THE    Site    of    Election,   a    Hand's- 

BREADTH   BELOW   THE    KnEE, 

The  continuous  line,  A,  B,  C,  indicates  the 
shape  of  the  large  external  flap  ;  the 
dotted  line,  B,  C,  the  incision  on  the 
inner  side  of  the  limb.  The  direction 
in  which  the  bones  are  sawn  is  also 
shown. 


1342 


A  MANUAL  OF  SURGERY 


external  flap  is  dissected  up,  commencing  anteriorly  ;  the  fingers  and  knife  being 
inserted  between  the  tibialis  anticus  and  the  tibia,  all  the  soft  parts  down  to  the 
bone  and  interosseous  membrane  arc  divided  obliqueh'.  The  anterior  tibial 
artery  is  cut  long,  and  care  must  be  taken  not  to  free  the  flap  from  the  interosseous 
membrane  too  high,  for  fear  of  injuring  the  trunk  of  this  vessel  as  it  passes 
between  the  bones,  an  accident  which  would  seriously  imperil  the  vitality  of 
this  large  and  flesh}-  mass.  The  tissues  on  the  inner  side  of  the  limb  are  now 
divided,  either  by  transfixion  or  circular  division.  The  interosseous  membrane 
and  bones  are  bared,  and  the  saw  applied  according  to  the  method  already 
described. 

Disarticulation  at  the  Knee-joint  is  a  very  useful  and  valuable  proceeding. 
The  methods  chiefly  employed  are  as  follows  :  (i.)  Stephen  Smith's  operation,  or 
amputation  by  equal  lateral  flaps.   The  incisions  extend  from  a  point  immediately 

below  the  tuberosity  of  the  tibia  backwards 
in  a  semilunar  fashion,  to  terminate  in  the 
middle  line  behind  on  a  level  with  the  joint 
(Fig.  576,  2).  The  incision  on  the  inner  side 
should  reach  a  little  lower  than  that  on  the 
outer,  in  order  to  ensure  sufficient  covering 
for  the  inner  condyle,  which  is  always  larger 
than  the  outer.  The  flaps  are  dissected  up 
all  round,  including  the  subcutaneous  and 
deep  fascia,  being  turned  back  in  front  like  a 
collar,  so  as  to  enable  the  surgeon  to  reach 
and  divide  the  insertion  of  the  ligamentum 
patellae.  The  knife  is  now  carried  along  the 
upper  margin  of  the  tibia,  separating  the 
attachments  of  the  semilunar  cartilages  to 
the  bones  bj'  dividing  the  coronary  liga- 
ments. The  surrounding  muscles  and  ten- 
dons are  cut  through  at  the  same  level, 
together  with  the  crucial  ligaments,  and  the 
leg  is  finally  separated  by  boldly  sweeping 
the  knife  through  the  soft  parts  at  the  back 
of  the  joint,  the  flaps  being  well  retracted. 
The  popliteal  vessels  are  secured,  and  the 
flaps  drawn  together  in  the  median  line. 
When  union  has  occurred,  the  cicatrix  is 
drawn  up  behind  into  the  intercondyloid 
notch  so  that  an  excellent  hooded  covering 
is  provided  for  the  lower  end  of  the  femur. 
The  chief  objection  to  the  operation  is  that 
the  upper  part  of  the  sj'novial  membrane  of 
the  joint  remains  intact,  and  may  become 
distended  by  a  serous  effusion  through  the 
irritation  produced  by  wearing  an  artificial 
limb,  (ii.)  Amputation  can  be  undertaken 
by  a  long  anterior  flap,  the  patella  being  left  in  situ  or  removed,  according  to 
circumstances.  A  short  posterior  flap  is  also  formed  and  dissected  up,  so  as  to 
enable  the  muscles  and  vessels  to  be  divided  transversely. 

Supracondyloid  Amputation  of  the  Thigh  is  an  operation  often  requisite  in 
order  to  deal  with  disease  or  injury  involving  the  knee-joint,  {a)  Garden's 
amputation,  slightly  modified,  is  one  excellently  adapted  to  this  purpose.  An 
anterior  flap  (Fig.  577,  A)  is  fashioned  from  the  most  prominent  point  of  one 
condyle  to  that  of  the  other,  the  incision  crossing  the  mid-line  in  front  halfway 
between  the  patella  and  the  tibial  tubercle.  This  flap  is  dissected  up  in  front  of 
the  patella  as  far  as  its  upper  border.  A  short  rosterior  flap  is  then  dissected  up 
(Garden  made  his  posterior  incision  horizontal).  A  transverse  cut  above  the 
patella  lays  the  knee-joint  open,  and  after  flexing  the  limb  the  lateral  and  crucial 
ligaments  are  divided.  The  hamstring  muscles,  etc.,  are  severed  by  cutting  from 
without  inwards,  and  a  few  touches  of  the  knife  will  then  serve  to  disarticulate. 


Fig   576. — I,  Amputation  OF  THE 
Leg   by   Lateral    Flaps  ;     2, 

Stephen  Smith's  Amputation 

THROUGH    THE    KneE-JOINT. 


AMPUTATIONS 


1343 


The  muscles  are  retracted,  and  the  femur  divided  a  little  above  the  condyles. 
{b)  Lister's  modification  (Fig.  577,  B)  consists  in  making  a  transverse  incision 
across  the  front  of  the  limb  on  a  level  with  the  upper  border  of  the  tubercle  of 
the  tibia.  The  horns  of  this  incision  are  joined  posteriorly  by  carrying  the  knife 
downwards  at  an  angle  of  forty-five  degrees  to  the  axis  of  the  leg.  This  flap  is 
dissected  up,  and  the  whole  of  the  integuments  and  subcutaneous  tissues  are  freed 
and  retracted  like  a  cuff,  so  as  to  enable  the  muscles  to  be  divided  circularly  just 
above  the  patella.  The  saw  is  then  applied,  and  the  bone  removed.  By  this 
means  the  covering  of  the  end  of  the  bone  is  taken  more  from  the  back  than  from 
the  front  of  the  limb,  (c)  Grittfs  operation  (Fig.  578)  is  thus  performed  :  A  large 
anterior  flap  similar  to  that  used  in  Garden's  operation  is  dissected  up,  including 
the  patella,  and  a  shorter  posterior  flap  is  then  fashioned.  The  soft  parts  are 
divided  by  a  circular  cut  of  the  knife,  and  the  femur  sawn  across  about  the  level 
of  the  adductor  tubercle.  The  cartilaginous  surface  of  the  patella  is  then  removed 
with  the  saw,  and  the  remaining  portion  of  the  bone  secured  by  a  silver  wire  to 
the  divided  end  of  the  femur.     Considerable  difficulty  may  be  experienced  in 


Fig.  577. —  Incisions  for  Supra- 
CONDYLOID  Amputation  of  the 
Thigh. 

A,  Garden's  operation  ;  B,  Lister's 
modification  of  the  same. 


Fig.  578.— Stokes-Gritti  Amputation, 
showing  Incision  in  the  Soft 
Parts  and  the  Lines  of  Section 
IN  THE  Femur  and  Patella. 


keeping  the  patella  in  accurate  apposition,  and  to  obviate  this  Stokes  recommended 
division  of  the  femur  at  a  slightly  higher  level — i.e.,  above  rather  than  through 
the  condyles,  (d)  Amputation  by  a  long  posterior  flap  is  sometimes  required  in 
cases  where  the  tissues  in  front  of  the  limb  have  become  disorganized  from 
disease  of  the  joint,  or  when  cicatrices  produced  by  a  previous  excision  are 
present.  The  posterior  flap  is  first  marked  out  and  dissected  up,  including 
merely  the  skin  and  subcutaneous  tissues.  A  transverse  incision  is  made  across 
the  limb  above  the  cicatrices  or  sinuses,  the  bone  sawn  just  above  the  site  of  the 
preceding  excision,  and  the  posterior  muscles  and  vessels  divided  circularly.  A 
very  good  stump  usually  results. 

Amputation  of  the  Thigh  may  be  conducted  by  any  of  the  general  methods 
already  described,  but  Lister's  operation,  modified  flap  and  circular  (Figs.  560 
and  561)  is  perhaps  the  best. 

Amputation  through  the  Hip-joint. — Disarticulation  at  the  hip-joint  is  always 
an  operation  of  the  greatest  gravity,  and  every  precaution  should  be  taken  to 


1344  A  MANUAL  OF  SURGERY 

minimize  the  immediate  risks  by  preventing  haemorrhage  and  lessening  shock. 
No  part  of  the  body  should  be  unnecessarily  exposed,  whilst  the  head  is  kept  low, 
and  although  the  operation  must  not  be  hurried  over,  no  time  is  wasted. 

Perhaps  "the  best  way  of  preventing  haemorrhage  is  to  secure  the  main  vessels 
before  dividing  them,  and  then  to  take  up  each  bleeding  point  as  it  appears  ;  the 
limb  can  thus  be  removed  with  the  loss  of  merely  a  few  ounces  of  blood.  Other 
plans  which  have  been  suggested  are  :  (a)  Lister's  aortic  tourniquet,  which, 
however,  is  not  to  be  recommended,  partly  because  it  is  difficult  to  apply  to  stout 
or  muscular  individuals,  and  in  any  case  it  is  very  liable  to  slip.  (6)  Daw's  rectal 
lever  for  compression  of  the  common  iliac  artery  consists  of  a  rod  of  ebony, 
vulcanite,  or  metal,  which  is  inserted  into  the  rectum,  and  directed  so  as  to 
compress  the  artery  against  the  briin  of  the  pelvis.  It  is  dangerous  in  application, 
and  not  alwaj^s  efficient,  (c)  An  elastic  tourniquet  may  be  applied  either  around 
the  upper  part  of  the  thigh  to  control  the  lower  end  of  the  external  iliac,  or 
around  the  body  in  such  a  way  as  to  compress  the  abdominal  aorta.  For  the 
latter  purpose  a  pin-cushion  or  pad  is  placed  on  the  abdomen  over  the  aorta,  and 
behind  the  back  a  board  projecting  a  few  inches  on  each  side  of  the  trunk,  and 
with  two  notches  cut  at  either  end.  The  elastic  rod  is  passed  over  the  cushion, 
and  around  the  notches  at  the  end  of  the  board  in  a  figure-of-8  fashion,  sufficient 
tension  being  emplo^-ed  to  force  the  cushion  down  on  the  aorta,  and  thus  control 
the  circulation  through  it.  This  method,  which  was  also  suggested  by  Lord 
Lister,  is  certainly  efficient,  though  somewhat  cumbersome,  (d)  ^More  recently 
Wyeth,  of  New  York,  has  introduced  a  method  of  preventing  hsemorrhage  by 
applj-ing  a  rubber  toiirniquet  close  to  the  pelvic  brim,  which  is  prevented  from 
slipping  by  inserting  long  needles  immediately  below  it.  The  limb  is  first 
exsanguinated  by  elevation,  or  possibly  by  the  use  of  an  Esmarch's  bandage. 
Two  long  steel  needles,  lo  inches  in  length  and  ^  inch  in  thickness,  are  then 
inserted,  one  on  the  outer  side  of  the  thigh  and  one  on  the  inner.  The  former  'is 
introduced  ^  inch  below  the  anterior  superior  spine  of  the  ilium,  and  slightly  to 
the  inner  side  of  this  prominence,  and  is  made  to  traverse  superficially  for  about 
3  inches  the  muscles  and  fascia  on  the  outer  side  of  the  hip,  emerging  on  a  level 
with  the  point  of  entrance.  The  point  of  the  second  needle  is  thrust  through  the 
skin  and  tendon  of  origin  of  the  adductor  longus  muscle  J  inch  below  the  crutch, 
the  point  emerging  i  inch  below  the  tuber  ischii.  The  points  should  be  shielded 
at  once  with  cork  to  prevent  injury  to  the  hands  of  the  operator.  No  vessels  are 
endangered  by  these  skewers.  A  mat  or  compress  of  sterile  gauze  2  inches  thick 
and  4  inches  square  is  laid  over  the  femoral  artery  and  vein  as  they  cross  the 
brim  of  the  pelvis  ;  over  this  a  piece  of  strong  white  rubber  tubing,  ^  inch  in 
diameter  when  unstretched,  and  long  enough  when  in  position  to  go  five  or  six 
times  round  the  thigh,  is  now  wound  very  tightly  around  and  above  the  fixation 
needles  and  tied.'*  By  this  means  the  Hmb  can  be  removed  with  practically  no 
loss  of  blood. 

Formerly  but  one  operation  was  utilized  for  the  removal  of  the  Hmb  at  the  hip- 
joint,  viz.,  by  transfixion,  the  flaps  being  cut  antero-posteriorly.  The  great 
advantage  of  this  method  was  the  rapidity  with  which  it  was  executed  ;  it  has, 
however,  been  replaced  by  other  plans,  one  of  which  should  always  be  adopted. 

Amputation  by  an  external  racqjiet  incision  (Fig.  579  ;  right  leg)  has  been  recom- 
mended by  many  surgeons,  especially  Furneaux  Jordan,  Esmarch.  and  Lister,  each 
of  whom  has  advocated  some  slight  modification.  The  surgeon  should  always 
stand  to  the  outer  side  of  the  limb,  whilst  the  pelvis  of  the  patient  rests  at  the 
extreme  edge  of  the  table.  The  essential  features  of  this  operation  consist  in  a 
circular  division  of  the  structures  down  to  the  bone  below  the  lesser  trochanter, 
whilst  the  head  of  the  bone  is  disarticulated  and  removed  through  the  external 
vertical  portion  of  the  incision  extending  downwai'ds  from  above  the  great 
trochanter  ;  it  matters  little  whether  the  vertical  incision  is  made  before  or  after 
the  tissues  in  the  thigh  have  been  divided.  Perhaps  the  simplest  plan  of  carrying 
out  this  operation  is  as  follows  :  A  circular  incision  is  made  through  the  skin  and 
subcutaneous  tissues  5  or  6  inches  below  the  great  trochanter.  These  are  dissected 
up  for  a  few  inches,  and  the  muscles  divided  circularly  down  to  the  bone,  which 

•  "Wyeth,  Annals  of  Surgery,  February,  1897. 


AMPUTATIONS 


1345 


is  at  once  sawn  through.  The  external  incision,  6  or  8  inches  long,  is  then  made, 
the  tissues  being  freed  from  the  anterior  and  posterior  surfaces  of  the  femur,  and 
the  rotator  muscles  divided  along  the  borders  of  the  great  trochanter.  The  lower 
end  of  the  fragment  of  the  femur  is  then  grasped  by  lion  forceps,  and  after 
forcibly  flexing  and  rotating  the  bone  inwards,  the  capsule  of  the  joint  is  laid  open 
on  its  posterior  aspect.  By  everting  the  bone,  the  anterior  part  of  the  capsule 
can  be  reached  and  incised,  and  the  attachment  of  the  ilio-psoas  muscle  severed. 
The  ligamentum  teres  is  then  divided  by  inserting  the  point  of  the  knife  into  the 
acetabulum,  and  the  head  of  the  bone  is  thus  set  free.  One  great  advantage  of 
this  operation  is  that  the  incisions  are  placed  as  far  as  possible  from  the  risk  of 
infection  from  the  genital  organs  and  perineum. 

In  the  majority  of  cases,  however,  the  best  method  of  amputating  at  the  hip- 
joint  is  by  means  of  an  anterior  racquet  incision  (Fig.  579  ;  left  leg).  This  com- 
mences over  the  centre  of  Poupart's  ligament,  and  is  carried  down  along  the 


Fig.  579. — Amputation  through  the  Hip-joint. 

On  the  right  leg  Furneaux  Jordan's  method  is  indicated  ;  on  the  left  leg  the 
flaps  required  for  the  anterior  racquet  operation  are  shown. 

course  of  the  main  vessels  for  about  3  inches.  The  common  femoral  sheath  is 
exposed,  and  both  artery  and  vein  are  secured  by  double  ligature  and  divided. 
The  incision  is  then  completed  ;  it  sweeps  over  the  inner  side  of  the  thigh  4  or 
5  inches  below  the  perineum  to  the  back,  and  is  brought  up  again  to  the  front 
3  or  4  inches  below  the  great  trochanter.  The  muscular  structures  in  the  outer 
flap  are  then  cut  through,  and  the  external  circumflex  artery  and  other  bleeding 
vessels  secured  by  pressure  forceps  en  route.  By  rotating  the  limb  inwards,  the 
insertion  of  the  gluteus  maximus  can  be  divided,  as  also  the  muscles  attached  to 
the  great  trochanter.  The  muscles  in  the  inner  fiap  are  then  similarly  dealt  with 
after  rotating  the  limb  outwards,  the  internal  circumflex  artery,  etc.,  being  secured. 
The  capsular  ligament  is  next  divided  transversely,  and  the  head  of  the  bone 
disarticulated.  Finally,  the  limb  is  rotated  forcibly  outwards,  and  all  the  soft 
parts  at  the  back  of  the  limb,  including  the  sciatic  vessels  and  nerves,  are 
divided  from  within  outwards  with  one  sweep  of  the  knife.  The  wound  when 
sutured  lies  antero-posteriorly. 


85 


CHAPTER  XLIV. 

AN-SSTHESIA. 

The  practice  of  surgery  has  alwaj-s  been  of  such  a  nature  as  to  render  some 
means  of  abolishing  the  pain  caused  thereby  a  desideratum  ;  but  although  in  the 
old  days  various  plans  were  adopted  to  attain  this  object,  yet  it  was  not  until  the 
end  of  the  eighteenth  century  that  any  real  advance  was  made  in  this  direction. 
In  1799  Sir  Humphry  Davy  suggested  the  possibility  of  using  nitrous  oxide  gas 
as  a  means  of  rendering  patients  anaesthetic  during  surgical  work ;  but  as  then 
employed,  it  was  so  uncertain  in  its  action  that  no  great  benefit  was  derived  from 
the  knowledge  thus  acquired,  and  many  years  elapsed  before  it  came  into  ex- 
tensive use.  The  demonstration  of  the  properties  of  ether  in  1S46  by  ]\Iorton,  in 
Philadelphia,  and  of  chloroform  in  January,  1S47,  by  Sir  James  (then  Professor) 
Simpson,  heralded  in  a  new  era  of  surgery.  Operations,  which  before  were 
scanty  in  number,  became  greatly  multiplied,  and  at  the  present  da\-,  with  our 
advanced  knowledge  and  experience,  and  our  constant  dependence  on  this  agent, 
it  is  difficult  to  understand  how  surgical  practice  could  have  been  conducted 
without  it.  Anesthetics  have  enabled  the  surgeon  confidently  to  attack  almost 
every  region  of  the  body,  and  instead  of  operations  being  hurried  over,  in  order 
to  minimize  the  patient's  sufi^erings,  they  are  now  undertaken  \'iith  much  more 
deliberation,  accuracy  being  the  great  requisite  at  the  present  day,  and  not,  as 
formerly,  rapidity. 

Anaesthesia  may  be  produced  in  three  ways  :  (i)  By  introducing  the  anaesthetic 
directly  into  the  part  where  insensitiveness  is  required  {local  anaesthesia)  ;  (2)  by 
introducing  it  into  the  spinal  canal,  and  acting  upon  the  nerve  centres  or  nerve 
roots  present  therein  {spinal  anaesthesia  or  analgesia)  ;  and  (3)  b)-  employing  a 
volatile  substance,  and  administering  itb)'  inhalation  through  the  nose  or  mouth 
{general  anaesthesia). 

Local  Anaesthesia  is  utilized  for  the  purpose  of  rendering  parts  insensitive 
to  pain,  where  slight  operations  of  short  duration  are  to  be  undertaken,  or 
occasionally  in  more  serious  cases  where  the  patient  cannot  staxid  a  general 
anaesthetic. 

I.  Cocaine  is  an  alkaloid  obtained  from  the  dried  leaves  of  the  ErytJiroxyloti 
coca  (S.  America).  The  salt  most  commonly  used  is  the  hydrochlorate,  which 
exists  in  the  form  of  colourless  needles,  or  a  crystalline  powder  readilj-  soluble 
in  water.  Its  properties  as  a  local  anaesthetic  were  discovered  b}'  Koller,  of 
Vienna,  and  it  was  at  the  Ophthalmic  Congress  at  Heidelberg  in  September, 
18S4,  that  its  value  in  ophthalmic  and  surgical  work  was  first  publicly  demon- 
strated. 

Mucous  membranes  are  readily  anaesthetized  by  applying  a  5  or  10  per  cent, 
solution  to  them  for  about  five  or  ten  minutes,  the  insensibility  lasting  for  about 
the  same  time.  In  dealing  with  the  skin  or  deeper  tissues,  h3-podermic  injections 
of  the  drug  are  relied  on,  the  anesthesia  following  the  course  of  the  peripheral 
nerves.  The  action  of  cocaine  is  supposed  to  depend  parti}-  on  an  anaemic  con- 
dition of  the  affected  tissues  induced  by  arterial  contraction,  partly  on  paralysis 
of  the  termination  of  the  sensory  nerves.  Inflamed  tissues  are  but  little  affected 
by  it,     "When  applied  hypodermically,  the  needle  should  be  inserted  in  the  line 

1346 


ANESTHESIA  1347 

of  incision,  and  the  injection  diffused  equally  along  it.  In  making  use  of  this 
reagent,  it  must  always  be  remembered  that  cocaine  has  a  distinctly  depressing 
influence  upon  the  heart,  and  hence  more  than  ^  grain  should  never  be 
employed.  Should  toxic  effects  be  manifested  (as  by  pallor  of  the  face,  a  cold 
clammy  sweat,  giddiness,  weak  and  rapid  pulse),  the  patient's  head  should  be 
lowered,  and  stimulants  administered.  Some  recommend  that  a  little  nitro- 
glycerine (i  drop  of  a  I  per  cent,  solution)  should  always  be  injected  at  the  same 
time  as  the  cocaine,  so  as  to  prevent  contraction  of  the  peripheral  arterioles.  In 
some  parts  of  the  body  it  may  be  possible  to  control  the  circulation  so  as  to  hinder 
the  general  absorption  of  the  drug.  Thus,  for  circumcision  the  base  of  the  penis 
may  be  constricted  by  an  elastic  band,  whilst  a  similar  arrangement  may  be 
applied  to  the  fingers  and  toes  for  small  operations,  such  as  avulsion  of  a  toe-nail. 

2.  A  substitute  for  cocaine  has  recently  been  proposed  in  the  synthetic  com- 
pound known  as  Eucaine  Hydrochloride.  Its  toxic  properties  are  much  less 
marked  than  those  of  cocaine,  and  doses  of  even  5  or  10  grains  may  be  employed 
either  hypodermically  or  by  painting  over  a  mucous  membrane.  Its  action  is 
somewhat  slower  than  that  of  cocaine,  and  it  causes  a  little  congestion  of  the 
part,  whilst  cocaine  leads  to  anaemia  ;  it  also  gives  rise  to  a  little  tingling  pain  on 
injection,  and  may  leave  a  certain  amount  of  cedematous  thickening  for  a  time. 
The  reports  hitherto  given  have  been  very  satisfactory,  although,  on  account  of 
the  irritation  produced,  it  does  not  seem  to  be  quite  so  suitable  for  ophthalmic  work. 

Schleich's  Method  of  inducing  local  anaesthesia  consists  in  infiltrating  the 
tissues  of  the  part  with  a  dilute  solution  of  cocaine.  This  has  been  modified  of 
late  by  the  employment  of  eucaine  and  adrenalin,  and  Barker*  recommends  the 
following  formula : 

Distilled  water       ..          ..          ..          ..  1000  c  c.          =  3^  ounces 

^-eucaine     ..          ..          ..          ..          ..  o '2  gramme  =  3  grains 

Sodium  chloride    ..          ..          ..          ..  o-8gramme=i2 

One  pro  mille  adrenalin  chloride  solution  . .          . .          lo  minims 

There  are  no  toxic  effects  associated  with  this  solution,  and  a  considerable 
quantity  is  employed  in  order  to  infiltrate  the  tissues.  If  allowed  to  act  for  thirty 
or  forty  minutes,  the  parts  are  often  found  to  be  not  only  anaesthetic,  but  also 
practically  bloodless.  Operations  of  gravity  can  be  performed  without  pain, 
including  such  conditions  as  strangulated  hernia,  intestinal  obstruction,  tracheo- 
tomy, thyroidectomy,  etc.,  when  a  general  anaesthetic  may  be  undesirable. 

3.  Local  anaesthesia  is  also  produced  by  freezing  the  part,  either  by  the  appli- 
cation of  ice  and  salt,  or  by  the  ether  spray,  or  with  ethyl  chloride.  The  latter 
reagent  is  now  put  up  conveniently  in  small  glass  or  thin  metal  flasks  with  a  fine 
capillary  outlet ;  on  holding  the  flask  in  the  hand  a  spray  is  produced,  which  is 
allowed  to  play  upon  the  part  to  be  operated  on.  The  rapid  evaporation  from 
the  surface  leads  to  the  freezing  of  the  skin,  which  becomes  of  a  dead  white 
colour.  The  anaesthesia  produced  is  of  a  very  fugitive  nature,  and  a  certain 
amount  of  pain  may  be  associated  with  the  thawing  process,  but  less  than  that 
caused  by  the  ether  spray. 

Spinal  Analgesia  is  a  condition  which  results  from  the  introduction  within  the 
spinal  membranes  of  some  substance  which  acts  upon  the  nerve  centres  or  roots, 
and  produces  insensitiveness  to  pain  in  the  regions  supplied  by  them.  At  first 
cocaine  was  employed  for  this  purpose,  but  the  after-effects  were  so  troublesome 
that  it  had  to  be  given  up,  and  the  substance  now  most  generally  utilized  is 
stovaine.  It  is  prepared  in  sterilized  solution  in  glass  ampoules  containing  o"i 
gramme ;  as  a  rule  6-8  centigrammes  are  injected  into  the  cerebro-spinal  cavity. 

The  proceeding  is  very  simple  in  technique.  A  suitable  series  of  needles  and  a 
syringe  easily  sterilizable  are  provided  by  most  instrument-makers  for  this 
purpose.  Care  must  be  taken  that  no  alkali  is  used  in  the  sterilization  of 
syringe  or  needles,  as  stovaine  is  thereby  decomposed  and  becomes  inert.  The 
patient's  back  is  purified,  and  he  is  placed  either  sitting  with  the  head  bent 
well  forwards,  or  lies  on  his  side  doubled  up.  This  position  of  flexion  is  most 
important    in   order    to   open   up  the  intervertebral   spaces  posteriorly.      The 

*  British  Medical  Journal,  December  24,  1904,  p.  1683. 


1348 


A  MANUAL  OF  SURGERY 


site  usually  selected  for  the  injection  is  the  3rd  lumbar  interspace  {i.e.,  between 
the  3rd  and  4th  lumbar  vertebrae),  and  this  corresponds  to  the  summit  of  the  iliac 
crests  (Fig.  580).  The  spot  is,  if  need  be,  frozen  by  chloride  of  ethyl,  and  then 
the  needle  is  introduced  in  the  middle  line,  and  passes  directly  backwards  and 
perhaps  a  little  upwards.  Some  insert  the  needle  about  ^  inch  from  the  middle 
line,  and  then  it  must  also  be  inclined  a  little  inwards.  If  correctly  placed,  the 
resistance  of  the  ligamentum  subflavum  is  felt,  and  subsequently  that  of  the  dura 
mater.  A  successful  puncture  is  followed  by  a  flow  of  cerebro-spinal  fluid,  tinged 
at  first,  perhaps,  with  a  little  blood  ;  a  drachm  or  two  may  be  allowed- to  escape, 
although  the  necessity  or  desirability  of  this  is  not  proven,  and  then  the  stovaine 
solution  is  injected,  and  the  needle  is  withdrawn.  Should  the  needle  impinge  on 
bone,  it  is  wisest  to  take  it  out  and  make  a  fresh  puncture,  either  through  the 
same  interspace  or  through  the  next  above  or  below.  After  the  injection  the 
patient  lies  back  with  a  support  about  4  inches  high,  placed  under  the  sacrum,  so 
as  to  encourage  the  diffusion  of  the  stovaine  up  the  canal  for  a  short  distance. 


Fig.   5S0,— Diagram  of   Patient's  Back  in  the  Sitting  Posture,  and  Site 
OF  Injection  for  inducing  Spinal  Analgesia. 

The  pointer  merely  indicates  the  site  of  injection,  and  not  the  direction  in  which 
the  needle  must  be  inserted. 

This  upward  dissemination  must,  however,  be  limited,  as  the  analgesia  is  associ- 
ated with  motor  paralysis,  and  obviously  the  respiratory  muscles  must  not 
participate  in  this. 

Analgesia  usually  develops  in  from  five  to  twelve  minutes,  and  often  shows 
itself  in  the  perineum  before  appearing  in  the  feet.  Gradually  it  extends  over  the 
whole  lower  extremity,  and  may  reach  to  the  umbilicus,  or  a  little  higher.  It  is 
accompanied  by  motor  paralysis  and  loss  of  the  reflexes,  but  the  patient  may  be 
conscious  of  ordinary  tactile  sensations.  A  certain  proportion  of  failures  will  be 
noted,  and  at  present  it  is  impossible  to  explain  their  occurrence.  When  the 
injection  is  successful,  the  patient  lies  quietly  during  the  operation  with  complete 
muscular  relaxation,  and  can  engage  in  conversation,  smoke  a  cigarette,  or  read 
a  newspaper.  The  administration  need  not  be  followed  by  any  restriction  of  diet, 
but  some  amount  of  headache  may  be  experienced  on  the  same  or  the  following 
day,  and  in  a  few  cases  vomiting.  After-results  in  the  shape  of  nervous  diseases 
involvinff  the  spinal  cord  have  been  reported  in  a  few  instances  as  coming  on 


ANAESTHESIA  1349 

after  a  year  or  two  ;  but  it  is  a  little  difficult  to  be  certain  of  the  causal  relation- 
ship of  the  injection. 

At  the  present  time  the  general  opinion  as  to  the  value  of  this  procedure  is  that, 
whilst  in  suitable  cases  it  may  be  employed  for  operations  below  the  umbilicus 
when  a  general  anaesthetic  is  not  desirable,  yet  as  a  routine  method  of  inducing 
anaesthesia  it  has  but  slight  advantages  over  the  ordinary  plan.  It  is  not  always 
certain  ;  the  injection  is  not  always  painless  ;  the  after-results  are  sometimes 
unpleasant ;  the  patient  is  not  protected  from  nervous  shock  and  apprehension 
during  the  operation  ;  and  the  question  of  late  nervous  sequelae  still  remains  to 
be  decided.  On  the  whole,  its  employment  may  be  advised  when  a  general 
anaesthetic  is  undesirable  owing  to  the  condition  of  the  patient's  heart,  lungs, 
kidneys,  etc.  ;  when  diabetes  is  present  in  an  aggravated  form  ;  when  the  surgeon 
is  short-handed  ;  and  when  very  complete  muscular  relaxation  is  required,  as  in 
dealing  with  fractures.  The  absence  of  struggling  during  and  after  the  adminis- 
tration of  a  general  anaesthetic  makes  it  particularly  desirable  in  the  last  of  these 
conditions. 

It  has  been  shown  by  Jonnesco  and  other  Continental  surgeons*  that  the  higher 
nervous  centres  will  tolerate  the  presence  of  stovaine  as  an  analgesic,  if  a  suitable 
solution  of  strychnine  is  introduced  with  it  so  as  to  protect  the  respiratory  centres 
from  its  paralyzing  effects.  An  injection  of  the  combined  solutions  may  be  made 
between  the  ist  and  2nd  dorsal  vertebrae,  and  in  a  short  time  the  whole  body 
may  become  analgesic,  so  that  even  operations  on  the  head  may  be  undertaken. 
Whether  or  not  such  a  procedure  is  desirable  is  more  than  doubtful,  and  certainlj' 
in  this  country  it  has  not  been  received  with  great  favour. 

General  Anaesthesia. — i.  Nitrous  Oxide  Gas  (N.^O)  is  most  commonly  used  in 
dental  work,  or  for  short  operations,  such  as  bending  a  stiff  joint  and  breaking 
down  adhesions,  the  avulsion  of  a  toe-nail,  or  the  opening  of  an  abscess.  It  is 
practically  safe  and  not  unpleasant,  either  in  its  use  or  in  its  subsequent  effects. 
It  is  also  employed  in  conjunction  with  ether,  the  patient  being  first  anaesthetized 
with  gas,  and  the  condition  maintained  by  ether.  Gas  has  also  been  recom- 
mended for  the  removal  of  adenoids  ;  but  the  general  opinion  now  obtaining  is 
that,  to  perform  this  operation  satisfactorily,  a  more  lasting  anaesthetic  is  required. 
The  gas  is  stored  in  a  condensed  and  liquefied  form  in  special  steel  cylinders, 
closed  by  a  screw  which  can  be  readily  loosened,  so  as  to  allow  the  gas  to  escape 
through  a  tube  into  an  indiarubber  bag.  This  is  attached  to  a  closely-fitting  face- 
piece,  with  a  suitable  arrangement  of  valves  and  stop-cocks,  by  means  of  which 
the  gas  is  allowed  to  reach  the  patient.  A  valvular  exit  for  the  expired  air  is  also 
present  (Fig.  554).  In  its  usual  method  of  administration  the  bag  is  first  filled 
with  gas,  and  then  air  is  completely  excluded  by  carefully  adjusting  the  padded 
face-piece  to  the  irregularities  of  the  face.  Some  anaesthetists,  however,  by  means 
of  a  special  apparatus  devised  by  Dr.  Hewitt,  allow  the  administration  of  a 
minute  proportion  of  pure  oxygen  at  the  same  time,  in  order  to  prevent  the 
lividity  of  the  face  and  the  twitching  of  the  limbs  often  present  when  anaesthesia 
is  induced  in  the  ordinary  way.  These  symptoms  of  incipient  asphyxia  may  also 
be  avoided  by  allowing  the  last  few  inspirations  of  the  gas  to  be  mixed  with  air. 
This  may  be  done  by  raising  the  face-piece,  by  opening  the  air-valve,  or,  as 
suggested  by  Dr.  Flux,  by  using  an  open  inhaler  into  which  the  gas  is  poured. 
Of  course,  in  removing  teeth  the  mouth  is  firmly  gagged  open  prior  to  the  com- 
mencement of  the  administration. 

2.  Chloroform  is  perhaps  the  anaesthetic  most  generally  employed,  on  account 
of  the  ease  with  which  it  can  be  administered,  although  there  can  be  but  little 
doubt  that  its  use  is  attended  with  somewhat  more  risk  than  that  of  ether. 
Much  controversy  has  arisen  as  to  whether  the  heart  is  ever  directly  affected  by 
the  drug,  or  whether  the  dangerous  symptoms  met  with  are  not  due  to  primary 
failure  of  the  respiration.  The  experimental  evidence  on  the  subject  is  of  a  very 
conilicting  nature  ;  and  it  is  impossible  as  yet  to  consider  the  question  solved. 
The  Scotch  school  of  surgeons,  headed  by  Syme  and  Lister,  has  always  main- 
tained that  the  breathing  alone  need  be  watched  during  the  administration  of 
chloroform,  failure  of  the  respiration  being  the  first  danger-signal  ;  the  second 

*  See  Jonnesco,  Brit.  Med.  Journ.,  November  13,  igog. 


1350  A  MANUAL  OF  SURGERY 

so-called  Hyderabad  Commission  has  sought  to  confirm  this  view.  Many  practical 
surgeons  and  anaesthetists  oppose  the  statement,  holding  that,  although  the 
respirations  may  fail  first  in  a  large  percentage,  and  probably  a  majority,  of  fatal 
cases,  yet  there  are  a  certain  number  in  which  heart  failure  is  also  seeh  as  a  result 
of  the  direct  toxic  effect  of  the  chloroform  upon  its  muscular  substance.  Certainly 
in  not  a  few  instances  of  death  during  the  administration  of  chloroform  the  heart 
stops  first,  but  a  great  distinction  must  be  drawn  between  the  deaths  which  result 
from  chloroform,  and  the  deaths  that  occur  during  the  administration  of  chloroform. 
An  overdose  of  chloroform,  without  doubt,  leads  to  failure  of  the  respiration  ; 
but  in  the  majority  of  such  cases,  if  suitable  precautions  are  adopted  sufficiently 
early,  a  fatal  result  may  be  averted.  Cases  in  which  the  heart  stops  first  are 
probably  due  to  syncope,  and  are  not  entirely  dependent  on  the  nature  of  the 
anaesthetic  administered. 

Attention  has  been  drawn  recently  to  a  condition  known  as  delayed  chloroform 
poisoning,  which  is  chiefly  observed  in  children,  and  then  in  cases  where  grave 
toxaemia  is  present.  It  commences  about  12  hours  after  the  administration  with 
vomiting,  the  ejecta  usually  resembling  beef  tea,  which  persists  in  spite  of  all 
treatment,  and  the  child  becomes  drowsy,  apathetic,  and  finally  dies  about  the 
fifth  day  in  a  condition  of  coma.  Some  slight  degree  of  icterus  may  be  noted. 
The  breath  smells  of  acetone,  and  the  blood  contains  both  acetone  and  diacetic 
acid  ;  these,  however,  can  often  be  detected  in  children  after  chloroform,  and  in 
some  other  conditions.  Post  mortem  the  most  marked  phenomenon  is  an  intense 
fatty  degeneration  of  the  liver,  and  to  some  extent  of  other  organs  ;  but  Guthrie 
thinks  that  the  hepatic  condition  has  probably  preceded  the  administration  to  a 
slight  extent,  and  that  the  chloroform  was  merely  the  final  element  in  determining 
the  outbreak  of  trouble.  In  adults  a  similar  condition  arises  a  day  or  two  after 
the  operation,  and  perhaps  most  commonly  in  cases  of  grave  toxaemia,  e.g., 
suppurative  appendicitis.  The  symptoms  are  those  of  acute  yellow  atrophy  of 
the  liver,  including  persistent  vomiting,  well-marked  jaundice,  delirium,  and 
finally  coma.  The  liver  is  extensively  involved,  and  undergoes  evident  degenera- 
tive changes.  Nothing  can  be  done  as  a  rule,  although  the  indications  are  to 
reduce  the  toxic  absorption  from  the  wound  as  far  as  possible,  and  to  flood  the 
system  with  alkalies ;  death  is  the  usual  outcome,  and  occurs  about  the  third  day. 

Chloroform  may  be  given  in  several  different  ways,  but  in  all  the  chief  points 
to  be  attended  to  are  regularity  of  dose,  and  full  admixture  with  air,  so  that  not 
more  than  4  per  cent,  of  the  vapour  is  inspired.  The  plan  so  often  employed  of 
pouring  an  unknown  quantity  of  chloroform  on  a  piece  of  lint,  folded  in  two  or 
three  layers  and  held  close  to  the  patient's  nose  and  mouth,  is  most  unscientific  and 
to  be  strongly  condemned.  The  Open  Method  is  that  recommended  by  Lord 
Lister.  A  mask  reaching  from  the  root  of  the  nose  to  the  chin  is  made  from  the 
side  of  a  towel,  and  fixed  with  a  safety-pin.  This  is  first  held  some  inches  above 
the  patient's  nose,  and  moistened  from  the  outside  with  chloroform  from  a  drop- 
bottle.  As  the  respiratory  passages  become  tolerant  of  the  drug,  the  mask  is 
gradually  lowered  to  touch  the  face,  and  is  kept  continually  moistened.  At  the 
end  of  two  or  three  minutes  the  respirations  increase  in  frequency,  and  a  stage  of 
excitement  may  be  reached,  during  which  the  patient  may  sing,  shout,  or  struggle 
violently.  The  anaesthetic  is  still  cautiously  pushed,  care  being  taken  that  during 
the  deep  respirations  which  follow  the  struggling  stage  an  overdose  is  not  ad- 
ministered. Complete  anaesthesia  is  indicated  by  relaxation  of  the  muscles,  loss 
of  the  corneal  reflex,  and  contraction  of  the  pupil,  and  it  is  usually  attained  in 
about  five  minutes.  As  long  as  the  operation  lasts,  the  anesthetist  must  endeavour 
to  maintain  this  condition,  but  the  amount  needed  during  the  later  stages  is  much 
less  than  at  its  commencement. 

Junker's  inhaler  is  often  used  for  giving  chloroform,  especially  in  operations 
about  the  nose  and  face.  It  is  economical,  and  on  the  whole  satisfactory.  In 
this  apparatus  air  is  pumped  through  a  layer  of  chloroform  to  an  inhaler  placed 
over  the  patient's  mouth,  or  to  a  tube  passed  into  his  nose.  The  air  laden  with 
chloroform  is  inspired,  and  produces  the  usual  constitutional  effects  ;  the  amount 
administered  is,  to  a  certain  extent,  regulated  by  the  rapidity  with  which  the  india- 
rubber  bulb  of  the  apparatus  is  squeezed  ;  after  a  time,  however,  the  lowered 
temperature  induced  by  the  evaporation  leads  to  a  diminution  in  the  amount  of 


ANESTHESIA 


I3SI 


chloroform  vapour  given  off.     Accidents  have  happened  with  this  apparatus  from 
filling  the  bottle  too   full,  or  from  having  the  indiarubber  tubes  fixed   to  the 
wrong  nozzles  ;  in  either  instance  liquid  chloroform  may  be  pumped  out  of  the 
exit-tube. 
3.  Ether  is  generally  considered  to  be  a  safer  anaesthetic  than  chloroform,  in 


Fig.  581. — Apparatus  for  the  Administration  of  Nitrous  Oxide  and 
Ether  in  Combination. 

A,  Steel  cylinders  containing  compressed  nitrous  oxide  ;  B,  indiarubber  bag  ; 
C,  three-way  stop-cock  with  valves  ;  D,  Clover's  ether  chamber  ;  E,  face- 
piece.  If  nitrous  oxide  alone  is  administered,  D  is  omitted.  When  ether 
alone  is  used,  A  and  C  are  omitted,  and  a  smaller  bag  substituted  forB. 

that  it  is  a  cardiac  stimulant.     It  is  usually  administered  by  Clover's  apparatus  or 
by  an  Ormsby's  mask. 

Clover's  apparatus  (Fig.  581,  D  and  E)  consists  of  a  face-piece  similar  to  that 
utilized  for  giving  nitrous  oxide,  a  metal  receptacle  for  the  ether,  and  a  bag.  In 
this  apparatus  the  air  used  in  respiration  passes  over  the  surface  of  the  ether  con- 
tained in  the  receptacle,  the  proportion  of  ether  inspired  being  regulated,  so  that 


1352  A  MANUAL  OF  SURGERY 

at  first  a  considerable  admixture  of  air  is  permitted,  whilst  later  on  ether  vapour 
in  the  proportion  of  a  third,  a  half,  or  even  two-thirds,  is  inhaled.  The  chief 
advantage  of  this  apparatus  is  the  ease  with  which  the  amount  of  ether  adminis- 
tered is  regulated  ;  but  a  distinct  disadvantage  exists  in  the  fact  that  the  patient 
breathes  his  own  expired  air  again  and  again,  and  so  unless  care  is  taken,  he  is 
likely  to  become  C3-anosed.  This  can,  however,  be  prevented  by  removing  the 
mask  occasionally,  and  giving  the  patient  a  few  breaths  of  unmixed  air.  Another 
objection  lies  in  the  amount  of  mucus  which  often  collects  about  the  pharynx, 
whilst  the  moisture  in  the  expired  air  condenses  in  the  bag,  which  becomes  very 
objectionable  unless  carefully  washed  out  after  each  administration. 

In  Oymsby's  mask  the  ether  is  poured  over  a  sponge  which  is  contained  in  a 
wire  frame  prolonged  from  the  face-piece,  and  covered  by  a  rubber  bag  into  which 
the  patient  breathes.  It  is  an  unpleasant  means  of  inducing  anaesthesia,  but 
may  be  employed  for  maintaining  it  after  the  use  of  gas.  The  same  objections 
hold  good  as  in  Clover's  apparatus,  and  the  same  precautions  as  to  letting  in 
atmospheric  air  from  time  to  time  must  be  observed. 

In  the  administration  of  ether  it  is  now  usual  to  adopt  what  is  known  as  the 
'  gas  and  ether  method,'  by  which  is  meant  that  the  patient  is  first  anaesthetized 
with  nitrous  oxide,  and  the  anaesthesia  is  continued  and  maintained  by  means 
of  ether.  If  the  Clover's  inhaler  is  to  be  used,  the  arrangement  shown  in 
Fig.  581  is  emploj'ed,  a  Clover's  ether-chamber  being  interposed  between  the 
face-piece  and  the  three-way  tube  of  a  nitrous  oxide  apparatus.  The  patient  is 
first  allowed  some  six  or  eight  full  inspirations  of  nitrous  oxide  gas,  and  then  the 
ether-chamber  is  turned  to  permit  of  gradually  increasing  doses  of  ether  vapour. 
As  soon  as  symptoms  of  nitrous  oxide  narcosis  present  (t^^dtching  of  muscles, 
irregular  stertor,  etc.),  the  gas-bag  is  detached  and  the  ordinary  ether-bag 
substituted. 

The  Ormsby's  mask  does  not  permit  of  this  gradual  addition  of  ether  vapour ; 
full  nitrous  oxide  anaesthesia  must  be  induced  with  the  ordinary  apparatus,  and 
then  a  rapid  change  is  made  to  the  fully-charged  ether  inhaler.  The  results  are 
sufficient!}^  satisfactorj',  but  much  more  experience  and  skill  are  required  than 
when  the  Clover  apparatus  is  used. 

The  advantages  claimed  for  this  '  combined  method  '  are  that  anesthesia  is 
induced  much  more  rapidly  (two  minutes),  and,  what  is  far  more  important, 
the  process  is  much  less  unpleasant  for  the  patient  than  when  ether  alone  is 
employed.  The  patient  is  apt,  especially  when  the  Ormsby's  mask  is  used,  to 
become  rather  livid  and  rigid,  but  these  conditions  pass  off  in  the  course  of  a 
minute  or  two. 

4.  To  obviate  the  depressing  effects  of  chloroform,  a  combination  known  as 
the  A.C.E.  Mixture  is  often  used,  consisting  of  alcohol,  chloroform,  and  ether, 
blended  in  the  proportion  of  one,  two,  and  three  parts  respectively.  It  ma}^  be 
given  either  from  a  Rendle's  mask,  or  by  the  open  method  as  for  chloroform, 
but  the  latter  plan  is  only  applicable  to  children  and  weakly  individuals,  who 
require  but  little  anpssthetic.  Rendle's  mask  consists  of  an  oval  box  open  at  one 
end  and  shaped  to  fit  the  nose  and  mouth,  and  the  fundus  perforated  with  holes 
to  permit  of  the  free  entrance  of  air  ;  it  may  be  made  of  leather,  or  preferably  of 
celluloid  or  metal.  Two  or  three  sponges  are  placed  within  it,  and  soaked  with 
the  anaesthetic,  the  patient  breathing  in  and  out  of  the  cone.  The  inspired  air  is 
thus  laden  with  the  vapour,  and  the  amount  admitted  is  regulated  in  measure  by 
covering  a  certain  proportion  of  the  inlet  holes  with  the  hand.  The  objection  to 
this  reagent  is  that  it  evaporates  somewhat  unequally,  the  ether  coming  off  first, 
and  leaving  an  excess  of  chloroform,  which  when  administered  in  a  cone  may 
be  dangerous ;  this  can,  however,  be  obviated  by  remoistening  the  sponges 
alternately  with  the  mixture  and  with  pure  ether. 

5.  During  recent  years  ethyl  chloride  has  been  introduced  as  a  general 
anaesthetic  with  excellent  results.  It  may  be  used  {a)  for  short  operations  on 
the  mouth  or  nose — e.g.,  tooth-extraction  or  removal  of  adenoids,  where  a  single 
dose  is  sufficient  for  the  purpose;  (b)  for  minor  operations  elsewhere — e.g., 
opening  abscesses,  reducing  fractures  and  dislocations ;  and  [c)  for  inducing 
anaesthesia,  which  can  be  maintained  by  ether,  in  prolonged  operations.  Its 
utility  is  limited  by  its  extremely  volatile  nature  and  by  the  method  which  must 


ANESTHESIA  1353 

be  employed  in  its  administration.  For  this  purpose  an  Ormsby's  mask  is 
utilized;  2  or  3  c.c.  are  poured  on  the  sponge,  and  the  apparatus  is  firmly  placed 
over  the  patient's  mouth.  Anaesthesia  is  quickly  induced  without  struggling  or 
suffocative  effects,  and  after  the  operation  is  over  the  patient  rapidly  regains  con- 
sciousness, and  rarely  suffers  from  unpleasant  after-effects.  Ethyl  chloride,  how- 
ever, is  not  free  from  danger,  and  a  number  of  fatalities  have  been  reported  as  due 
to  it.  It  should,  therefore,  only  be  administered  by  a  skilled  anaesthetist,  and 
not  apart  from  careful  preparation  of  the  patient. 

G-eneral  Remarks  as  to  the  Administration  of  Anaesthetics. 

The  medical  practitioner  must  never  lose  sight  of  the  fact  that  a  certain  element 
of  risk  is  necessarily  attached  to  the  artificial  induction  of  a  condition  in  which 
the  activity  of  the  nervous  system  is  entirely  suspended,  except  for  the  maintenance 
of  those  phenomena  which  are  actually  essential  for  life.  Hence,  an  anaesthetic 
should  never  be  given,  unless  absolutely  necessary,  without  careful  preparation 
of  the  patient,  or  such  examination  as  shall  satisfy  the  doctor  as  to  his  capability 
of  safely  taking  it. 

The  Preparation  of  the  Patient  is  a  most  important  proceeding.  When  prac- 
ticable, the  general  habits  of  the  individual  should  be  carefully  regulated  for  a 
few  days  prior  to  the  operation,  and  on  the  preceding  night  a  suitable  purgative 
is  administered,  castor  oil  being,  perhaps,  the  most  efficacious.  Any  food  given 
on  the  morning  of  the  operation  should  be  light  and  easily  assimilable,  whilst 
nothing  should  be  taken  for  at  least  three  hours  previously,  so  as  to  make  sure 
that  the  stomach  is  empty.  In  casualty  cases,  it  may  be  advisable  to  relieve 
gastric  distension  with  an  emetic,  or  by  washing  out  the  organ  before  com- 
mencing the  administration.  The  anaesthetist  must  ascertain  that  no  loose 
artificial  teeth  are  present  in  the  mouth,  and  that  no  tight  clothes  or  bands 
encircle  the  neck  or  thorax.  In  veiry  nervous  patients,  or  where  much  shock  is 
anticipated,  a  preliminary  hypodermic  injection  of  strychnine  or  a  nutrient  enema 
may  be  administered. 

The  preliminary  hypodermic  administration  of  scopolamine  (gr.  -5^)  and  mor- 
phine (gr.  J),  has  been  recommended  by  some  authorities  as  a  means  of  inducing 
ordinary  sleep,  and  thereby  diminishing  the  amount  of  anaesthetic  required. 
A  dose  is  given  three  or  four  hours,  and  another  one  hour,  before  the  time  of 
operation.  There  is  a  good  deal  of  difference  of  opinion  as  to  the  value  of  this 
procedure  ;  sometimes  it  acts  perfectly,  and  the  patient  escapes  the  discomforts 
caused  by  the  larger  doses  of  anaesthetic ;  at  other  times  it  causes  great  mus- 
cular rigidity  and  increased  bleeding,  so  that  some  surgeons  condemn  it  most 
vigorously.  Further  experience  is  required  to  enable  us  to  indicate  the  type  of 
case  in  which  it  is  beneficial  or  otherwise. 

The  anaesthetic  should  never  be  pushed  in  the  early  stages,  but  is  given  slowly 
and  gradually,  especially  in  nervous  individuals.  When  there  is  any  struggling, 
the  movements  of  the  limbs  should  be  restrained  with  as  little  force  as  possible, 
and  care  must  be  taken  during  the  deep  respirations  which  follow  such  struggling 
not  to  administer  an  overdose.  The  condition  which  the  administrator  should 
aim  at  maintaining  is  one  characterized  by  total  muscular  relaxation,  insensitive- 
ness  of  the  cornea,  and  a  contracted  state  of  the  pupil,  whilst  the  pulse  and 
breathing  continue  regular.  If  the  pupil  commences  to  dilate,  and  the  corneal 
reflex  is  present,  the  patient  is  apt  to  move  when  the  knife  is  used,  indicating  that 
more  anaesthetic  is  required.  Dilatation  of  the  pupil  with  an  insensitive  cornea 
is  always  an  indication  for  suspending  the  administration  for  a  time.  If  the 
anaesthesia  is  not  sufficiently  deep,  vomiting  is  likely  to  occur,  being  ushered  in 
by  weakness  and  rapidity  of  the  pulse,  and  pallor  of  the  face ;  this  may  often  be 
averted  by  pushing  the  anaesthetic.  The  anaesthetist's  chief  attention  must  be 
directed  to  observing  the  state  of  the  respiration  and  pupil ;  but  he  should  also 
note  the  colour  of  the  lips,  cheeks,  and  ears,  as  thereby  valuable  information  is 
gained  as  to  the  condition  of  the  circulation.  The  pulse  should  be  felt  occasion- 
ally, but  it  is  less  important  to  attend  to  this  than  to  the  other  points  noted  above. 
After  the  deep  anaesthesia  required  in  division  of  the  skin,  most  operative  pro- 
ceedings on  the  subcutaneous  tissues  are  comparatively  painless,  and  hence  the 


1354  ^  MANUAL  OF  SURGERY 

anaesthetic  need  not  be  pushed  quite  so  far.  Whilst  the  wound  is  being  closed, 
the  patient  must  be  again  somewhat  more  completely  under  control.  In  opera- 
tions upon  the  mouth  associated  with  hsemorrhage,  the  head  must  be  occasion- 
ally turned  to  one  side  to  allow  the  blood  to  gravitate  out  of  the  mouth,  and  the 
pharynx  well  sponged,  so  as  to  prevent  the  admission  of  clot  and  other  matters 
into  the  air-passages.  It  is  also  a  valuable  routine  plan  to  insist  upon  the  hep.d 
always  being  turned  on  one  side,  especially  when  ether  is  being  given,  since 
mucus  tends  to  collect  about  the  pharynx. 

The  After-Treatment  of  the  patient  is  always  a  matter  of  considerable  im- 
portance. He  is  carried  from  the  table  and  placed  on  his  back,  or  preferably, 
when  possible,  on  his  right  side,  in  bed  with  the  head  low.  When  there  is  any 
tendency  to  shock,  hot-water  bottles,  well  wrapped  up,  should  be  applied  to  the 
feet  and  sides,  and  hot  blankets  over  all.  Absolute  quiet  must  be  enjoined  for 
some  hours,  and  the  room  darkened,  so  that,  if  possible,  the  patient  may  fall 
asleep.  No  food  is  administered  for  at  least  three  or  four  hours,  and  then  only 
very  cautiously,  a  little  weak  tea,  soda-water,  or  beef-tea  being  given.  The 
patient  is  likely  to  vomit  on  returning  from  unconsciousness,  perhaps  bringing 
up  a  little  bile-stained  mucus,  but  if  the  anaesthetic  has  been  judiciously  given» 
it  soon  ceases.  Occasionally,  however,  the  vomiting  persists  for  some  time, 
becoming  very  troublesome.  It  may  generally  be  checked  by  a  hypodermic 
injection  of  morphia,  and  by  washing  out  the  mouth  with  warm  water  ;  but  in 
more  severe  cases,  lasting  for  some  days,  the  patient's  nutrition  may  have  to  be 
maintained  by  enemata,  and  the  stomach  kept  absolutely  at  rest.  Benefit  may 
sometimes  be  derived  by  giving  a  little  bismuth  and  hydrocyanic  acid  in  an 
effervescing  mixture,  or  perhaps  champagne  ;  but,  as  a  rule,  all  administration  of 
food  by  the  mouth  should  be  stopped  until  the  vomiting  has  ceased. 

Three  chief  Dangers  are  encountered  during  the  administration  of  anaesthetics  : 

I  Obstructed  Eespiration  usually  results  from  falling  backwards  of  the  root 
of  the  tongue,  which  blocks  the  entrance  of  air  into  the  larynx.  The  respira- 
tions gradually  become  more  and  more  stertorous,  the  face  and  ears  become 
dusky,  and,  if  the  condition  is  not  relieved,  the  chest  continues  to  heave  without 
any  air  entering  or  leaving  it,  and  finally  ceases  when  the  patient  is  completely 
asphyxiated.  The  early  stages  of  this  condition  are  of  common  occurrence, 
whatever  the  anaesthetic,  and  the  administrator  must  always  be  on  the  look-out 
and  endeavour  to  prevent  it  by  turning  the  head  or  the  patient  himself  so  that 
the  tongue  falls  to  one  side.  If  it  occurs  in  spite  of  this  position  being  adopted, 
the  administration  is  at  once  suspended,  whilst  the  tongue  must  at  all  hazards  be 
drawn  forwards.  This  may  be  accomplished  in  the  early  stages  by  pulling  on  the 
beard  or  chin,  or  by  pressing  the  mandible  forwards  by  the  fingers  placed  behind 
the  angle  of  the  jaw.  In  the  later  stages  the  mouth  should  be  forcibly  opened  by 
a  gag,  and  the  tongue  grasped  by  forceps  and  pulled  well  forwards,  or  a  finger 
may  be  passed  back  into  the  pharynx  to  draw  the  root  and  epiglottis  forwards, 
and  at  the  same  time  ascertain  that  the  entrance  to  the  glottis  is  free  from  obstruc- 
tion. Artificial  respiration  should  be  undertaken  if  the  breathing  has  actually 
stopped.  Death  ought  never  to  result  from  this  cause,  and  if  it  occurs,  it  can  only 
be  attributed  to  the  carelessness  of  the  anaesthetist  . 

Obstruction  to  the  respiration  may  occasionally  arise  from  the  entrance  of 
vomited  material  into  the  air-passages  or  lungs,  the  patient  becoming  cyanosed 
during  an  attack  of  vomiting,  and  passing  rapidly  into  a  state  of  asphyxia.  In 
such  a  case  the  finger  must  be  swept  round  the  pharynx,  if  the  mouth  can  be 
opened,  to  see  that  the  glottis  is  clear,  whilst  tracheotomy  or  laryngotomy  may 
be  necessary  should  the  teeth  be  firmly  clenched,  or  if  the  obstruction  is  below 
the  entrance  to  the  glottis.     Fortunately,  this  accident  is  of  rare  occurrence. 

2.  Complete  Cessation  of  Respiration  is  the  usual  primary  phenomenon  from 
an  overdose  of  chloroform  ;  it  is  also  stated  to  happen  occasionally  during  ether 
narcosis.  The  pulse  continues  to  beat  distinctly  for  a  few  seconds,  although 
respiratory  movements  have  ceased.  Treatment  consists  in  at  once  stopping  the 
administration,  whilst  the  tongue  is  drawn  forwards,  and  the  fauces  cleared  by 
the  finger.  The  head  should  be  lowered  over  the  end  of  the  table,  and  young 
children  may  even  be  completely  inverted,  so  as  to  induce  a  flow  of  blood  to  the 
head.     Artificial  respiration  is  commenced  without  delay,   whilst  the  thoracic 


ANMSTHESiA  1355 

parietes  may  be  flicked  with  a  cold  wet  towel,  or  alternately  douched  with  hot 
and  cold  water.  Strychnine  or  ether  should  also  be  injected  hypodermically, 
and  if  the  condition  persists  and  the  heart's  action  ceases,  a  Faradic  current  may 
be  passed  from  the  second  or  third  intercostal  space  in  front  to  an  electrode 
placed  over  the  spine.  Attempts  at  resuscitation  should  be  continued  for  half  to 
three-quarters  of  an  hour.  At  the  same  time,  these  measures  must  be  undertaken 
with  discretion,  as  otherwise  it  is  quite  possible  to  extinguish  the  feeble  spark  of 
life  by  the  very  means  which,  used  wisely,  would  have  restored  it. 

3.  Death  occasionally  results  from  primary  Cardiac  Failure,  which  may  arise 
{a)  from  fright  during  the  administration  of  the  anesthetic  ;  (&)  from  shock  with 
cardiac  inhibition,  by  commencing  the  operation  before  complete  anaesthesia  has 
been  obtained  ;  and  [c)  from  an  overdose  of  chloroform  or  ether  acting  directly 
on  the  nerve  centres  or  on  the  muscular  substance  of  the  heart.  On  post-mortem 
examination  in  such  cases,  the  heart  muscle  is  found  to  be  thin  and  flabby, 
and  perhaps  infiltrated  with  fat ;  the  ventricular  walls  are  especially  affected. 
Unfortunately,  this  condition  cannot  be  recognised  with  certainty  by  the  stetho- 
scope. Patients  with  simple  valvular  lesions,  where  the  defect  has  been  more  or 
less  compensated,  do  not  generally  run  any  extra  risk.  The  treatment  to  be 
adopted  in  cases  of  cardiac  failure  during  anaesthesia  is  the  same  as  for  stoppage 
of  the  respiration. 

In  this  connection  it  is  important  to  note  the  association  of  sudden  death  from 
heart  failure  with  the  condition  known  as  Status  Lymphaticus.  It  usually  occurs 
in  children,  and  is  characterized  by  overgrowth  of  the  lymphatic  tissues  of  the 
body,  especially  in  the  pharynx,  and  of  the  tonsils,  abdominal,  and  mediastinal 
glands.  The  thymus  also  remains  enlarged,  and  the  spleen  and  bone  marrow  may 
be  in  a  condition  of  hyperplasia.  The  administration  of  an  anaesthetic  is  by  no 
means  the  only  cause  of  sudden  death  in  this  condition,  as  it  has  been  known  to 
follow  the  hypodermic  injection  of  antidiphtheritic  serum,  sudden  plunging  into 
cold  water,  and  such  minor  ailments  as  bronchitis.  It  is  usually  only  discovered 
after  death,  but  if  it  is  suspected,  the  greatest  care  must  be  exercised  in  adminis- 
tering an  anaesthetic,  since  the  lethal  dose  is  obviously  very  small  in  such 
patients.     Ether  should  be  given,  and  for  choice  by  the  open  method. 

The  Choice  of  an  Ansesthetic  in  any  particular  case  depends  mainly  on  the  con- 
dition of  the  circulatory  and  respiratory  apparatus  of  the  patient.  Ether  is  perhaps, 
on  the  whole,  the  safest  agent  to  employ,  especially  in  adults,  although  it  is  less 
pleasant  to  take  ;  it  may  cause  a  good  deal  of  bronchial  irritation  and  congestion, 
and  is  more  likely  to  give  rise  to  troublesome  after-vomiting,  although  such  does 
not  usually  last  long.  It  is  sometimes  followed  by  unpleasant  delirium.  Chloro- 
form is  easier  to  administer,  more  pleasant  to  take,  and  less  likely  to  lead  to 
objectionable  after-effects.  It  is  the  best  anaesthetic  for  young  children  and  old 
people,  though  its  action  upon  the  heart  contra-indicates  its  use  in  patients  whose 
circulation  is  weak,  or  where  there  is  any  suspicion  of  the  existence  of  the  status 
lymphaticus.  The  A.C.E.  mixture  may  also  be  safely  employed,  if  the  pre- 
cautions already  indicated  on  an  earlier  page  are  attended  to. 

Ether  is  certainly  contra-indicated  in  patients  suffering  from  any  bronchitic  or 
pulmonary  trouble,  and  its  administration  for  operations  about  the  face  or  mouth 
is,  of  course,  impracticable.  Chloroform  should  not  be  given  in  cases  of  cardiac 
weakness  or  advanced  renal  disease  ;  for  abdominal  work  it  is  usually  preferred 
to  any  other  agent,  as  also  in  operations  on  the  brain,  but  it  is  important  to  note 
that  in  septic  conditions  in  the  abdomen — e.g.,  suppurative  appendicitis  in  children 
— the  results  of  chloroform  administration  seem  to  be  much  less  satisfactory  than 
when  ether  is  given.  The  mortality  over  an  extended  series  of  cases  is  much 
greater  with  chloroform  than  with  ether. 


INDEX 


N.B. — The  more  important  references  are  always  placed  first,  the  less  important 

afterwards. 


Abbe's  string  saw,  883 
Abdominal  aorta,   compression  of,   290, 
326 
ligature  of,  327.  337 
aneurism.  326 
excision  of  rectum,  11 74 
exploration  of  kidney,  1179 
hysterectomy,  1309,  1314 
nephrectomy,  1208 
operations,  general  remarks  on,  969- 

976 
surgery    (Chapter    XXXIV.),    969- 

1086 
walls,  injuries  of,  976,  1063 
wounds,' mortality  of  gunshot,  243 
visceral  complications  of,   976, 
977 
Abdomino-perineal   excision   of  rectum, 

1175 
Abernethy's    operation    for    ligation    of 

external  iliac  artery,  339 
Abscess,  abdominal,  986 
acute,  62,  59 
due  to  auto-infection,  63 
signs  and  s\Tnptoms  of,  66 
structure  of,  64 
treatment  of,  71 
alveolar,  806,  810 
anal,  11 50 
antral,  811 

appendicitic,  1049,  105 1,  1059 
atheromatous,  304 
axillary,  366 

cerebellar,  784,  8g6,  782,  786 
cerebral,  782,  755,  761,  771,  894,  896 
chronic,  172,  72,  312,  678,  783,  1097, 
1192 
of  bone,  582 
of  brain,  783 
of  breast,  950 
of  joints,  657 
of  spinal  disease,  721,  730 
cold,     72.     See     also    Tuberculous 

abscess 
dorsal,  722,  730 
embolic,  1064,  63,  87 
encj'Sted,  of  breast,  950 
of  liver,  1066 


Abscess,  evacuation  of,  71 

extradural,  777,  784 

extraperitoneal,  990,  1050 

froatal  lobe  of  brain,  755,  783 

frontal  sinus,  755 

gas  in,  70 

gluteal,  682 

healing  of,  66 

iliac,  726 

in  appendicitis,  1049,  1051.  lu^g 

in  bone,  582 

in  groin,  366 

in  hip  disease,  682,  726 

in  kidney,  1191 

in  neck,  366 

in  spinal  disease,  721 

in  tram  am  m  ary,  947 

intrapelvic,  6S2,  688 

intraperitoneal,  1049,  986.  990,  995, 
998,  1023,  1024,  1051 

ischio-rectal,  115 1,  1272,  688 

lacunar,  137,  1273 

lumbar,  723,  730,  1113 

mastoid,  892 

of  brain.     See  Cerebellar  and  cere- 
bral abscess 

of  breast,  946 

of  labium,  1304 

of  liver,  1064 

of  lung,  915,  937 

of  scalp,  736 

of  spleen,  10S4 

of  tongue,  847 

palmar,  248 
^    parotid,  858,  823 

pelvic,  81 

pelvi-rectal,  1152 

pericaecal,  1062 

perineal,  1262,  1272 

perinephric,    1192,  726,  1050,    1184, 
1186,  1193 

perirectal,  1170 

peritonsillar,  87 1 

peri-urethral,  1271,  1259 

prostatic,  1245,  1272,  1273 

psoas,  723,  174,  682,  1 107 
treatment  of,  730 

pyaemic,  87,  88,  1191 


1357 


I35S 


A  MANUAL  OF  SURGERY 


Abscess,  residual,  725,  174. 

retroperitoneal,  990,  1021,  1197 

retropharj-ngeal,  S77,  721,  916 

secondax}',  SS,  89 

spinal,  721 

sterile,  62,  1065 

subaponeurotic,  736 

subcranial,  777,  744,  751,  894 

sublingual,  856,  81 

submammary,  947 

subpericranial,  736,  742 

subperiosteal,  569,  572,  810 

subphrenic.   990,    1002,    1019,    1049. 
1077,  1081 

subpsoas,  682 

supra -mammary,  947 

tropical,  1065 

tuberculous,  172,  72,  367,  368,  582, 
657.  678,  721,  725.  783.  929. 
950,  1151,  1193,  1285 
treatment  of,  176,  657,  730,  877 

typhoid,  63 

iirethral.     See  Perineal  abscess 

wall,  structure  of,  64,  172 
Accessory  auricles,  887 

sinuses  of  nose,  affections  of,  833 

thyroids,  910 
Accommodative  shortening  of  muscles, 

450 
A.C.E.  anaesthetic  mixture,  1352 
Acephiu^ocyst,  227 
Acetabulum,  fracture  of,  530,  632 

travelling,  678 
Acetone  in  diabetes,  1236 
Achondroplasia,  594 
Achorion  Schonleinii,  10 
Acid-fast  bacilli,  8 

Acid-phosphate  of  lime  calculi,  1195 
Acinous  cancer,  958,  814 

cj'Sts,  951 
Acne,  826 

Acquired  hernia,  causes  of,  1088 
Acquired  immunity,  15 

inguinal  hernia,  1088 

vaginal  hj'drocele,  1292 
Acro-arthritis,  672 
Acromegaly,  596,  434 
Acromion,  dislocation  of,  618 

fracture  of,  495 
Actinomycosis,  181,  8,  10,  13,  820,  856, 

1062,  1070 
Active  hyper£Emia,  46 

immimity,  15 

incontinence  of  urine,  1226 
Acupressure,  285 
Acupuncture  for  aneurism,  319,  32r,  326 

for  hydrocele,  1293 

for  neuritis,  379 
Acute  arthritis,  645,  678,  611,  572,  822 
of  infants,  570,  589 

bedsore,  112 

birrsites,  422 

cancer  of  breast,  961,  216 

cystitis,  121 5,  138 

dilatation  of  stomach,  loio 

emphj'sematous  gangrene,  113,  77 

enteritis,  1025,  1020,  1117,  1124 

epididjTnitis.  1283 


Acute  exanthemata,  86 

goitre,  910,  903 

hj'drocele,  1291,  1283 

infective   arthritis   of   infants,    570, 
589 

mfiammation  (Chapter  II.),  31-44 

intestinal  ob-'truction,  1129-1136 

intussusception,  1141 

meningitis,  761,  778 

myositis,  415 

neuritis,  379 

orchitis,  1283 

osteo- arthritis,  667 

osteo-m3'elitis,  568,  928 

pancreatitis,  108 1 

parenchymatous  glossitis,  846 

peritonitis,  982-987 

prostatitis,  1245 

pycemia,  88 

rhinitis,  830 

sapraemia,  84 

septicemia,  84,  247 

spreading  oedema  of  brain,  768,  765 
gangrene,  113 

synovitis,  641 

teno-sjTiovitis,  416 

tuberculosis,  13,  1192 

lilcer  of  stomach,  999 
Adams'  osteotomy,  677 

subcutaneous  operation  for  Dupuy- 
tren's  contraction,  440 
Adder's  bite,  246 
Adductor  longus,  injury  of,  414 
Adenocele  (of  breast),  956    * 
Adenoids,  840,  888,  889 
Adenoma,  sebaceous,  408,  738 
Adenomata,  209 

congenital,  716 

intracanalicular  of  breast,  956 

malignant,  214 

of  adrenal  bodies,  1207 

of  breast,  953,  963 

of  intestine,  1028 

of  kidney,  1025 

of  liver,  1069 

of  palatal  glands,  870 

of  post-anal  gut,  716 

of  prostate,  1248 

of  sebaceous  glands,  408,  738 

of  testis,  1289,  224 

of  thyroid,  905 
Adeno-carcinoma  of  breast,  982 
Adeno-fibroma.     See  Fibro-adenoma 
Adhesions  after  fractiure,  476,  481 

after  synovitis,  642,  672 

in  appendicitis,  1048,  105 1 

in  cancer  of  stomach,  1006 

in  hernial  sac,  1089,  1113 

in  ovarian  cysts,  1322,  1324 

in   peritonitis,    982,    987,    988,    990, 
1002 

leading    to    intestinal    obstruction, 
1131,  988,  995,  1129,  1136 

leading  to  stricture  of  intestine,  981, 
1027 

strangulation  of  intestine  by,   1020, 
1129,  1131 
Adiposis  dolorosa,  197 


INDEX 


1359 


Adolescent  genu  valgum,  446 

rickets,  593,  429 

scoliosis,  430,  446 
Adrenal  adenomata,  1207 

rests,  1207 
Adrenalin,  use  of,  in  shock,  261 
Adventitious  burs£e,  422,  225  ' 
Aerial  fistula,  902 
Aerobes,  5 

After-treatment  cf  abdominal  operations, 
972 

of  operations,  274 
Agglutinins,  22,  21 
Air  embolism,  346 
Air,  entrance  into  veins,  293,  773 
Air-hunger,  277,  978 
Air-passages,  examination  of,  912 

foreign  bodies  in,  912-916 

operations  on,  919 

surgery  of  (Chapter  XXXII.),  812- 

943 

wounds  of,  900 
Albuminoid  disease,  74 
Albuminous  infiltration,  39 
Albuminuria,  1232,  102 

importance  of,  r233 
Alcohol-fast  bacilli,  8 
Alcohol  injections  in  tic-douloureux,  383 
Alexander's  operation  of  shortening  the 

round  ligaments,  1305 
Alexins,  17,  23,  33 
Alibert's  keloid,  257 
Alopecia  in  syphilis,  150 
Alveolar  abscess,  806,  8ro 

processes,  affections  of,  806 
fracture  of,  487 

sarcoma,  194 
Amazia,  944 
Amboceptor,  23 

Ambulatory  treatment  of  fractures,  476 
Ammonium  urate  calculus,  11 95 

deposits  in  urine,  1229 
Amceba  coli,  1065,  ir,  1025 
Amorphous  phosphates  in  urine,  1230 
Ampulla  of  Vater,  gall-stones  impacted 

in,  1077 
Amputation,  length  of  flaps,  1330 

methods  of,  1328 

circular,  1328 

elliptical,  1329 

flap,  1329 

modified  flap  and  circular,  1330 

of  breast,  964-968 

of  penis,  1277,  1260 

of  stumps,  1332 

racquet,  1329 
Amputations    (Chapter    XLIIL),    1328- 

1345 
for  acute  arthritis,  648,  238,  574 
for  aneurism,  319,  325 
foi  chronic  ulcer  of  leg,  95 
for  compound  fractures,   238,   245, 

481 
for  dislocations,  615 
for  elephantiasis,-  365 
for  gangrene,  106,  107,  109,  in,  319 
for  infantile  palsy,  734 
for  lacerated  wounds,  237,  23S 


Amputations  for  necrosis  of  bone,   569, 
573.  574 

for  pyiemia,  90,  575 

for  rupture  of  main  artery,  238,  300 

for  sarcoma  of  bone,  607 

for  secondary  haemorrhage,  293 

for  senile  gangrene,  107 

for   spreading    traumatic    gangrene, 
114 

for  tuberculous  disease  of  joints,  658, 
662,  687 

general  remarks  on,  1330-1332 

nerves  in  stumps  of,  374,  1332 

special,  1332-1345 
Amussat's  operation  of  colostomy,  1035 
Amygdaloid  glands,  148 
Amyloid  degeneration  of  arteries,  306 

disease,  74,  646,  655,  725.  1233 

spleen,  1085 
Anaerobes,  5 
Anaerobiosis,  126 
Anemia  from  oral  sepsis,  77 

in  secondary  syphilis,  148 

pernicious,  77 

splenic,  1085 
Anaamic  ulceration  in  gangrene,  loi 
Anassthesia  (Chapter  XLIV.),  1346-1355 

dolorosa,  724 

in  abdominal  operations,  1355,  970 

in  reduction  of  dislocations,  614 

in  thyroid  operations,  908 

local,  1346,  1347 

spinal,  1347-1349 
Anassthetic,  choice  of,  1355 

leprosy,  180 
Anaesthetics,  administration  of,  1353 

dangers  of,  1354 
Anal  abscess,  1150 
Analgesia,  spinal,  1347-1349 
Anaplasia,  188,  210 
Anastomosis  of  nerves,  378,  386 
Anatomical  neck  of  humerus,  fracture  of, 
496 

tubercle,  246 
Anel's  operation  for  aneurism,  316 
Aneurism  (Chapter  XII.),  308-328,  884 

causes  of,  308 

cirsoid,  737,  207 

diffuse  traumatic,  298,  726 
of  bone,  608 
of  scalp,  736 

gangrene  after,  312,  313 

treatment  of,  314 

varicose,  302,  737 

varieties  of,  309 
Aneurism  by  anastomosis,  608,  207,  324, 
737 
of  bone,  608 
of  skull,  737 

rupture  of,  313,  298,  319,  726 
Aneuiismal  varix,  301,  324,  350,  775 
Aneurisms,  special,  320-328 
Angina  of  Ludwig,  81,  858,  916 
Angioma,  205,  207 
of  liver,  1069 
Angular  curvature  of  spine,  717,  434 
Ankle-joint  : 

acute  arthritis  of,  649 


is6o 


A  MANUAL  OF  SURGERY 


Ankle-joint ; 

amputation  through,  1339 

ankylosis  of,  676 

dislocation  of,  635 

effusion  into,  640 

excision  of,  694 

fracture-dislocation  of,  55>S 

tuberculous  disease  of,  662 
Ankyloglossia,  845 

Ankylosis,  675,  646,  658,  672,  683,  689, 
718,  823,  181,  109 

fibrous,  675 

osseous,  449,  675 

treatment  of,  676 
Annular  stricture  of  urethra,  1261 
Anterior  crural  nerve,  injury  of,  396 

gastro-enterostomy,  1016 

poliomyelitis,  733 

rhinoscopy,  828 

tibial  artery,  compression  of,  290 
ligation  of,  342 
Anthracsemia,  132 
Anthrax,  131,  2,  13 

spores,  2 
Anti-anthrax  serum,  29,  133 
Anti-bodies,  21,  33 
Anti-pneumococcic  serum,  29 
Antiseptic  treatment  of  wounds,  265 
Antiseptics,  265 

in  abdominal  operations,  970 
Anti-sera,  16,  17 

Anti-streptococcic  seriun,  28,  79,  86,  90, 
124,  641 
before  operations  on  joints,  641 
in  cellulitis,  79 
in  erysipelas,  124 
in  pyaemia,  90 
in  septicaemia,  86 
Anti-tetanic  serum,  129 
Anti-toxins,  19,  20,  21,  33 
Anti-toxic  sera,  28 
Anti-venene,  Calmette's,  246 
Antrum  of  jaw,  affections  of,  811-814 

hydrops  of,  813 

suppuration  in,  805,  806,  811,  833 

transillumination  of,  812 

tumours  of,  813 
Antyllus's  operation  for  aneurism,  316 
Anuria,  calculous,  1196,  1197 
Anus,  absence  of,  1147 

artrhdal,  1126,  977,  1028,  1030, 
1031, 1033,  1123, 1135,  1136,  1138, 
1142 

closure  of  artificial,  1038 

condyloma  of,  11 66,  11 60 

epithelioma  of,  11 6g,  11 61 

fissure  of,  1156 

imperforate,  1147 

malformations  of,  1147 

mucous  tubercles  of,  1166,  1160 

prolapse  of,  1163 

varicose  veins  of,  11 58 
Aorta,  abdominal,  aneurism  of,  326 

compression  of,  290 

ligature  of,  337,  327 

thoracic,  aneurism  of,  320 
Aortic  tourniquet.  Lister's,  1344 
Aphasia,  769,  784 


Aphonia,  902,  882 

Aphthous  stomatitis,  844 

Aplasia  cranii  congenita,  740 

Apnoea.     See  Asphyxia 

Apparently  drowned,  treatment  of  the, 

941 
Appendicitis,  1043-1062,  726,  1019,  iigg 
abscess  in,    1049,    986,    105 1,    1054-, 

1129 
cetiology  of,  1043-1046 
appendicular  colic,  1053 
complications  of,  1050 
diagnosis  of,  1054,  726,  1134 
early  operation  in,  1059,  1060 
extraperitoneal  suppuration,  1050 
faecal  concretions  in,  1044 
faecal  fistula  after,  io6r,  1048 
.  foreign  bodies  causing,  1044 
injury  a  cause  of,  1045 
intestinal  obstruction  in,  1049,  1133 
leucocytosis  in,  value  of,  1052,  1060 
necrosis  in,  1047 

operations  in  fulminating  appendi- 
citi:;,  1058 
in  quiescent  period,  1056 
in     suppurative     appendicitis, 
1056,  1059,  1060 
pathological  anatomy  of,  1046 
peritoneal  phenomena  of,  1048,  986 
prognosis  of,  1055 
pylephlebitis  in,  1052,  1050 
quiescent  interval,  1052 
rectal  examination,  importance  of, 
!  1052 

I  recurrences  of,  1053 

I  recurrent,  1053 

relapsing,  1053 

septic  peritonitis  in,  1052,  1049 
subphrenic  abscess  in,  991,  1049 
symptoms  of,  1050 
treatment  of,  1055-1061 
varieties  of,  1046 
Appendicostomy,  1026 
Appendicular  gastralgia,  1054 
Appendix  veriiiiformis,  actinomycosis  of, 
182,  1062 
cancer  of,  1062 
in  hernial  sac,  1090,  1050 
stenosis  of,  1047 
strangulation    of  intestine   by, 

1131 
tuberculosis  of,  1062 
use  of,  in  treatment  of  colitis, 
1026 
Arachnoid  cyst,  231,  225,  768,  776 
Aran's  theory  of  irradiation,  745 
Arm,  amputation  through,  X335 

deformities  of,  436 
Arrest  of  haemorrhage,  280 
Arsacetin  in  treatment  of  syphilis,  159 
Arterial  haemorrhage,  288,  276 
treatment  of,  288 
suture,  300 
thrombosis,  107,  no,  298,  307 

gangrene  from,  103,  107 
varix,  737 
Arteries,    affections    of    (Chapter    XII.), 
29S-328 


INDEX 


1361 


Arteries,   calcareous   degeneration,    306, 
106 

cause  of  gangrene,  106 

degeneration  of,  306,  302 

digital  compression  of,  289,  283,  315 

diseases  of,  302 

inflammation  of,  302 

injuries  of,  298 

ligature  of,  289,  291,  328-343 

secondary  haemorrliage  from,  treat- 
ment of,  293 

suture  of,  300 

wounds  of,  300 
Arteriorrliapliy,  314 
Arterio-sclerosis,  303,  305 
Arterio-venous  aneurism,  301,  302 

wounds,  301,  357,  736 
Arteritis,  302 
Artery,  implication  of  main,  in  fractures, 

482 
Arthrectomy,  658,  660,  661,  662 
Arthritis,  acute,  645,  238,  570,  572,  611, 
678,  822 

deformans,  664,  596 

following  nerve  injuries,  672,  379 

gonorrhoeal,  652,  139,  645,  822 

gouty,  650 

infective  (acute),  645,  570,  573 

neuropathic,  669,  672 

pneumococcal,  651,  61 

pyemic,  88,  645,  651 

senilis,  664 

Sfptic,  645 

sicca,  664 

traumatic,  664,  481,  645 

tuberculous,  652-662,  585 

typhoid,  651 
Arthrodesis,  734,  458 
Arthrotomy  (incision  of  joints),  647 
Artificial   anus,    1326,    977,    1028,    1030, 
1031,    1033,    1123,    1135,    1136,    1138, 
1142 
Artificial  respiration,  methods  of,  940 
Arylarsonates  in  treatment  of  syphilis, 

158 
Ascending     pyelonephritis,    1188,    1220, 

1242,  1266 
Ascites,  892,  1007 
Ascitic  tuberculous  peritonitis,  988 
Aseptic  moist  gangrene,  100 

traumatic  fever,  262,  470 

treatment  of  wounds,  267,  970,  1331 

wounds,  236 
Asphyxia,  940-943,  401,  430 
Aspiration  for  hydronephrosis,  1187 

of  bladder,  1253,  1270 

of  chronic  abscess,  177 

of  cysts  of  kidney,  1208 

of  empyema,  935 

of  hydatid  cyst,  1069 

of  joints,  644,  671 

of  liver  abscess,  1066,  1067 

of  pericardium,  934 

of  pneumothorax,  931,  432 

of  tuberculous  abscess,  177 
Asthenic  fever,  39,  43,  263 
Asthma,  eosinophilia  in,  55 
Astragalus,  dislocation  of,  636 


Astragalus,  excision  of,    694,    662,    457, 
582,  637 

fracture  of,  561 

in-  talipes,  453 

tuberculous  disease  of,  580,  582,  662 
Atheroma,  304,  307,  100,  104,  106 
Atheromatous  abscess,  304 

ulcer,  304 
Atla  ,  dislocation  of,  702 

and  axis,  tuberculous  disease  of,  718 
Atony  of  bladder,  1228,  1216,  1242,  1251. 
1262 

of  stomach,  997 
Atoxyl  in  syphilis,  158 
Atrophic  pharyngitis,  876 

rhinitis,  832 

scirrhus,  962,  216 
Atrophy  of  bone,  466,  532,  614 

of  breast,  949 

of  kidney,  1179,  11 86 

of  muscle,  375,  709,  647,  672 

of  skull,  740 

of  testis,  1298,  857,  1102,  1280,  1281, 
1282,  1283,  1284 
Attenuation  of  virulence,  12 
Auditory  nerve,  injury  of,  388 
Auricles,  accessory,  887 

of  heart,  wounds  of,  938 
Auto-infection,  7,  63,  645 
Auto-intoxication  in  osteo-arthritis,  664 
Autoplasty,  740 
Avenoliths,  1024 
Axillary  abscers,  366 

aneurism,  326 

artery,  ligature  of,  334 

cellulitis,  79 

Baccelli's  treatment  of  tetanus,  129 
Bacilli,  3 

acid-fast,  8 

alcohol-fast,  8 

asporogenous,  2 

culture  media  for,  8 

sporogenous,  2 
Bacillus  aerogenes  capsulatus,  113,  71 

anthracis,  132,  2,  8,  12,  13 

coli  communis,  61,  3,  4,  8,  8g,  1.35, 
571,  777,  976,  981.  987.  9S8,  1049, 
1116,  1188,  1190,  1214,  1259 

influenzffi,  8 

leprae,  179,  8,  10 

mallei,  178,  8 

cedematis  maligni,  113,  2,  7t,  jy,  85 

of  diphtheria,  8,  40 

of  soft  sore,  140,  8 

pyocyaneus,  62,  5,  8,  85,  777 

smegma,  8 

tetani,  125,  2,  8,  20 

tuberculosis,  165,  8,  11,  981,  1194 

typhosus,  61,  651.  3,  8,  22,  87,  575, 
1073 
Back-door  splint,  Gauvain's,  728 
Back-knee,  447 
Bacteria  (Chapter  I.),  i 

classification  of,  3 

cultures  of,  8 

distribution  of,  6 

eftect  of  light  on,  5 

86 


1362 


A  MANUAL  OF  SURGERY 


Bacteria,  enzymes  of,  5 

flagella  of,  2,  i,  3 

growth  of,  4 

Eanging-drop  preparation  of,  7 

in  blood,  57 

inoculation  of  animals  with,  9 

latent,  63 

methods  of  observation,  7 
of  reproduction,  2 
fission,  2 
spore-formation,  2 

pathogenic,  4 

pyogenic,  59 

staining  cf,  8 

structure  of,  i 

toxins,  5 

vacuoles  in,  i 

virulence  of,  11 
Bacterial  inflammation,  35 
Bacteriological  examinations,  i 
Bacteriology  (Chapter  I.),  1-29,  59 
Bacteriol5-sins,  22,  21 
Bag-truss,  1109 
Baker's  cj'sts,  645,  225,  418 
Balanitis,  1276,  137,  141,  147,  1274 
Balano-pcsthitis,  1276 
'Ballooning'  of  bowel,  1029,  1167,  ii7r 
Bairs  operation  for  pruritus  ani,  1157 
Bands,  peritoneal,  1131,  1129 
Bank's    operation    for    inguinal    hernia, 

1103 
Banti's  disease,  1085 
Barbadoes  leg,  362 
Bardenheuer's  modification  of  Kraske's 

operation,  11 74 
Barker's  operation  for  fractured  patella, 

549 
Barlow's  disease,  593 
Barrow,    Boyce,    operation    for    ectopia 

vesicae,  121 2 
Bartholin's  gland,  cyst  of,  1304 
Basal  meningitis,  835 
Base  of  skull,  fracture  of,  745,  761 
Basedow's  disease  (exophthalmic  goitre), 

908 
Basilar  artery,  aneurism  of,  324 
Bassini's  operation  for  inguinal  hernia, 

IIOO 

Baths,  mercurial  vapour,  157 
use  of,  in  cellulitis,  79 
use  of,  in  inflammation,  43 

Bavarian  splint,  476 

5azin's  disease,  98 

Beafson's  operation  (oophoiectomj')  for 
cancer  of  breast,  968 

Bedsores,  iir,  478,  725 

in  spinal  injuries,  701,  706 

Bee-stings,  245 

BeUocq's  sound,  843 

Bell's  palsy,  386 

'  Belly-ache  '  in  spinal  caries,  38,  719 

Benign  tumomrs,  187 

Bennett's  fracture  of  the  thumb,  528 

Berger's  amputation  of  upper  extremitv, 
1336,  607 

Bezold's  perforation  of  mastoid,  892 

Biceps  cruris,  tenotomy  of,  420 

Bireps  cubiti,  injury  of,  413 


Bier's  suction-glasses,  387,  3S9 

treatment  by  induced  hvperaemia, 
46,  43',  71,  175,  248',  485.  567. 
657 
of  tuberculous  joints,  657 
of  un-united  fractmes,  485 
Bigelow  on  dislocation  of  hip -joint,  627 
Bigelow's  method  of  reducing  dislocated 

hip -joint,  629 
Bilharzia  haematobia,  1150,  1188,  1231 
Biliary  coUc,  1067,  1054 
fistula,  1078,  980 
passages,  affections  of,  1070-1080 
gall-stones  impacted  in,    1076, 

1079 
treatment  of,  1079 
tumours  of,  1079 
Bilious    vomiting    after    gastro-enteros- 

tomy,  1017,  1018 
Billington's  operation  for  movable  kid- 
ney, ir82 
Bilocular  hydrocele,  r292,  1304 
Biniodide  of  mercury,  266 
Birth-paralysis,  3 89 
Bismuth  meal,  997 

subnitrate   in   treatment    of   tuber- 
culous sinus,  177 
Bites,  snake,  246 
Bivalve,  tracheotomy-tube,  924 
Bladder,  affections  of  (Chapter  XXXIX.) 
1210-1256 
atonv   of,    1216,    1228,    1242,    i25r, 

1262 
cancer  of,  1222 
congenital  afl"ections  of,  12  ri 
cystitis,  1214-1218 
distension,  signs  of,  1211 
extroversion  of,  i2ri 
foreign  bodi'^s  in,  1214 
functional  affections  of,  1225-1228 
hypertrophy  of,  1215,  1250,  1262 
in  paraplegia,  701,  709,  710 
in  sac  of  hernia,  1091 
methods  of  examining,  i2ro 
papilloma  (villous  tumour)  of,  12  21 
rupture  of,  I2r3 
sarcoma  of,  1222 
simple  ulcer  of,  1220 
soimding,  the  method  of,  1238,  1210 
stone  in,  1236-1245 
tubercle  of,  1220 
tumours  of,  1221 
Blanket-suture,  233 
Blastomycetes,  10 
Blastomycetic  dermatitis,  ro 
Blind  external  fi=tula,  1154 

internal  fistula,  1154 
Blisters,  46,  95 
Blood,    examination    of,    in   health    and 

disease  (Chapter  III.),  49-58 
Blood-clot,  healing  by  organization  of, 

256,  281,  282 
Blood  conditions  in  various  diseases,  57, 

5S,  55 
Blood-counts,  t^'pical,  58 
Blood-cj-sts,  226,  9C0 
Blood,  extravasation  of,  276 
in  septicaemia,  85 


INDEX 


1363 


Blood,  in  suppuration,  58 
Blood-letting,  356,  43 
Blood-pressure  in  haemorrhage,  278 
Bobbins,  decalcified  bone,  1042 
Boas-Oppler  bacillus,  997 
Boils,  60,  103,  247.  397,  890 
Bone,  affections  of  (Chapter  XX.),  562- 
609 

atrophy  of,  466 

bending  of,  465 

carcinoma  of,  607,  466 

caries  of,  564 

cyst  of,  608 

expansion  of,  579,  598 

grafting,  825,  828 

growth  of,  562 

hydatid  cysts  of,  608 

hypertrophy  of,  596 

inflammation  of,  562-589 

injuries  of,  465-561 

necrosis  of,  566,  569,  572,  103 

sarcoma  of,  598,  605,  466,  473,  595 

syphilis  of,  586-589,  566,  576 

tubercle  of,  577.  565.  566,  576,  578. 

tumouis  of,  598-609,  577 
Bones,   effects  of  rickets  on,   590,   591, 

592 
Boric  (boracic)  acid,  266 
Bougies,  oesophageal,  882 

rectal,  11 68 

urethral,  1264 
Bowel.     See  Intestine 
Bow-leg,  448 
Bowles'  method  of  artificial  respiration, 

941 
/3-oxybutyric  acid  in  diabetes,  1235 
Brace,  Taylor's,  729 
Brachial  aneurism,  326 

artery,  compression  of,  290 
ligature  of,  335 

plexus,  injury  of,  389,  494 
operations  on,  390 
pressure  on,  429 
Brain,  abscess  of,  782 
Brain    and    membranes,     affections    of 
(Chapter  XXVI.),  757-793 

embolus  in,  347 

injury,  effects  of,  768 

laceration  of,  767 

softening,  yellow,  of,  768 

tumours  of,  785 

wounds  of,  767,  771 

See  also  Cerebral,  Cerebellar,  Con- 
cussion, and  Compression 
Branchial  carcinoma,  8g8 

clefts,  affections  of,  897 

cysts,  897 

fistulas,  897 
Brasdor's  operation  for  aneurism,   317, 

323 
Braun-Lcssen's  operation  on  fifth  nerve, 

384 
Brawny  arm  in  cancer  of  breast,  961 
Breast,  diseases  of  (Chapter  XXXIII.), 
944-968 
abscess  of,  acute,  946 
areolar,  946 
chronic,  950 


Breast,  adenoma,  953,  963 
adeno-carcinoma,  962 
adeno-fibroma,  953 
amputation  of,  964 
cancer,  958-968,  949 
acute,  961 
diagnosis  of,  963 
duct,  962 

en  cuirasse,  96c,  968 
operations  for,  964 
scirrhus,  958 

atrophic,  962 
congenital  malformations,  944 
cysto-adenoma,  956,  963 
cysts,  951,  948,  963 
diffuse  hypertrophy  of,  944 
duct  papilloma,  957 
fibro-adenoma,  953 
mastitis,  acute,  946 
chronic  lobar,  948 
chronic     lobular     (interstitial), 
948 
nipples,  affections  of,  945 
sarcoma,  957,  963 
syphilitic  affections  of,  950 
tuberculous  disease  of,  950 
Bridled  stricture  of  m-ethra,  1261 
Broad  ligament,  cysts  of,  1321 

treatment  of,  1326 
Bronchiectasis,  operation  for,  937 
Bronchocele,  903.     See  Goitre 
Bronchoscope,  Killian's,  915,  912 
Bronchus,  foreign  bodies  in,  915,  922 
Brood  capsules,  227 
Broth,  8 
Brow-ague,  383 
Brownian  movements,  3 
Brown-Sequard  syndrome,  705 
Bruise,  230,  231 

Bryant's  test  for  dislocated  shoulder,  619 
line,  535 
treatment  of  fractured  femur,  544 
Bubo,  141,  137 
Bubonocele,  1092 
Buck's  method  of  extension,  537 
Bulbous  nerve-ends,  374,  1332 
Buller's  shield,  138 

Bullet  wounds.     See  Gunshot  wounds 
Bullets  in  abdomen,  245 
in  brain,  772 
in  limbs,  244 
Bunion,  462 
Burghard,  dilatation  of  congenital  hyper 

trophy  of  pylorus,  1009 
Burns,  116,  117,  104 
Burrowing  epithelioma,  810,  814 
Bursas,  adventitious,  225,  422 
diseases  of,  422 

of  special,  423,  640 
Bursal  cysts  in  neck,  899 
Bursitis,  422,  423 
Butcher's  wart,  246 
Button,  Murphy's,  1042 
Buttonhole  stitch,  233 

Cachexia  in  malignant  disease,  187 

strumipriva,  910 
Cascal  colostomy.  1026,  1034 


1304 


A  MANUAL  OF  SURGERY 


Cascal,  tumour,  tuberculous,  1027,  1062 
Caecum  in  hernise,  1090 
Calcaneum.     See  Os  calcis 
Calcareous  degeneration  of  arteries,  306, 
106,  304 
of  fibroids,  1307 
Calcification  of  arteries,  306,  106 

of  fibro-myomata,  1307 
Calcium  chloride  in  blood,  344 

lactate  in  treatment  of  haemophilia, 
297 
in    treatment    of   hasmorrhage, 
284 
Calculi  cystine,  1239 
oxalate,  1x95,  1237 
phosphatic,  1195,  1236 
urate  of  ammonium,  1195,  1236 
uric  acid,  1195,  1236 
xanthine,  1237 
Calculous  anuria,  1196,  1x97 
Calculus,  biliary.     See  Gall-stones 
fusible,  1236 
intestinal,  1024 
mulberry,  1236 
pancreatic,  1081 
prostatic,  1247 
renal,  1188,  1195 
salivary,  858 
ureteral,  1205,  1185,  1198 
mrethral,  1225,  1259 
vesical,  1236-1245,  1216 
diagnosis,  of  1238 
signs  of,  1238 
structure  of,  1237 
treatment  of,  1240-1244 
varieties  of,  1236 
in  boys,  1244 
in  females,  1245 
Callaway's  test  for  dislocated  shoulder, 

619 
Callosity,  399 
Callus,  471 

compression  of  nerves  by,  483 
Calmette's  antivenene,  246 

reaction,  167 
Calvarium,  syphilis  of,  586 
Canal  of  Nuck,  225 

hernia  into,  1087,  1304 
hydrocele  of,  1304 
Cancellous  osteomata,  200 
Cancer,  acute,  of  breast,  961 
Cancer  en  cuirasse,  960,  968 
Cancer,  general  facts  of,  210 
of  antrum,  813 
of  appendix,  1062 
of  bladder,  1222 
of  bone,  607,  466 
of  branchial  clefts,  898 
of  breast,  958-968,  945,  949 
of  common  bile-duct,  1080 
of  cranium,  737 
of  Fallopian  tubes,  1320 
of  gall-bladder,  1079 
of  intestine,  1029,  1136 
of  jaw,  814,  821 
of  kidney,  1207 
of  larynx,  919 
of  lip,  803 


Cancer  of  liver,  1069 

of  nasal  fossae,  838 

of  oesophagus,  881 

of  omentum,  995 

of  ovary,  1327 

of  pancreas,  1083 

of  parotid,  860 

of  penis,  1276 

of  pharynx,  877 

of  prostate,  1255 

of  rectum,  1169 

of  scrotum,  1302 

of  sebaceous  glands,  409 

of  spine,  733,  434 

of  spleen,  1085 

of  stomach,  997,  1005 

of  testis,  1290 

of  thyroid,  910 

of  tongue,  850-856 

of  tonsil,  874 

of  umbilicus,  980,  1080 

of  urethra,  1260 

of  uterus,  1312 

parasites,  185 

treatment  of,  218 

See  also  Carcinoma. 
Cancrum  oris,  114,  85,  103,  823,  845 
Capillary  hemorrhage,  294,  276 

lymphangioma,  360 

nffivus,  354 
Carbolic  acid,  265 

danger  of,  in  albuminuria,  1233 
gangrene  from,  112 
in  treatment  of  tetanus,  129 
Carboluria,  266 
Carbonic  acid  snow,  354 
Carbuncle,  398,  103,  60 
Carbuncular  boil,  397 
Carcinoma,  210 

acinous,  958 

acute,  216 

branchial,  898 

colloid,  218,  210,  995,  1029 

columnar,  216,  980,  1029,  1169 

duct,  962 

encephaloid,  216,  215,  957 

epithelioma,  212 

glandular,  216 

malignant  papilloma,  212 

radium,  use  of,  in,  219 

rodent  ulcer,  408 

scirrhous,  215,  958,  1255 

spheroidal-celled,  958,  214 

treatment  of,  218 

X  rays,  use  of,  in,  218 
Carden's  supracondyloid  amputation  of 

thigh,  1342 
Cardiac  failure  under  anaesthetics,  1355, 

T-3A9'  1350 
Cardiolysis,  939 
Caries,  564,  563,  586 

fungosa,  565 

necrotica,  565,  575,  647 

of  palate,  870 

of  spine,  717 

of  temporal  bone,  890 

sicca,  565 
suppurative,  565 


INDEX 


I3<;S 


Caries,  syphilitic,  586,  870 
tuberculous,  437,  717 
Carless's  operation  of  gastrostomy,  1012 

for  inguinal  hernia,  1105 
Carotid    artery,    abnormal    arrangement 
of  the  branches  of,  333 
aneurism  of,  322,  323 
compression  of,  289 
haemorrhage  from,  295 
ligature  of,  331,  321,  322,  323, 

324 
wounds  of,  775 
Carpal  bones,  dislocation  of,  626 
Carpus,  fractures  of,  527 
Carr's  splint,  523 
Carrying  angle,  504 

Cartilage,  affections  of,  in  joint  disease, 
647.  653,  663,  665,  673 
semilunar,  displacement  of,  633,  674 
Cartilages,   laryngeal,   necrosis   of,    914, 

917.  918 
Cartilaginous  tumours.     See  Chondroma 
Caruncle,  urethral,  1360 
Caseation,  171,  153,  367 
Castration,  operation  of,  1300 
for  haematocele,  1383 
for  hernia  testis,  1389 
for  tuberculosis  of  testis,  1387 
for    tumours    of    testis,     1390, 
1291 
Catarrhal  appendicitis,  1046,  1050 
inflammation,  39 
jaundice,  1072 
stomatitis,  844 
Cat-gut,  371,  386 
Catheter-a-boule,  1364 
Catheter  bicoude,  1352 
coude,  1353 
Eustachian,  886 
fever,  1265,  1253 
Catheterism,  asepsis  in,  1266,  1253,  7oi' 
731,  1263 
dangers  of,  1264 
difficulties  in,  1264 
for  atony  of  bladder,  1228 
for  enlarged  prostate,  1252 
■for  rupture  of  urethra,  1259 
for  stricture  of  urethra,  1260,  1261 
shock  in,  1263 
Catheterization  of  ureters,  1177 
Catheters,  method  of  introducing,  1264 
sterilization  of,  1263 
varieties  of,  1263 
Caustics,  gangrene  from,  113 
Cauterization  for  haemorrhage,  284 
Cautery  for  haemorrhoids,  11 61 

uses  of,  384,  706,  708 
Cavernous  lymphangioma,  360,  996 
naevus,  206,  354 
sinus,  injury  of,  173,  775 
thrombosis  of,  781,  755,  835 
Cell-nests,  314,  409 
Cellular  theory  of  immunity,  17 
Cellulitis,  77-81,  60,  247 
bacteriology  of,  77 
gangrenous,   after  extravasation   of 

urine,  1273 
of  axilla,  79 


Cellulitis  of  neck,  80,  927 
of  orbit,  80,  381 
of  scalp,  79,  736 
of  scrotum,  1301 
pelvic,    81,    77,    1027,    1167,    1214, 

I216,  I330 

peri-rectal,  1153 

submaxillary,  858,  916 

treatment  of,  78 
Cellulo-cutaneous  erysipelas,  122,  120 
Cellulo-humoral  theory  of  immunity,  19 
Central  dislocation  of  femur,  530 

necrosis,  574 

sarcoma  of  bone,  605 
Cephal-ha;matoma,  735,  231 
Cephal-hydrocele,  traumatic,  744,  737 
Cephalo-tetanus,  128 
Cerebellum,  abscess  of,  784,  782,  786,  896 

wounds  of,  770 
Cerebral  abscess,  782,  755,  761,  771,  894, 
896 

compression,  764,  752 

concussion,  761,  261,  774 

haemorrhage,  776 

irritation,  763 

laceration,  763,  767 

tumours,  786 

operations  on,  789 
Cerebro-spinal  fluid,  escape  in  fractures 
of  base  of  skull,  747 
in  various  states,  characters  of, 
761 
Cerebrum,  wounds  of,  767-773 
Cerumen  in  ear,  887 
Cervical  caries,  877 
Cervical  iibroid  of  uterus,  1308 

fistula,  median,  899 

glands,  tuberculosis  of,  841 

plexus,  injury  to,  389 

rib,  429,  325.  108 

sympathetic  ganglia,  excision  of,-  910 

vertebrse,  dislocation  of,  702-704 
Cervico-facial  actinomycosis,  182 
Cervix  f  em  oris,  fracture  of,  531,  533 
Chance's  spinal  splint,  435,  428 
Chancre,  digital,  147 

extragenital,  144,  147 

hard,  145,  148 

"Hunterian,  146 

of  anus,  1 165 

of  lip,  801 

of  nipple,  946 

of  tongue,  849 

of  tonsil,  874 

of  urethra,  146,  1261 

relapsing,  148 

satellite,  141 

soft,  140 

syphilitic,  145 

treatment  of,  159 
Chancroid.    See  Soft  chancre 
Chapped  lips,  802 
Charcot's  disease,  669,  449,  645 
Chassaignac's  tubercle,  289 
Chauffeur's  fracture,  517 
Cheiragra,  650 
Chemosis,  138 
Chemotaxis.  18,  i2 


1366 


A  MANUAL  OF  SURGERY 


Chest,  deformity  of,  in  scolicosis,  430 

Cheyue-Stokes  respiration,  765,  771 

Chilblains,  401 

Chimney-sweep's  cancer,  1303 

Chinosol,  267 

Chloroform,  delayed  poisoning  by,  1350 

method  of  administering,  1350 

for  reduction  of  dislocations,  614 
Chlorophyll,  i 
Chlorosis,  56 

Cholangitis,  suppurative,  1065,  1072 
Cholecystectomy,  1078 
Cholecystendysis,  1078 
Cholecystenterostomy,  1079,  1072,  1078 
Cholecystitis,  1073,  61,  1072,  1076 
Cholecystotomy,  1077,  1073,  1078 

for  pancreatitis,  1082 
Choledochoduodenostomy,  1079 
Choledochotomy,  1079 
Cholelithiasis,  1074 

operative  treatment  of,  1071 
Cholesteatoma,  892 
Cholesterin,  172,  304,  1074 
Chondro-arthritis,  syphilitic,  663 
Chondrodystrophia  foetalis,  594 
Chondroma,    199,    733,    814,    819,    929, 

1290 
Chopart's  amputation,  1338 

modifications  of,  1339 
Chordee,  137 

Chorion-epithelioma,  1314 
Chronic  abscess.     See  Abscess 

constipation,  1045,  1046,  1132 

cystitis,  12 1 6 

epididymitis,  1284 

gonorrhoea,  134 

inflammation,  44-48,  35 

intestinal  obstruction,  1136-1139 

intussusception,  1141 

meningitis,  781 

■neuritis,  379 

orchitis,  1284 

osteo-arthritis,  664 

otorrhoea,  889,  782 

pancreatitis,  1082 

peritonitis,  987,  994 

pharyngitis,  875 

pyaemia,  88,  89 

rhinitis,  830 

superficial  glossitis,  847,  849,  850 

synovitis,  643,  417 

tetanus,  127 

ulcer  of  stomach,  999 
Chylous  ascites,  993 

hydrocele,  1295,  361 
Chyluria,  1232 
Cicatrices.     See  Scar 
Cicatrix  after  amputation,  1331 

tuberculous,  368 
Cinder-sifting   movements  of   moveable 

kidney,  11 80 
Circular  amputation,  1328 

modified,  1330 
Circumcision,  1274 
Circumflex  nerve,  injury  of,  390,  498 
Circumscribed  aneuiism,  311 
Cirsoid  aneurism,  737,  207 
Civiale's  urethrotome,  1268 


Clamp  and  cautery  operation  for  haemor- 
rhoids, 1161 
Clavicle,  dislocation  of,  617 

fracture  of,  492 
Clavus,  399 
Claw-foot,  461 

-hands  in  leprosy,  180 

in  ulnar  paralysis,  394 
Cleft  palate,  862-869 

operations  for,  865 
Clefts,  branchial,  affections  of,  897 
Cline's  splint,  555,  559 
Cloacae,  567 
Closure  of  jaw,  causes  of,  823 

of  vessels,  280 
Cloudy  swelling,  39 
Clover's  inhaler  for  administering  ether, 

1351- 
Club-foot,  450 

-hand,  437 
Coagulation  necrosis,  34 

of  blood,  344 

in  haemorrhage,  280 
Coagulum,  internal  and  external,  280 
Cocaine,  uses  of,  as  an  anaesthetic,  1346 
Cocci,  3,  645,  888,  935 
Coccydynia,  531 
Coccygeal  tumours,  716 
Coccyx,  excision  of,  531 

fracture  of,  531 
Cochlea,  disease  of,  891 
Cock's  operation  of  perineal  section,  1270 

peculiar  tumour,  407 
Cold  abscess,  54.     See  also  Tuberculous 

abscess 
Cold,  effects  of,  on  tissues,  116 

in  treatment  of  haemorrhage,  283 
of  inflammation,  41 
Coley's  fluid,  195 
Colic,  appendicular,  1053 

biliary,  1076,  1054 

gall-bladder,  1070 

intussusception,  11 40 

renal,  1197,  1054,  1183,  1196,  1203 
Colitis,  1025,  1045,  1054 
Collagen,  251 
Collapse,  258 

in  intestinal  obstruction,  1144,  1143, 
1128,  1130,  1141 

in  intussusception,  1141 

in  peritonitis,  983 

in  strangulated  hernia,  11 17 
Collateral  circulation,  288 
Colles's  fascia,  1272 

fracture,  518 

law,  161 
Colley's,     Davies,     operation    for    cleft 

palate,  868 
Colliquative  necrosis,  35 
Colloid  cancer,  218,  210,  995,  1029 
Colon,  idiopathic  dilatation  of,  1031 

transverse,  colostomy  of,  1034 
Colopexy,  1165 

Colostomy  (colotomy),  1033,  1138,  1168, 
1176 

comparison  of  methods,  1038 

for  cancer  of  rectum,  1175,  1176 

iliac,  1036,  1138,  1149 


INDEX 


1367 


Colostomy     (colotomy),     lumbar,     1035, 
1138 
preliminary,  11 72,  1173 
spur  in,  1034 
uses  of,  1035 
Colour-index,  49 
Columnar  carcinoma,  216 
of  bladder,  1222 
of  intestine,  1029 
of  rectum,  11 69 
of  stomach,  1005 
of  upper  jaw,  814 
of  uterus,  13 12 
Coma,  diabetic,  108,  1235 
diagnosis  of,  766 
in  cerebral  abscess,  778,  784 
in  cerebral  tumour,  788 
in  head  injuries,  765,  766,  774    776, 

778,  779.  793 
in  renal  disease,  11 89,  766 
Comminuted  fiacture,  481,  468 
Common  bile-duct,  anatomy  of,  1071 
stone  impacted  in,  1076 
treatment  of,  1079 
carotid  artery,  aneurism  of,  322 
compression  of,  289 
ligature  of,  331,  321,  323,  324 
iliac  artery,  ligature  of,  337,  327 
Compensatory  talipes,  451 
Complement,  23,  33 
Complete  fistula,  1153 

fracture,  467 
Complicated  fracture,  481 
dislocations,  612,  625 
Composite  odontome,  207 
Compound  dislocations,  612,  615 

fractures,  479,  467,  746,  754,  771 
amputations  for,  238 
septic  osteo-myelitis  after,  574 
palmar  ganglion,  418 
Compression,  cerebral,  764,  752,  774 

digital,  of  arteries  for  cure  of  aneur- 
ism, 315,  283,  285 
to  control  haemorrhage,  289 
fractures,  466,  560 
of  nerves,  373 

theory  of  fracture  of  base  of  skull, 
745 
Concentric  hypertrophy  of  skull,  742 
Concussion  of  brain,  761,  261,  747,  774 

of  spine,  704,  707,  708 
Condyles,  fracture  of  femur,  544 
of  humerus,  508 
of  jaw,  487 
Condylomata,  150,  209 
of  anus,  1160,  1165 
of  tongue,  849 
Congenital  abnormalities  of  testis,  1279 
of  tongue,  845 
absence  of  radius,  437 
adenoma,  716 
affections  of  bladder,  1211 
of  cranium,  738 
of  kidney,  ii7'9,  11 80 
atrophy  of  bone,  740 
cysts,  222,  897 
deformities  of  fingers,  437 
dislocation  of  hip,  440 


Congenital  dislocations,  611 

elevation  of  shoulder,  436 

epilepsy,  791 

fissures  of  lips,  794-800 

fractures,  467 

hernia,  1087,  1093,  nog,  1280,  1304 

hydrocele,  1291,  1294 

hydronephrosis,  11 85 

hypertrophy  of  pylorus,  1009 

induration  of  muscle,  427,  898 

malformation  of  breast,  944 
of  foot,  449 
of  intestine,  1020 
of  oesophagus,  878 
of  rectum,  1147 
of  urethra,  1257 

phimosis,  1274 

sacral  tumour,  716 

sarcoma  of  kidney,  1206 

syphilis,  160,  802,  1085 

talipes,  450,  451,  454 

torticollis,  426 

umbilical  fistulae,  980 
hernia,  1109 
Congestive    stricture    of    urethra,    1260, 

134 
Conical  stump,  1332 
Conjunctivitis,  gonorrhoeal,  138 
Connective  tissue,  tumours  derived  from, 

189-207 
Constipation,  absolute,  983,  1118,  1130, 

1133,  1137.  1145 
Constipation  as  a  cause  of  hernia,  1088 

in  appendicitis,  1046 

in  cerebral  tumours,  788 

in  cholecystitis,  1073 

in  fjecal  impaction,  113 7 

in  fibroids  of  uterus,  1308 

in  intestinal  obstruction,  1137,  1145 

in  obstructed  hernia,  1115 

in  stricture  of  rectum,  11 67,  11 70 

in  volvulus,  1132 
Contraction,  Dupuytren's,  439,  438 

of  fingers,  438 

of  knee,  449 

of  palmar  fascia,  439 

of  scars,  256 

of  sterno-mastoid,  426 

Volkmann's  ischajmic,  479 
Continuous    dilatation    of    stricture    of 

urethra,  1267 
Contrecoup  laceration  of  brain,  767 
Contused  wounds,  236 
Contusions,  230 

of  abdominal  walls,  976 

of  arteries,  289 

of  bone,  465 

of  brachial  plexus,  389 

of  cranium,  744 

of  hip,  535 

of  intestine,  1020 

of  lung,  929 

of  kidney,  11 83 

of  muscles,  411 

of  nerves,  373 

of  scalp,  734 

of  testis,  1281 
Cooper  Rose's  inflating  plug,  843 


A  MANUAL  OF  SURGERY 


Cooper's,  Astley,  operation  for  ligaturing, 

external  iliac  artery,  339 
Copaiba  rash.  136 
Coprostasis,  11 27 
Cgracoid  process  of  scapula,  fractu;e  of; 

495 
Corded  veins,  178.     See  Glanders 
Corns,  399 

in  hammer-toe,  463 

in  perforating  ulcer,  400 
Corona  radiata,  injury  of,  770 

Veneris,  149 
Coronary  arteries,  compression  of,  290 
Coronoid  process  of  jaw,  fracture  of,  487 

of  ulna,  fractmre  of,  514 
Corpus  luteum  cysts,  1323 
Corradi's  method  of  treating  aneurisms, 

318 
Corrosive  sublimate,  266 
Corrosives,  gangrene  from,  112 
Costal  cartilage,  separation  of,  492 
Counter-irritation,  45 
Courvoisier's  law,  1076 
Coverings  of  femoral  hernia,  1106 

of  inguinal  hernia,  1092,  1095 
Cowper's  glands,  inflammation  of=    137, 

1272 
Coxalgia,  678 
Coxa  valga,  445 
Coxa  vara,  444 
Coxitis,  tuberculous,  678 
Cracked  lips,  802 

nipples,  945 

tongue,  847 
Cranial  complications  of  otorrhoea,  890 

lesions  of  seventh  nerve,  386 
Cranial  nerves,  affections  of,  381-389 
Craniectomy,  linear,  741 
Cranio-cerebral  topography,  757 
Craniotabes,  589,  740 
Cranium,  affections  of,  738-756 

injuries  of,  744 

methods  of  opening,  759.     See  also 
under  Skull 
Crede  preventive  treatment,  139 
Creeping  epithelioma,  810 
Crepitus,  469 

in  affections  of  joints,  642,  643,  666 
Cretinism,  903 
Cricotomy,  922 
Crile,  pathology  of  shock,  260 

treatment  of  shock,  261 
Croft's  splint,  476 
Crossea  paralysis,  771 
Croupous  inflammation,  40 
Crucial  ligaments,  rupture  of,  635 
Crural  canal,  1106 
Crus  cerebri,  wound  of,  770 
Crutch  palsy,  478,  390 
Cryoscopy,  11 78 
Cryptoscope,  1203 
Cubitus  valgus,  504 

varus,  504,  508 
Cultural  methods  of  bacteriology,  8 
Cultures,  attenuation  of,  12 

media  for,  8 
Cuneiform  osteotomy,  450,  677 
Cupping,  in  treatment  of  inflammation,  41 


Curvature  of  legs.     See  Genu  varum 
Curvature  of  spine,  angular,  717,  434 

in  hip  disease,  433 

in  torticollis,  426 

lateral,  429 

rachitic,  429,  591 
Cushing's  suture,  975 
Cutaneous  appendages,  affections  of,  405 

gummata,  154 

leprosy,  179 

syphilides,  149 
Cut  throat,  900-903 
Cyclical  albuminuria,  1233 
Cylindroma,  221 
Cystectomy,  1225 
Cystic  degeneration  of  fibroids,  1307 

disease  of  breast,  949 
of  kidney,  1205 

duct,  anatomy  of,  1070 

impaction  of,  gall-stone  in,  1076 
Cystic  hygroma,  361,  225,  716,  898,  899 
Cystic  sarcocele,  of  testis,  1289 
Cystine  calculus,  1198,  1237 
Cystitis,  acute,  1216,  138 

urine  in,  12 16 
Cystitis,  causes  of,  12 14,  1242 

chronic,  1216,  61,  1214-1218,  1242 
I  urine  in,  12 17 

in  gonorrhoea,  138 

in  prostatic  enlargement,  1215,  1250, 
1252 

in  spinal  affections,  701,  706,  1215 

in  stricture  of  urethra,  1215 

pathological  effects  in,  1215 
Cysto-adenoma  of  breast,  956,  951,  963 

of  ovary,  1321 

of  thyroid,  906 
Cysto-sarcoma  of  breast,  956 
Cystoscope,  12 10 

Cystoscopy     in     diagnosis     of     bladder 
disease,  1220,  1223,  1224 
of  tuberculous  kidney,  11 94 
Cystotomy,  exploratory,  121 1 

perineal,  1216,  1218 

complications  of,  12 19 

supra-pubic,  for  enlarged  prostate, 

1254 

for  tuberculous  disease  of  blad- 
der, 1220 

for  tumours  of  the  bladder,  1224 
Cysts  (Chapter  VIII.),  222-229 
acinous,  951 

arachnoid,  231,  225,  768,  776 
Baker's,  645,  225,  418 
blood,  226,  900,  996 
branchial,  897 

broad  ligament,  1321,  1323,  1326 
bursal,  899 
corpus  luteum,  1323 
degeneration,  229,  952 
dental,  808,  813 
dentigerous,  813,  819,  207,  223 
dermoid,    222,    226,    407,    716,    738, 
850,  857,  897,  898,  952,  1207,  1223 
distension,  222,  225 
extravasation,  225 
exudation,  225 
foreign  bodies,  226 


INDEX 


1369 


Cysts,  hydatid,  226,  60S,  733,  900,  1065, 
106S,  1207 

implantation,  226 

in  connection  with  teeth.  223,  207 

in  floor  of  mouth,  856 

involution,  94S,  951 

irritation  cysts,  951 

malignant,  898,  900 

mucous,  756,  803, .856 

of  bone,  608 

of  breast,  951,  94S,  963 

of  broad  ligament,  1321 

of  canal  of  Nuck,  225 

of  embryonic  origin,  222 

of  epididymis,  1294 

of  funicular  process,  225 

of  Gartner's  duct,  225 

of  jaw,  808,  819,  207,  223 

of  kidney,  1207 

of  Kobeit's  tubes,  225,  1321,  1323, 
1295 

of  labia,  1304 

of  lip,  803 

of  liver,  1069 

of  mamma,  951 

of  mesentery,  996 

of  neck,  S97,  S98 

of  new  formation,  226 

of  ovary,  1321,  996,  1055,  221 

of  pancreas,  1082,  996 

of  round  ligament,  225 

of  scalp,  73S 

of  sebaceous  glands,  407,  738,  S99 

of  spermatic  cord,  225 

of  spleen,  1085 

of  thyroid,  900,  906 

of  thyro-glossal  duct,  898,  850,  857, 
223 

of  tunical  vaginalis,  225 

of  Wolffian  body,  224,  1295,  1323 

parasitic,  226 

paroophoritic-,  1322,  224 

parovarian,  1323,  224,  1326 

retention,  951,  226 

sebaceous,  407,  738,  899 

serous,  225,  900,  931,  1207 

traimiatic  dermoid,  226 
Cytolysins,  21,  22.  23 
Czemy-Lembert  suture,  974 

Dactylitis,  tuberculous,  579 
Dangerous  area  of  scalp,  735 

region  of  neck,  294 
Davy's  rectal  lever,  1344 
Dean's  operation  for  abscess  of  brain,  7S6 
Death,  signs  of,  in  tissues,  99 
Deciduoma  malignum,  13 14 
Decompression    operations    for    ceiebral 

timiour,  790 
DecorticatioD,  pulmonary,  937 

of     kidney     for     chronic     Bright's 
disease,  118  7 
Deep  sensation,  375 
Definite  callus,  472 
Deformities  (Chapter  XVIII. ),  426-464 

in  rickets,  590 

in  spine,  429-436,  720,  590 

of  hand,  439 


Deformities  of  lower  extremity,  440 

of  nose,  825 

of  upper  extremity,  436 
Degeaeration  cysts,  229,  952,  222 

in  arteries,  306 

in  muscles,  375 

in  nerves,  Wallerian,  374 

in  sarcoma,  190 

reaction  of,  375 
Delirium,  traumatic.  263 

tremens,  263.  470 
Deltoid  bursa,  inflammation  of,  425.  639 

muscle,  paralysis  of,  390 
Demarcation,  line  of,  ia  gangrene,  102 
Dental  cysts,  808,  813, 

splints,  4S9 

iilcers  of  tongue,  848 
Dentigerous  cysts,  813,' 819,  207,  223 
Depressed  fracture  of  skuU,  749.  751,  467 

treatment  of,  752,  754 
Derangement  of  knee-joint,  internal,  633 
Dercxmi's  disease,  197 
Dermatitis  maligaa,  945 

traumatic,  272 
Dermoid  cysts,  222,  226,  407 

acquired,  226 

of  breast,  952 

of  kidney,  1207 

of  mouth,  857 

of  neck,  S9S,  899 

of  ovary,  221,  1321 

of  scalp,  73S 

of  tongue,  850 

sacral,  716 

traumatic,  226 
Descending  pyeloaephritis,  1187 
Descent,  incemplete,  of  testis,  1279 
Development  of  Lips  and  palate,  796 
Diabetes,  1234,  102,  39S,  400,  676 

relation    to    pancreatic    aflections, 
10S2 

operations  in,  1234 
Diabetic  coma,  1235,  766 

gangrene,  103.  loS,  1234 

spinal  analgesia  in,  109 
Diapedesis,  33 
Diaphragm,  congenital  defects  in,  10S8, 

1113 
Diaphragmatic  hernia,  11 13,  loSS 
Diaphysitis,  acute,  56S 
Diathermy,  46 
Dietl's  crises,  iiSi 
Diffuse  aneurism,  treatment  of,  319 

arterio-sclerosis,  305 

hydrocele  of  cord,  1295 

lipoma,  197 

traumatic  aneurism,  298 
Diffusion  of  aneurisms,  313 
Digital  arrest  of  hemorrhage,  283.  932 

chancre,  147 

compression   of  arteries,    289,    283, 
285 
DUatation,  acute,  of  stomach,  loio 

of  cardiac  orifice.  883 

of  colon,  idiopathic,  103 1 

of  oesophagus,  for  stricture,  882 

of  pylorus,  1009 

of  rectum,  116S 


1370 


A  MANUAL  OF  SURGERY 


Dilatation,  of  stomach,  1007,  1008 

of  stricture  of  urethra,  1267 

of  urethra  in  females,  1245,  1226 
Diphtheria,  40,  916,  922,  926,  928 
Diphtheritic  inflammation,  40 
Diplococci,  3 
Diplococcus  iutracellularis,  777 

of  rheumatism,  650 

ure«  liquefaciens,  I2r4 
Direct  inguinal  hernia,  1094 
Diseases  of  scars,  256 
Dislocation  of  himaerus,  with  fracture  of 

surgical  neck,  502 
Dislocations  (Chapter  XXL),  610-638 

accomp£in5"ing    fracture,    4S1,    612, 
502,  530,  556,  625 

complete,  612 

complicated,  612,  625 

compound,  615,  612 

congenital,  611,  440 

of  spine,  702 

pathological,  611 

special,  615,  638 

traumatic,  611 

treatment  of,  614 

unreduced,  614,  615 
Displacement  of  tendons,  411 

of  kidney   11 80 

of  liver,  1062 

of  uterus,  1305 
Dissecting  aneurism,  310,  304 
Dissection  wounds,  247 
Dissemination  of  sarcoma,  190 
Distal  ligatirre  for  aneurisms,  317,  321, 

322,  323,  325 
Distension  C3-sts,  222 
Distension  of  bladder  with  overflow,  1227 
Disunited  fracture,  4S6 
Diverticula  of  oesophagus,  87S 
Diverticulum  of  Meckel,  1020,  980,  1131 
Division  of  ner\'es,  effects  of,  374 
Dorsal  abscess  in  spinal  caries,  722,  730 

dislocation  of  hip,  628,  627 
Dorsalis  pedis  artery,  ligature  of,  342 
Drainage  in  abdominal  operations,  972, 
984 

in  acute  inflammation,  43 

of  empyema,  935 

of  woimds,  235,  273 
Dressings  for  operations,  273 
Drowning,  941 

Drugs  in  treatment  of  inflammation,  43 
Dry  gangrene,  100 
Duchenne's  ape-hand,  392 
Ducrey's  bacillus,  140 
Duct  cancer  of  breast,  962,  957 

papilloma  of  breast,  957,  951 
Duodenal  ulceration,  118 
Duodeno-jejunal  fossa,  1132 
Duodenum,   perforating  ulcer  of,    1018, 
1054,  118 

stenosis  of,  1020 

ulcers  of,  1018,  990 
Dugas's  test  for  dislocated  shoulder,  619 
Dupuytren's  classihcation  of  bums,  117 

contraction,  438,  439 

fracture,  556 

splint,  560 


Dura  mater,  inflammation  of,  751,  777 

injuries  of,  751 

sarcoma  of,  743,  737 

thickening  of,  causing  epilepsy, 
791 
Duret's  theory  of  concussion  of  brain,  762 
D5Tiamic  Ueus,  1129 
Dysentery,  22,  1027,  1065,  1149,  1167 
Dyspeptic  ulcer  of  tongue,  848 
Dysphagia,  883,  881,  127,  320,  321,  617 
Dj-spncea,  320,  321,  617,  879,  913,  916, 
922.  930,  940 

Ear,  affections  of  (Chapter   XXX).  885- 
896 
examination  of,  885 
middle,  affections  of,  888 
otitis  media,  888 

complications  of,  890-896 
Ebumation  of  joint  cartilages,  666 
Eccentric  hj-pertrophy  of  skull,  742 
Ecchondroses,  200,  673,  665,  672 
EcchjTnosis  in.  fracture  of  base  of  skull, 

747 
Echinococcus,  taenia,  226,  1068,  347 
Ecthj-ma,  152 
Ectocyst,  227,  1068 
Ectopia  testis,  1280 

vesicae,  1211,  980,  1257 
treatment  of,  121 2 
Ectopic  gestation,  131 7 

rupture    of,    and    treatment,    1318, 

1319 
Ectrodactylism,  437 

Eczema    of   external    auditory*    meatus, 
890,  887 

of  nipple,  945,  958 

of  scrotum,  1301 

of  umbilicus,  980 

rub  rum,  123 

varicose,  352,  94 
Eczematous  ulcer,  94,  96 
Edebohl,  operation  for  nephritis,  1187 
Effletirage,  47 
Eggshell   crackling,   605,   606,   756.   812, 

819 
Ehrlich-Hata's  salvarsan  ('  606  '),  159 
Ehrlich's  theory  of  immunity,  20 
Elbow,  pulled,  625 
Elbow -joint,  acute  arthritis  of,  648 

amputation  through,  1335 

ankjiosis  of,  676 

dislocation  of,  622 

effusion  into,  639 

excision  of,  691,  660,  677 

tuberculous  disease  of,  659 
Electricity'  for  treatment  of  incontinence 

of  urine,  122S 
Electroh-sis  for  aneurism,  31S,  321,  325 

for  cirsoid  aneurism,  737 

for  hj'datid  cyst,  1069 

for  nffi^^,  354,  355,  803 
Elephantiasis,  361,  359 

Gragcorum  (leprosy),  179 

scroti,  363 
Elevated  fracture,  751 
Elliptical  (oval)  method  of  amputating, 
1329 


INDEX 


1371 


Emboli,  346,  104,  307 

infective,    346,    87,    104,    307,    570, 
645,  1064 

malignant,  347,  190,  1206 

parasitic,  347 
Em.bolic  abscess,  63 

arteritis,  302,  995 

gangrene,  103,  104 
Embolism,  346, 

fat,  471 

pulmonary,  347 
Embolus,  347,  346,  766,  910 

effects  of  an,  347 
Embryonic  origin,  cysts  of,  222 

tumours  of,  186 
Emphysema  of  abdominal  wall  in  rup- 
ture of  bowel,  1022 

interstitial,  931 

surgical,  930,  486,  755,  901 
Emphysematous  gangrene,  ii',  jy,  1273 
Emprosthotonos,  127 
Empyema,  933,  60,   77,  2,  726,  915,  931, 
992,  1002,  io65 

of  antrum,  811 

of  frontal  sinuses,  756 

of  gall-bladder,  1076 

pulsating,.  934 

scoliosis  from,  429 
En  bee  de  flute  fracture,  467 
Encephalitis,  778,  780 
Encephalocele,  737,  738,  792 
Encephaloid  cancer,  215,  216,  957,  962 
Encysted  abscess  (chronic),  of  bone,  582 
of  breast,  950 
of  liver,  1066 

ascites,  993 

calculus,  1237,  1240 

hernia,  1094 

hydrocele  of  cord,  1295,  225,  1097 
of  epididymis,  1294,  224 
of  round  ligament,  1304,  225 
of  testis,  1294 
Endarteritis,  acute,  303 

chronic,  303 

obliterans,  305,  107 

syphilitic,  305,  153 

tuberculous,  305,  171,  578 
Endocarditis,  infective,  87,  346 

ulcerative,  57,  84 
Endocyst,  227,  1068 
Endogenous  spore  formation,  i 
Endognathion,  796 
Endometritis,  140 
Endosteal  sarcoma,  605,  743,  820 
Endothelioma,    219-221,    189,    194,    382, 
733.  861 

of  parotid,  859,  220 
End-to-end  anastomosis  of  bowel,  1040 
Enemata   in   treatment   of   chronic   ob- 
struction, 1 138 

in     treatment     of     intussusception, 
1142 

turpentine,  973 

use    of,    in    diagnosis    of   intestinal 
obstruction,  1145 
Enlargement  of  spleen,  causes  of,  1084 
Ensheathing  callus,  471 
Enterectomy,  1028,  1030,  1039,  1^42 


Enterecto'ny    for    strangulated    hernia, 

1123,  1126 
Enteric  fever,  1054 

intussusception,  1140 
Enteritis,  1025 

after  injury  to  bowel,  1021 

after  strangulated  hernia,  1124 
intestinal  obstruction  in,  1133 
Entero-anastomosis,  1040,  1028,  1031 
Enterocele,  1090 
Entero-epiplocele,  1090 
Enteroliths,  1024,  1133 
Enteroplasty,  1039,  1028 
Enteroptosis,  1032,  1009,  1181 
Enterorrhaphy,  1030 
Enterospasm,  1129,  1134 
Enterostomy,  1033,  986,  995,  1135 

for  acute  obstruction,  1135 
Enterotomy,  1033 
Entrance  of  air  into  veins,  293 
Enucleation  of  prostate,  1254,  1255 

of  thyroid  adenomata,  908 

of  tonsil,  874 
Enuresis,  nocturnal,  1226 
Enzymes,  5,  70 
Eosinophiles,  51 
Eosinophilia,  55,  52 
.  Epicritic  sensation,  375 
Epidemic  parotitis,  857 
Epididymectomy,  1286 
Epididymis,  cysts  of,  1294 

encysted  hydrocele  of,  1294,  224 
Epididymitis,  acute,  1283,  1265,  138 

chronic,  1284 

gonorrhoeal,  138,  1283 

syphilitic,  1287 

tuberculous,  1285 
Epiglottis,   affections   of,   in  diseases   of 
larynx,  916,  917,  918 

wounds  of,  900 
Epilepsy,  congenital,  791 

hystero-,  791 

idiopathic,  791 

Jacksonian,  788,  791 

reflex,  791 

surgical  treatment  of,  790 

traumatic,  791,  744,  771 
Epileptiform  tic,  382 
Epiphora,  812,  815 
Epiphyses,  separation  of,  468,  594 

'    suppuration  in  connection  with,  468, 
568 
Epiphysitis,  566 

syphilitic,  589,  468 

tuberculous,  582,  468,  653,  678 
Epiplocele,  1090 

strangulation  of,  11 19 
Epiploitis,  994 

Epiplopexy,  operation  of,  for  ascites,  993 
Epispadias,  1257,  121 1 
Epistaxis,  842,  276,  486,  394,  838,  747,  782 
Epithelial  odontone,  207,  819 

tumoiurs,  207-719 
Epithelioma,  212,  188 

"after  lupus,  403,  405 

'  burrowing,'  810,  814 

branchial,  898 

columnar,  216 


1372 


A  MANUAL  OF  SURGERY 


Epithelioma  of  anus,  1161,  1169 

of  bladder,  1222 

of  cervix  uteri,  I3r2 

of  glands  in  neck,  898 

of  gum,  810 

of  larynx,  918 

of  lower  jaw,  821,  810 

of  lip,  802,  830 

of  nipple,  946 

of  nose,  838 

of  cesophagus,  88 r 

of  palate,  870 

of  penis,  1276 

of  pharynx,  87/ 

of  scalp,  738 

of  scars,  257 

of  scrotum,  1302 

of  stomach,  1005 

of  tongue,  850,  848 

of  tonsil,  874 

of  umbilicus,  980 

of  upper  jaw,  814 

of  urethra,  1260 
Epithelium,  tumours  derived  from,  189, 

207 
Epityphlitij.     See  Appendicitis 
Epulis,  809,  870,  199 

malignant,  809,  819,  598 
Erasion  of  joints,  operation  of,  658 
Erb-Duchenne  paralysis,  389 
Erethitic  shock,  259 
Ergot,  gangrene  from,  103,  no 
Erysipelas,  120,  60,  980 

ciurative  action  of,  123 

of  fauces,  122,  871,  875 

of  scalp,  122,  736 

of  scrotum,  122,  1301 
Erythema  ab  igne,  117 

induratum,  98 

nodosum,  122 

solare,  123 
Esmarch's  operation  for  closure  of  jaw, 

823 
Estlander's    operation   for    chronic    em- 
pyema, 936 
Ether,  method  of  administering,  135 
Ethmoid,  diseases  of  the,  834 
Ethyl  chloride  as  a  general  anaesthetic, 
1352 
as  a  local  anassthetic,  1347 
Eucaine  hydrochloride  as  an  ansesthetic, 

uses  of,  1347 
Eustachian  catheter,  886 
Evacuator  for  removal  of  stones  from 
bladder,  1241 

use  of,  in  diagnosis  of  vesical  disease, 
1210 
Eve's  operation  for  gastroptosis,  10 10 
Evisceration  in  treatment  of  peritonitis, 

984 
Examination  of  air-passages,  912 
Exanthemata,  acute,  86 

necrosis  of  jaw  after,  810 
Excision   of  astragalus,    694,    457,    582, 
637,  662 

of  condyle  of  jaw,  824,  669 

o'f  coccyx,  531 

of  Gasserian  ganglion,  385 


Excision  of  gastric  ulcer,  1004 

of  head  of  metatarsal,  463-464 

of  head  of  radius,  624 

of  hydrocele  sac,  1294 

of  intestinal  growths,  1030 

of  joints,  689-694,  658 

for  acute  arthritis,  68g,  648 
for  ankylosis,  677,  68g 
for  dislocation,  615,  689 
for  fractmres,  689,  482 
for  oesteo-arthritis,  669,  689 
for  tuberculous  disease,  658 

of  larynx,  920 

of  lower  jaw,  821,  811 

of  maxilla,  817,  838,  839 

of  nsevi,  354 

of  OS  calcis,  582 

of  parotid  gland,  861 

of  piles,  1162 

of  pylorus,  1014,  1008 

of  rectum,  1171-1176 

of  rib  for  empyema,  935,  936 

of  rib  for  hepatis  abscess,  1067 

of  rib  for  subphrenic  abscess,  992 

of  stomach,  1014,  1008 

of  stricture  of  urethra,  1267 

of  thyroid  tumours,  907 

of  tongue,  852-856 

of  tuberculous  foci  in  kidney,  1194 

of  varicocele,  1297 
Exclusion  of  intestine,  operation  of,  1031 
Exercises  in  scoliosis,  433 
Exogenous    multiplication    of    hydatid 

cysts,  227 
Exognathion,  796 
Exomphalos,  1109 
Exophthalmic  goitre,  908,  903 
Exophthalmos,  908,  324,  382,  782,  812 

pulsating,  775 
Exostoses,  201,  743  » 

Exostosis  bursata,  201 

cancellous,  220 

ivory,  202 

of  ear,  888 

of  rib,  325 

subungual,  201 
Expansile  impulse  in  aneurisms,  311 

in  hernia,  1091 
Expansion  of  bone,  579,  598 
Exploratory    laparotomy,     1022,     1023, 

1030,  1064,  1072,  1138 
Extension    of   leg   in   hip-joint    disease, 
684 

in  fractures  of  femur,  537 

in  reduction  of  dislocations,  614,  621, 
630,  632 

in  spinal  caries,  727 
External  ear,  deformities  of,  887 
External  carotid,  aneurism  of,  323 

ligature  of,  331,  295,  861,  877,  902 

coagulum  in  hiemorrhage,  280 

direct  hernia,  1095 

fistula  of  anus,  1154 

genitals,  affections  of,  1303 

iliac  artery,  aneurism  of,  327 
ligature  of,  338,  327 

piles,  1 1 58 

popliteal  nerve,  affection  of,  396 


INDEX 


1373 


External  urethrotomy,  1268 
Extirpation  of  aneurism,  315,  325 
of  thyroid,  907,  gio 
of  tuberculous  glands,  368 
Extracapsular  fracture  of  femur,  533 

of  humerus,  497 
Extracellular  toxins,  6 
Extracranial  complications  of  otorrhoea, 
890 
lesions  of  seventh  nerve,  386 
neurectomy  for  trigeminal  neuralgia, 
383 
Extraction  of  teeth,  805 
Extradural  abscess,  777,  784 
Extragenital  chancres,  147 
Extramedullary      hemorrhage,      spinal, 

705  I 
Extraparietal  hernia,  1096 
Extraperitoneal  abscess,  1050,  990 
rupture  of  bladder,  1214 

of  tubal  gestation,  1319 
Extravasation  cysts,  225 
of  blood,  276 

of  urine,  1272,  1228,  1258,  1262 
treatment  of,  1273,  1259 
Extrinsic  cancer  of  larynx,  919 
Extroversion    of     bladder,     1211,     980, 
1257 
treatment  of,  121 2 
Exudation  cysts,  225 

of  leucocytes,  31,  249 

Facial  artery,  compression  of,  290 
ligation  of,  333 
cleft,  oblique,  800 
nerve,  affections  of,  385,  891 
operations  on,  387 
Facial  palsy,  385,  748,  860,  891 

tic.  387 
Facies  hippocratica,  983,  11 18,  1130 
FaBcal  concretions  in  appendicitis,  1044 
fistula,    1126,   980,   987,   988,    1021, 
1023,  1024,  1026,  1061 
umbilical,  980,  988 
impaction,  1137,  1129,  1136 
vomiting,    986,    1118,    1128,    1130, 
1137,  1144,  1145 
Fagces,  retention  of,  1129 
Faciiltative  aerobes,  5 
anaerobes,  5 
parasites,  4 
Facultative  saprophytes,  4,  125 
Fallopian  tubes,  affections  of,  1315-1320 
strangulation  by,  1131 
in  sac  of  hernia,  109 1 
False  ankylosis,  675 

incontinence  of  urine,  1227 
joints,  483,  615 
membrane,  40 
neuromata,  203 
passages,  1265 
Faraboeuf's  amputation  of  big  toe,  1337 
of  fingers,  1333 
of  leg,  i34i.'95 
Farcy -buds,  178.     See  Glanders 
Fat  embolism,  471,  346 

.     necrosis,  1080 
Fatty  degeneration  of  arteries,  306 


Fatty  hernia,  iiii,  197 

txmiours,  195.     See  also  Lipoma 
Fauces,  erysipelas  (./f,  122,  871,  875 
Favus,  10 
Female     genital     organs,     surgery     of 

(Chapter  XLII.),  1303-1327 
Femoral  artery,  anemrism  of,  327 
compression  of,  290 
ligature  of,  339,  327,  328 
Femoral  hernia,  1105,  1087 
diagnosis  of,  1106 
operations  for  radical  cure,  1107 
strangulated,  11 25 
thrombosis,  346,  1050 
truss,  1 107 
Femur,  abscess  of  neck  of,  683,  678 
central  dislocation  of,  530 
incurvation  of  neck  of,  444 
fractures  of,  531-547 
periostitis  of  lower  end,  596 
separation  of  lower  epipnysis,  544 

upper  epiphysis,  541 
shaft,  fracture  of,  541 
Fever,  38 

catheter,  1252,  1265 
hectic,  74,  84 
traumatic,  262,  84,  470 
Fibrin  ferment,  32 
Fibro-ad.enoma  of  breast,  953 

of  thyroid,  905 
Fibroblastic  cells,  35 
Fibroblasts,  249,  35 
Fibro-cicatricial  tissue,  251 
Fibro-cystic  disease  of  jaw,  819,  207 

of  testis,  1289,  224 
Fibroid  bursitis,  423 
myositis,  415 
polypus,  1307 
recurrent,  957,  192 
Fibroids,  uterine,  1307-1311 
degenerations  in,  1307 
lordosis  from,  435 
operations  for,  1309 
Fibrolysin,  257 

Fibroma  of  naso-pharynx,  S37,  199 
Fibromata,  198,  203,  733,  738,  809,  813, 

819,  1221,  1290 
Fibro-myoma,  202,  1307 

cysts  in,  229 
Fibro-myomata  of  uterus,  1307-1311 

operations  for,  1309 
Fibro-sarcoma,  192,  963,  202,  1290 
Fibrosis,  45 

in  tuberculous  nodules,  171 
Fibrous  ankylosis,  675 
goitre,  905 
odontome,  207 

polypus  of  nose,  835,  837,  199 
stricture  of  oesophagus,  880 

of  rectum,  11 66 
tuberculous  peritonitis,  988 
union  of  fracture,  483 
Fibula,  absence  of,  455 
fracture  of,  552 
rachitic,  450 

syphilitic  deformity  of,  450 
Fifth  nerve,  affections  of,  382 

operations  on,  383-385 


1374 


A  MANUAL  OF  SURGERY 


Filaria  sanguinis  hominis,  363,  347,  361, 

1232 
Filariasis,  56,  363 
Filiform  bougies,  1264 
Filigree,  silver,  in  treatment  of  hernia, 

1112 
Fingers,  adhesions  of  tendons  of,  417,  414 

amputation  of,  1332 

chancre  of,  147 

deformities  of,  437 

division  of  tendons  of,  414 

sloughing  of  tendons  of,  414 

webbed,  438 
Finsen-light  cure  of  lupus,  404 
First  intention,  healing  by,  253 
Fish-hook  wounds,  241 
Fission,  2,  i 
Fission  fungi,  i 
Fissure  of  anus,  1156 

of  lip,  congenital,  794,  800 

of  Rolando,  757 

of  Sylvius,  758 
Fissured  fracture  of  skull,  744,  46 

fractures,  467 
Fissures  of  lips,  802 

of  nipple,  945 

of  tongue,  847 
Fistula,  73 

aerial,  902 

biliary,  980,  1078 

bimucopa,  988 

branchial,  897 

cervical,  899 

faecal,    1126,    980,    987,    988,    1021, 
1023,  1024,  1026,  1061 

gastric,  1002 

-in-ano,  1155,  1150,  1153 

median  cervical,  899 

oesophageal,  903 

penile,  137,  1273 

perineal,  1273,  1262,  1271 

pharyngeal,  903,  921 

recto-vesical,  1166,  1170,  1171, 1219, 
1224 

salivary,  861 

scrotal,  1273,  1301 

umbilical,  980,  988,  1257 

urinary,  1273,  980,  1184,  1196,  1205, 
1213, 1225,  1255. 1257.  1259.  1271 

vesical,  12 13 
Fixation  of  fractures,  474 
Flagella,  2,  i 
Flap  method  of  amputation,  1329 

modified,  1330 
Flaps  in  amputation,  1330 
Flat-foot,  459,  446,  451 

gonorrhoeal,  139 
Flexible  bougies,  1264 

catheters,  1263 
Floating  kidney,  11 80 

spleen,  1084 
Fluctuation,  69 
Foetal  goitre,  905 

residues,  186,  673 

origin  of  tumours  in,  186 
Follicular  odontone,  207,  819 

pharyngitis,  875 

tonsillitis,  871 


Folliculitis,  suppurative,  247 
Foot,  amputation  of,  1339 
deformities  of,  450-464 
laceration  of,  238 
painful  lipoma  of,  196 
Forcible  correction  in  talipes,  457 

dilatation  of  stricture  of  urethra,  1267 
Forcipressure  treatment  of  haemorrhage, 

285 
Forearm,  amputation  through,  1335 
Foreign  bodies,  cysts  in  connection  with, 
226 
in  air -passages,  912 
in  appendix,  1044 
in  bladder,  12 14 
in  brain,  treatment  of,  772 
in  bronchus,  915,  922 
in  cure  of  aneurisms,  318 
in  ear,  887 
in  hernial  sac,  1091 
in  intestine,   1024,   1129,   1133, 

1136 
in  larynx,  922 
in  nose,  829 
in  oesophagus,  878 
in  rectum,  1149 
in  stomach,  998 
in  trachea,  914 
in  urethra,  1259 
Formalin,  267 

Fossa  duodeno-jejunalis,  1132 
Fossa  retro-caecal,  1132 
Fourth  nerve,  paralysis  of,  382 
Fowler's  position  in  peritonitis,  985,  584 
Fracture-dislocation  of  ankle,  556 
of  femur,  530 
of  humerus,  502 
of  spine,  699 
Fracture-dislocations,  612,  481,  502,  530, 

556,  625 
Fracture  en  bec-de-flute,  467 
Fracture  fever,  470 

green-stick,  467 
Fractures  (Chapter  XIX.),  465-561 
comminution  of,  481,  468 
complications  of,  470,  481 
during  treatment,  478 
compound,  479,  467,  746,  771 
compression,  466,  560,  745 
congenital,  467 
disunited,  486 

early  operative  treatment  of,  477 
effects  of,  470 

impacted,  468,  518,  534,  539 
implication  of  joints  in,  481 
of  main  artery  in,  482 
Fractures,  intra-uterine,  467 

massage  in  treatment  of,  476 
nerves,  involvement  of,  483 
signs  of,  469 

spontaneous,  466,  594,  605 
treatment  of,  473 
union  of,  451,  480 
ununited,  483 
varieties  of,  467 
veins,  lacertaion  of,  483 
vicious,  union  of,  485,  560 
See  also  special  fractures 


INDEX 


1,575 


Fragilitas  ossium,  466 

Frank's  operation  of  gastrostomy,  1012 

Freezing  for  anaesthesia,  1347 

Fremitus  hydatid,  1068 

French  olive-headed  catheter,  1263 

operation  of  rhinoplasty,  827 
Fringes,  synovial,  644 
'  Frog-nose,'  826 
Frontal  bone,  fracture  of,  755 
Frontal  lobes  of  brain,  abscess  in,  755 

lobes,  injuries  of,  769,  763,  767 

sinuses,  affections  of,  754,  834 
suppuration  in,  755,  783,  834 
Fronto-nasal  process,  796 
Frost-bite,  116,  104 
Functional     derangement     of     bladder, 

1225-1228 
Fungi,  filamentous,  10 
Fungus  haematodes,  187,  216 
Funicular  hernia,  1094 

process  in  hernia,  1087 
Furuncle,  399 
Fusible  calculus,  1236 
Fusiform  aneurism,  309 

Galatocele,  951 

Gall-bladder,  affections  of,  1070-1080 
anatomy  of,  1070 
colic,  1070 

rupture  of,  1071,  981 

tumours  of,  1079 
Gall-stones,  1073,  1074,  1079 

complications  of,  1075 

impaction  of,  1071,  1076 

in  intestine,  1024,  1133 

operations  for,  1077 

pancreatitis,  due  to,  1082 
Ganglion,  418 

Gasserian,  removal  of,  383,  385 

compound  palmar,  418 
Gangrene  (Chapter  VI.),  99-119,  35 

acute  emphysematous,  113,  77,  85, 

1273 
after  aneurism,  313,  328,  312 
amputation  for,  106,  107 
diabetic,  103,  108 
dry,  100 

embolic,  104,  103,  347,  995 
from  arterial  thrombosis,  107,   no, 

103.  345.  995 
from  carbolic  acid,  112 
from  cervical  rib,  108,  429 
from  corrosives  (chemicals),  112 
from  ergot,  103,  no 
from    fractures   during,    treatment, 

482,  479 
from  ligature  of  arteries,  330,  no 
from   obstruction   of  main   vessels, 

no 
from  rupture  of  arteries,  299 
from  splint-pressure,  in 
from  thermal  causes,  104 
moist,  100 
Gangrene  in  intestinal. obstruction,  1128 
in  intussusception,  1139 
of  appendix,  1047 
of  intestine   in   hernia,    ni6,    11 18, 

1120,  1123,  1125 


Gangrene  of  lung,  933,  937 

senile,  106,  103,  306 

spontaneeus,  109 

symptomatic,  103,  104 

traumatic,  no,  100,  103 

varieties  of,  103 
Gangrenous  cholecystitis,  1074 
Gangrenous  periproctitis,  1153 

stomatitis,  844 
Gant's  osteotomy  of  femur,  677 
Garre  and  Bockhardt,   observations  of, 

62 
Gartner's  duct,  cyst  of,  225 
Gas  in  abscesses,  70,  991,  1002,  1049 
Gasserian  ganglion,  removal  of,  383,  385 
Gastralgia  appendicular,  1054 
Gastrectomy,  1008,  1013 
Gastric  fistula,  1002 

juice  in  cancer  of  stomach,  997,  1006 

ulcer  and  its  effects,  999-1005,  990, 
997 
Gastritis  phlegmonous,  998 
Gastrocnemius,  rupture  of,  414 
Gastro-enterostomy,  operation  of,  1015 

for  cancer  of  stomach,  1008 

for     haemorrhage     from     duodenal 
ulcer,  1020 
from  stomach  ulcer,  1000 

for  hour-glass  stomach,  1004 

for  pyloric  stenosis,  1004 

for  stenosis  of  duodenum,  1020 

for  ulcer  of  stomach,  1000,  1004 

haemorrhage  after,  1017 

in  gastrectomy,  1014 

recurrence  of  symptoms  after,  1004 

vicious  circle  after,  1016 

vomiting  after,  1018 
Gastroptosis,  1009 
Gastroplication,  loio 
Gastroscopy,  997 

Gastrostomy,  ion,  883,  922,  1008 
Gastrotomy,  loio,  880,  883,  998 
Gauvain's  back-door  splint,  728 
Gelatin  media,  9 
'  Gelenkmaus,'  674 
Genital  organs  of  female,  affections  of, 

1303-1307 
Genu  recurvatum,  448,  663 

valgum,  445,  429,  592 

varum,  448,  592 
Giant  cells,  168,  281 

in  sarcoma,  193 
in  tubercle,  i58 
Gigantism,  184,  596 
Gigli's  saw,  760,  476 
Giraldes,  organ  of,  224,  1289 
Girdle  pain,  394,  38 
Glanders,  178 

Glands,    lymphatic,    affections    of,    365, 
996 

malignant,  898,  372 

mesenteric,  996 

syphilitic,  366 

tuberculous,  367,  371,  996 
Glandular  cancer,  214 
Glass  wounds,  301 
Gleet,  134,  1246 

treatment  of,  136 


1376 


A  MANUAL  OF  SURGERY 


Gleety  discharge  in  stricture  of  urethra, 

1262 
Glenard's  disease,  1009,  1032,  1062,  1181 
Gliomata,  205 

of  brain,  786 
Globus  hystericus,  880 
Glossitis,' 846,  847,  849 
Glosso-pharyngeal  nerve,  affections  of,  388 
Glossy  skin,  376 
Glottis,  acute  cedema  of,  916.     See  also 

Oidematous  laryngitis 
Glover's  stitch,  233 
Gloves,  use  of,  for  operating,  270 
Gluteal  abscess,  682 

artery,  aneurism  of,  327 
haemorrhage  from,  296 
ligature  of,  338 

bursa,  disease  of,  425 
Glycogen  in  diagnosis  of  suppuration,  54 
Glycosiiria,  771,  1234 
Goadby,  on  pyorrhoea  alveolaris,  808 
Goitre,  903-910,  323,  884 
Golding  Bird's  sling  for  flat-foot,  460 
Gonococcaemia,  134,  139 
Gonococcus,  133,  8,  62,  85,  87,  981 
Gonorrhoea,  133,  55,  140,  1227,  1261 

affections  of  fascise  in,  139 

of  joints  in,  139,  645,  652 

arthritis  in,  652,  139,  645,  822 

stricture  in,  1260,  135,  137 

vaccine  treatment  of,  139 
Gonorrhoeal  conjunctivitis,  138 

cystitis,  138 

epididymitis,  138,  1283 

flat-foot,  459 

peritonitis,  990,  140 

proctitis,  138,  1149 

prostatitis,  138,  1246 

pyaemia,  139 

rheumatism  of  spine,  732 

rhinitis,  138,  830 

sclerotitis,  139 

urethritis,  134,  652 

vaginitis,  140,  1304 

vulvitis,  140,  1304 

warts,  137,  1276 
Gordon's  splint  for  CoUes's  fracture,  518, 

522 
Gottstein's  curette,  841 
Gouty  arthritis,  650 

deposits  in  bursae,  423 
Gradual  dilatation  of  stricture  of  urethra, 

1267 
Graefe's,  von,  sign,  909 
Grafting  of  nerves,  378 
Gram's  method  of  staining  organisms,  8, 

133 
Granny  knot,  291 
Granular  degeneration,  39 

urethritis,  135 
Granulation  tissue,  251,  65,  loi,  471 
Granulomata,  44 
Graves'  disease,  908 
Gravitation  paraplegia,  705 
Green-stick  fracture,  467 
Gritti's  supracondylar  amputation,  1343 
Groin,  abscess  in  glands  of,  366 

tuberculous  glands  in,  370 


'  Growing-out  hip,'  432 

'  Growing-out  shoulder,'  431,  436 

'  Growing  pain,'  357 

Growth  of  bone,  562 

Gubernaculum  testis,  anatomy  of,  1279 

Gumboil,  806 

Gum-elastic  catheters,  1263 

Gumma,  153 

of  bone,  576,  586 

of  brain,  786 

of  lip,  802 

of  larynx,  917 

of  liver,  1069 

of  muscles,  415,  427 

of  pharynx,  876 

of  rectum,  11 66 

of  ribs,  929 

of  spine,  733.  434 

of  sternum,  929 

of  testis,  1287,  1288 

of  tongue,  849,  415 

of  tonsil,  874 

perisynovial,  663 

subcutaneous,  155 

subperiosteal,  586 
Gummata,  cutaneous,  154 
Gummatous  osteo-myelitis,  588 

synovitis,  663 

ulcer,  154 
Gums,  affections  of,  806-811 
Gunshot  wounds,  242-245 
of  abdomen,  243 
of  lung,  932 
of  skull,  243,  751,  772 
tetanus  in,  126 
treatment  of,  244 
Gutter  fracture,  750 
Gynecomastia,  944 

Haematemesis,   276,   880,   881,   979,   998, 

1007,  1009,  1086 
Haematocele,  diagnosis  of,  1299 

of  cord,  1282,  1097 

of  tunica  vaginalis,  1281,  225 
Haematoma,  231 

of  abdominal  walls,  976 

of  ear,  887 

of  vulva,  1303 

of  scalp,  735 

scroti,  1301 
Haematomyelia,  705 
Haematorrhachis,  705 
Haematuria,  1231,  277 

constitutional,  1231 

diagnosis  of  source  of,  1232 

from  injuries,  1183 

in  calculus  of  bladder,  1238 
of  kidney,  1196,  1197 

in  prostatic  affections,  1253,  1256 

in  tubercle  of  bladder,  1220 
of  kidney,  1194 

in  tumours  of  bladder,  1221,   1222 
1224 
of  kidney,  1207 

in  urethral  affections,  1231,  1258 
HaBmocytometer,  49 
Haemoglobinometer,  49 
Haemoglobinuria,  paroxysmal,  1232,  icr.' 


INDEX 


1277 


Hfemolysins,  20,  22,  23 
Haemophilia,  296 
joints  in,  672 
Haemoptysis,  277,  930 
Hffimorrhage  (Chapter  XL),  276-297 
after  gastro-enterostomy,  1017 
after  removal  of  teeth,  806 
blood  examination  after,  49 
cerebral,  776 
during    amputations    at    hip-joint, 

1344 
effects  of,  277,  499 
from  catheterism,  1265 
from  duodenal  ulcer,  1019 
from  gastric  ulcer,  999,  1000 
from  nipple,  956,  962 
from  varicose  vein  or  ulcer,  352,  353, 

94 
intermediate,  291 
intraperitoneal,  978,  994,  1063,  108  |, 

1183 
in  fibroids  of  uterus,  1308 
in  fracture  of  skull,  747,  768 
in  fractures,  470,  480 
in  ruptured  ectopic  gestation,  131S 
kidney,  11 83 
urethra,  1258 
in  scurvy  rickets,  594 
in  villous  (papillomatous)  tumour  of 

bladder,  1221 
leucocytosis  after,  55 
meningeal,  773 
natural  arrest  of,  280 
primary,  288 
pulmonary,  933 
recurrent,  291 
secondary,  291,  330 
special  sources  of,  295 
spinal,  705 

subperiosteal,  in  scuivy  rickets,  594 
treatment  of,  general,  278 

siurgical,  283 
venous,  293,  276 
Hajmorrhagic  infarct,  347,  88 

pancreatitis,  1081 
Haemorrhoids,  1157-1163 
complications  of,  11 60 
diagnosis  of,  11 60 
external,  11 58 

treatment  of,  1159 
internal,  1159 

treatment  of,  11 61 
varieties  of,  11 58 
Haemostasis,  273,  284 
Haemostatics,  284 
Hemothorax,  930,  491 
Hahn's  xracheotomy-tube,  855,  924 
Hallux  rigidus  {Hallux  flexits),  462 

valgus,  462 
Halstead's  intradermic  stitch,  234,  370 
operation  for  hernia,  1104 

for     removal     of     tuberculous 

glands,  369 
for  scirrhus  mamme,  964,  967 
suture,  intestinal,  975 
Hamilton's  splint,  544 

test  for  dislocated  shoulder.  619 
Hammer-nose,  S26 


Hammer-toe,  463 

Hammond's  wire  splint  for  fracture  of 

lower  jaw,  489 
Hand,  amputation  of,  1334 

deformities  of,  437 
Handley's     operation     of     lymphangio- 

plasty,  961 
Hands,  sterilization  of,  269 
'  Hanging-drop  '  preparation,  7 
Haptophore,  20 
Hard-bake  spleen,  371 
Hard  fibroma,  198 

sore,  145 
Hare-lip,  794-800 

operations  for,  797 
Hartley-Krause  operation  for  the  removal 

of  Gasserian  ganglion,  385 
Head  injuries.      See  Fractures   of  skull 

and  injuries  of  brain 
Head  of  radius,  fracture  of,  514 
Healing  of  wounds,  253 
by  granulation,  253 
by  organization  of  blood-clot,  256 
by  primary  union,  253 
by  secondary  union,  253 
under  a  scab,  255 
Hearing,  investigation  of,  885 
Heart,  wounds  of,  938 
Heat  in  inflammation,  36 

in  treatment  of  inflammation,  42 
Heat-stroke,  766 
Heberden's  nodosities,  667 
Hectic  fever,  74,  84,  646,  655,  723 
Hemianaesthesia  in  head  injuries,  770 
Hemianopia,  769 
Hemiatrophy  of  tongue,  845 
Hemiplegia  after  head  injuries,  764 
Henoch's  purpura,  1141 
Hepatic  abscess.     See  Abscess  of  U\oc 
duct,  anatomy  of,  1070 

stone  impacted  in,  1076 
Hepatoptosis,  1062 
Heredity  as  a  cause  of  tumourg,  184 
Hernia  (Chapter  XXXV.),  X087-1126 
astiology  of,  1087 
bladder  in,  1091 
ca3cum  in,  1090 
enterocele,  1090 
epiplocele,  1090 
Fallopian  tube  in,  1091 
inflammation  of,  11 14,  1089 
irreducibility  of,  1113,  iioo,  iioi 
obstructed,  1114 
ovatry  in,  1091 
sac  of,  1089 

adhesions  in,  1089,  iioi 
foreign  bodies  in,  1091 
hydrocele  of,  1089 
signs  of,  1091 
strangulated,  1115-1126 

complications    after    operation, 

1124 
after  taxis  for,  1120 
gangrene    of    bowel    in,    rir6, 

1118,  1120,  1123,  1124,  1125 
operative   treatment   of,    iii'i- 

1126 
pathological  effects  .f,  11 16 

87 


1378 


A  MANUAL  OF  SURGERY 


Hernia,  strangulated,  prognosis  of,  1119 
sequelaa  of,  1126 
signs  and  symptoms  of,  11 17 
taxis  in,  11 19 
structure  of,  1089 
treatment  of,  1098-1105 
vermiform  appendix  in.  1090 
volvulus  in,  II 20 
Hernia,  acquired,  1088,  1093 
bubonocele,  1092 
cerebri,  792,  7.37,  752,  772 
congenital,  1087,  1093,  1103,  1109 
diaphragmatic,  11 13 
direct,  1094 
en  bissac,  1095 
encysted,  1094 
fatty,  nil,  197 
femoral,  1105 
funicular,  1094 
infantile,  1094 
inguinal,  1092-1105 
inguinalis  ante-vesicalis,  1096 
inguinalis  intra-iliaca,  1096 
internal,  1131 
interstitial,  1095,  1121 
Littre's,  1115 
lumbar,  11 12 
obturator,  11 13 
of  lung,  933 

Richter's,  1115,  1118,  1126 
testis,  1288 
umbilical,  980,  11 09 
vaginal,  1093 
ventral,  iiii,  971,  1061 
Herpes  labialis,  802 
in  neuralgia,  380 
preputialis,  1276 
zoster,  380,  394 
Hesselbach's  triangle,  1095 
Heteroplasty,  740 
Hey's  amputation,  1338 
Hey's  saw,  753 

Hilton's  method  of  opening  abscesses,  71 
Hinged -cup  truss,  11 14 
Hip  disease,  678-687,  726 

diagnosis  from   sacro -iliac    dis- 
ease, 688 
-joint,  acute  arthritis  of,  649,  679 
amputation  at,  1343,  687 
ankylosis  of,  676 
contusion  of,  536 
dislocation  of,  congenital,  440 

traumatic,  627-632,  536 
effusion  into,  640 
excision  of,  691,  684 
osteo-arthritis  of,  669,  536 
scissor-like  deformity  of,  676 
tuberculous  disease  of,  678 
Hirschsprung's  disease,  103 1 
Histrionic  spasm,  387 
Hodgen's  splint,  540,  543 
Hodgkin's  disease,  370,  55 

blood  in,  56 
Hoffa's  operation  for  congenital  displace- 
ment of  the  hip,  443 
Hoffmann's  bone  rongeur,  753 
Hollow-foot,  461 
Hooklets,  227,  1068 


Horn,  sebaceous,  407,  1276 
Horse-shoe  fistula,  1153 

kidney,  11 79 
Horsley's  classification  of  epilepsy,  791 
knife,  790 
wax,  760 
Hospital  gangrene,  114 
Hour-glass  stomach,  1003 
Housemaid's  knee,  424 
Howship's  lacunae,  565 
Hot-air  baths,  46 
Hot  water  in  treatment  of  haemorrhage, 

284 
Humerus,   fracture,  with  dislocation  of 
head,  502 

fractures  of,  496-513 

separation  of  lower  epiphysis,  506 
of  upper  epiphysis,  498 
'  Hurnmy,'  422 

Humoral  theory  of  immunity,  17 
Hunger  pain,  1018 
Hunterian  chancre,  146 
Hunter's  canal,  ligature  of  femoral  artery 
in,  340 

operation  for  aneurism,  316 
Hutchinson's  teeth,  164 

wart,  150,  849 
Hyaline  cells,  52 
Hydatid  cysts,  226,  415 

eosinophilia,  in,  55 

of  bone,  608 

of  brain,  786 

of  breast,  952 

of  kidney,  1207 

of  liver,  1068,  227,  1065 

of  lung,  937 

of  neck,  900 

of  spine,  733 

of  spleen,  1085 
Hydatid  of  JMorgagni,  224 
cysts  of,  1295 
fremitus,  1068 
Hydrarthrosis,  645,  663,  643 
Hydrencephalocele,  738 
Hydrocele,  acute,  1283,  1291 

chronic,  1291-1296,  1299,  1097 

bilocular,  1292 

congenital,  1291,  1295 

chylous,  1295,  631 

encysted,  1294,  1295, 

infantile,  1291 

of  breast,  951 

of  cord,  1295,  225,  1097 

of  epididymis,  1294,  224 

of  hernial  sac,  1089 

of  neck,  900 

of    round    ligament,     1134,     1295, 
225 

of  tunica  albuginea,  1295 

of  tunica  vaginalis,  1291,  1299 

ovarian,  1321,  1323 

radical  cure  of,  1293 

tapping,  method  of,  1295 

vaginal,  1292 
Hydrocephalus,  740,  714,  739 
Hydrogen,  peroxide  of,  267 
Hydronephrosis,  1185,  1188,  1223 

from  disease  of  bladder,  12 16 


INDEX 


1319 


Hydronephrosis  from  stricture  of  urethra, 
1262 

in  enlarged  prostate,  1251,  1253 

in  moveable  kidney,  1181,  1185 

in  renal  calculus,  11 96 

in  uterine  fibroids,  1308 
cancer,  13 12 
Hydrophobia,  130,  128 
Hydrops  antri,  813 

articuli,  645,  643 

of  frontal  sinus,  756 

of  gall-bladder,  1076 

tuberculous,  655 
Hydrosalpinx,  13 17 
Hygroma,  cystic,  361,  716,  225 

of  neck,  899,  898 
Hyoid  bone,  fracture  of,  490 
Hyperaemia,  31,  44 
Hyperchlorhydria,  997.  1003,  1018 
Hypernephromata,  1207 
Hyperostoses,  202,  814 
Hyperplasia,  due  to  lymphatic  obstruc- 
tion, 362 
Hypertrophic  cancer  of  intestine,  1029 

osteo-arthropathy,  598,  434 

tonsillitis,  872 
Hypertrophy,  concentric  and  eccentric, 
742 

of  bladder,  1215,  1250,  1262 

of  bone,  598 

of  breasts,  944 

of  gums,  808 

of  lips,  801 

of  prostate,  1248- 1256 

of  pylorus,  1009 

of  scars,  257 

of  skull,  741 

of  spleen,  1085 

of  tonsils,  872 
Hyphomycetes,  10 
Hypochlorhydria,  997 
Hypodermic  injections  in  shock,  261 
Hypodermoclysis,  280 
Hypoglossal  nerve,  injury  of,  388 
Hypopyon,  71 
Hypospadias,  1257 
Hypostatic  pneumonia  in  fractures,  478, 

532 
Hysterectomy,  abdominal,  1309 

for  cancer  of  uterus,  1334 

for  deciduoma  maligna,  1315 

vaginal,  1313,  1306 

Wertheim's,  1314 
Hysteria,  427 

in  spinal  injuries,  707 
hysterical  joints,  449,  674 

stricture  of  oesophagus,  880 
Hysteio-epilepsy,  791 
Hysteiopexy,  1305 

Ichthyosis  linguas,  827 
Icterus.  See  Jaundice 
Idiopathic  dilatation  of  colon.  103 1 

erysipelas,  122,  120 

psathyrosis,  594 
Ileo-caecal  intussusception,  1140 
lleo-colic  intussusception,  1140 
lleo-colostomy,  1028,  1031 


Ileus,  1 127 

dynamic,  1129 

mechanical,  1129 
Iliac  abscess,  726 

aneurism,  327 

colostomy,  1034,  1036 

vessels,  ligature  of,  337,  338 
Immunity,  13-29,  982 

theories  of,  17,  18,  19 

to  tumours,  186 
Impacted  calculus  in  ureter,  iig7,  1185, 
1196 

f3ces,  1129,  1136;  1137 

fracture,  468,  532,  533 

gall-stones,  efiects  of,  1076 

urethral  calculus,  1227.  1259 
Impaction   of  foreign   bodies  in   bowel, 

1133,  1024,  1025,  1129.  1136 
Impassable   stricture   of   urethra,    1261, 
1269 

treatment  of,  1269 
Imperforate  anus,  1147 
Impermeable  stricture  of  urethra,  1261 
Impetigo  contagiosa,  60 
Implantation  cysts,  226 
Impulse,  expansible  in  aneuiism,  311 

in  hernia,  1091 
Incised  wounds,  232 

Incision,  parietal,  in  abdominal  opera- 
tions, 970 
Incisions  in  treatment  of  inflammation,  43 
Incomplete  descent  of  testis,  1279 

dislocation'^,  612 

fracture,  467 
Incontinence  of  lurine,  1226,  1227,  1251 

in  women,  1226,  1245 
Incurvation  of  neck  of  femur,  444 
Indian    ink    method    of    demonstracing 

spirochaetae,  144 
Indian  operation  of  rhinoplasty,  827 
Induced  hyperaemia,  46 
Induration  of  sterno-mastoid-congenital, 

427 
Infantile  hernia,  1094 

hydrocele,  1291 

palsy,  733.  451 

scurvy,  593 

umbUical  hernia,  1109 
Infarct.     See  also  Emboli 

haemorrhagic,  347,  88 

pyaemic,  347 
Infection  (Chapter  I.),  11-13 

mixed,  62,  72 

secondary,  172 
Infections,  non-specific  pyogenic  (Chap- 
ter IV.),  59-90 
Infectious  diseases,  non-specific,  12 

specific,  12 
Infective  arteritis,  302 

disease,  specific  (Chapter  VII.).  120 

183 

emboli,  346,  87,  308 

endocarditis,  87,  88 

gangrene,  113,  103 

osteo-myelitis,  acute,  568,  566 

phenomena    of    intestinal    obstruc- 
tion, 1128 

phlebitis.  348,  87,  781 


i38o 


A  MANUAL  OF  SURGERY 


Infective  processes,  13 

thrombosis  of  cerebral  sinuses,  781 
Inferior    dental    nerve,    operations    on, 
384 
maxilla,  fractmre  of,  487 
Infiltration  in  carcinoma,  211 
Inflamed  aneurism,  313 

treatment  of,  319 
haemorrhoids,  1158.  1159,  1160 
hernia,  11 14 
h'mphatic  gland  simulating  hernia, 

1097,  1107 
undescended       testis,       simulating 
hernia,  1125 
Inflammation  (Chapter  II.),  30-48 
of  ovarian  cyst,  1324 
resolution  in,  36,  35 
signs  of,  36 
tissue  changes  in,  34 
varieties  of,  39 
Inflammatory  fever,  118 
leucocytosis,  53 
lymph,  33 

senile  gangrene,  107 
Inflation    of    bowel   in   intussusception, 
1 142 
of  stomach,  997 
of  tympanic  cavities,  885 
Infra-orbital  nerve,  operations  on,  383 
Infusion  of  salt  solution,  278,  83 
for  abdominal  injuries,  979 
for  haemorrhage,  278 
for  peritonitis,  985 
for  sepsis,  83,  86 
for  shock,  261 

into  subcutaneous  tissues,  985 
Ingrowing  toe-nail,  406 
Inguinal  aneurism,  327 
bubo,  137 

(iliac),  colostomy,  1034,  1036 
hernia,  1092-1105 
acquired,  1093 
congenital,    varieties    of,    1093, 

1103 
diagnosis  of,  1097,  1106 
direct,  1094 

infantile  (encysted),  1094 
interstitial,  1095 
oblique,  1092 
strangulated,  11 25 
treatment  of,  1098-1105 
varieties  of,  1092 
Inherited  syphilis,  160,  802,  1085 

bone  affections  in,  588,  450 
Injections  for  cure  of  hydrocele,  1293 

in  gonorrhoea,  136 
Injuries  a  cause  of  tumoxurs,  184 

of  arteries,  298 
Innominate  artery,  aneurism  of,  321 

ligature  of,  330,  325 
Inoperable  malignant  disease,  treatment 
of— 

(a)  by  Coley's  fluid,  195 
(6)  by     double     oophrectomy, 
968 

(c)  by  pancreatic  ferments,  219 

(d)  by  X  rays,  218 
Insanity,  traumatic,  792 


Insect  stings,  245 

Instruments,  preparations  of,  for  opera- 
tions, 270 
Interacinous  cysts  of  breasts,  951 
Intercostal  aitery,  haemorrhage  from,  295 

neuralgia,  394 
Intermaxilla  in  hare-lip,  796 

treatment  of,  799 
Intermediate  haemorrhage,  291 
Internal  callus,  472 

Internal    carotid    artery,    aneurism    of, 
323,  324 
ligature  of,  331,  324,  325 
wounds  of,  775 
Internal    coagulum    in    the    arrest    of 
haemorrhage,  280,  291 
derangement  of  knee-joint,  633 
ear,  disease  of,  891 
fistula  of  anus,  1150,  1154 
haemorrhoids,  11 59 
hernia,  1131 

iliac  artery,  ligature  of,  337 
malleolus,  fracture  of,  552,  556 
mammary  artery,  haemorrhage  from, 
295 
ligature  of,  334 
popliteal  nerve,  affections  of,  396 
strangulation    of     intestine,     1134. 

1129,  1131 
urethrotomy,  1267 
Interparietal  hernia,  1096 
Interscapulo-thoracic  amputation,  1336, 

607 
Interstitial  emphysema  of  lungs,  931 
fibroids,  1307 
hernia,  1095,  1121 
inflammation,  40 
keratitis,  164 
mastitis,  948 

nephritis  (suppurative),  1187 
Intestinal  adhesions,  986,  982,  988,  1048, 
1129,  1131 
anastomosis,  1040 
bobbins,  1041 
calculi,  1024 

obstruction      (Chapter      XXXVI.), 
1127-1145 
acute,  1129-1136,  1117 
chronic,  1136-1139 
paralysis,  11 17,  1129 
sutures,  973 
Intestines,  affections  of,  1020-1032 
carcinoma  of,  1029 
colitis,  1025 

congential  malformations  of,  1020 
embolus  in,  348 
enteritis,  1025,  1117 
enteroptosis,  1032 
foreign  bodies  in,   1024,  1129,  ii33. 

1136 
idiopathic  dilatation  of  colon,  103 1 
injuries  of,  1020 
operations  on,  1033-1043 
perforation  of,  1023,  982,  1117.  i^37 
sarcoma  of,  1028 

stenosis  of,  1129,  11:36,  1126,  1027 
tuberculous   ulcers   of,    1023,    1026, 
1027 


INDEX 


1381 


Intracanalicular  adenoma  of  breast,  956 
Intracapsular  fracture  of  femur,  531 

of  humerus,  496 
Intracellular  toxins,  6 
Intracoracoid    dislocation    of    humerus, 

620 
Intracranial  aneurism,  324 

bloodvessels,  injuries  of,  773-776 
complications  of  otorrhoea,  S94 
inflammation,  776 
lesion  of  seventh  nerve,  385 
Intradermic  suture,  234 
Intramammary  abscess,  947 
Intramedullary    haemorrhage    of    spine, 

705 
Intrameningeal  haemorrhage,  775 
Intramuscular  Lnjectoins  of  mercury,  157 
Intra-orbital  aneurism,  324 
Intraparietal  hernia,  1095,  1121 
Intraperitoneal   abscess,    9S6,    990,    995, 
99S,  1023,  1024,  1051 
haemorrhage,  978,  994,   1063,   1084, 

1183 
rupture  of  bladder,  12 13 
ectopic  gestation,  1318 
Intrathoracic  aneurism,  320 

goitre,  904 
Intra-uterine  fractures,  467 
Intrinsic  cancer  of  lar\Tix,  919 
Intubation  of  lar^iix,  917,  927,  940 
Intussusception,  acute.  1139,  ro2o,  1129, 
1141,  1164 
anatomy  of,  1139 
treatment  of,  1142 
varieties  of,  1140 
chronic,  114 1 

treatment  of,  1142 
Inunction  of  mercury  for  syphili?,  157 
Inversion  of  testis,  1280 
Involucrum,  567,  572 
Involution  cysts,  94S,  951 
Iodine,  sterilisation  of  skin  by,  272 

pain,  46 
Iodoform,  266 

and  glycerine,  266 
emulsion,  657 
lodolysin,  257 
Ionic  medication,  410,  47 
Ions,  zinc,  treatment  by,  410 
Ipecacuanha  in  treatment  of  hepatitis, 

1067 
Iritis,  svphUitic,  151 
Irradiation,  Aran's  theory  of,  745 
Irreducible  hernia,  iioi,  iioo 
Irrigation  of  abdomen,  984 
of  bowel  for  colitis,  1026 
of  chronic  abscess,  177 
of  peritoneal  cavity,  984 
of  urinary  bladder,  12 17 
irritable  bladder,  1216,  1221,  1222,  1246, 
1251,  1261 
ulcer,  96 
Irritation,  cerebral,  763 
cysts  of  breast,  951 
Ir\Tng's  apparatus  for  suprapubic  cysto- 
tomy, 1255 
Ischaemic  contraction  of  muscles,  479 
Ischio-rectal  abscess,  1151,  1272 


Italian  operation  of  rhinoplasty,  827 
Ivory  exostosis,  202 

Jacques'  catheter,  1263 
Jacksonian  epilepsy,  788,  791 
Jaundice,  catarrhal,  1072 

in  cancer  of  bile-ducts,  loSo 
in  cancer  of  pancreas,  1083 

of  stomach,  1007 
in  gall-stones,  1076 
in  rupture  of  gall-bladder,  1072 
Jaw,  lower,  closure  of,  823 
dislocation  of,  615 
excision  of,  821,  811 
of  condyle  of,  824 
fracture  of,  487 
necrosis  of,  8ro 
tumours  of,  819-821 
upper,  excision  of,  817 
fracture  of,  48  7 
necrosis  of,  Sio 
tumours  of,  814 
Jaws,  afiections  of,  806-824 
Jejunostomy,  1033,  1008 
Jenner's  stain,  50 
Jerk -finger,  439 
Joints,  ankylosis  of,  675 

diseases  of  (Chapter  XXII.),  639-694 

dislocation  of,  610-638 

effusion  into,  evidences  of,  639 

excision  of,  689-694,  658,  648 

false,  483,  613 

gonorrhceal,  affections,  652,  139,  645 

haemophilic  disease  of,  672 

hysterical,  674 

implication  of,  in  fractures,  481 

injuries  of  (Chapter  XXL),  610-638 

loose  bodies  in,  672 

neuralgic,  674 

operations  on,  640,  65 3 

pyaemic,  651 

sprains  of,  610 

syphilitic  affections  of,  663 

tuberculous    disease    of,    652,    585, 

645 
typhoid  disease  of,  651 
wounds  of,  610 
Jordan's  (Furneaux)  amputation  at  hip- 
joint,  1344 
Jugular  vein,  haemorrhage  from,  295 

ligature  of,  896,  349 
Junker's  inhaler,  1350 
Juxta-epiphyseal  strain,  469 

Kader-Senn's  gastrostomy,  1013 
Kangri  cancer,  184 
Keloid,  257 

Keratitis,  interstitial,  164 
Keratomycosis,  10 

Kidnevs,        affections        of        (Chapter 
XXXVIIL),  1177-1209 

abscess  of,  1189,  1191 

adenoma  of,  1205 

adrenal  adenomata,  1205 

amyloid  disease  of,  1233.  76 

atrophy  of,  11 79 

congenital  affections  of,  11 79 
displacement  of,  iiSo 


1382 


A  MANUAL  OF  SURGERY 


Kidneys,  calculus  in,  1195,  1196 
carcinoma  of,  1207 
cystic  disease  of,  1205 
embolus  in,  348 
enlarged,  signs  of,  ii77 
estimation    of    functional    activity, 

methods  of,  11 78 
examination  of,  11 77 
exploration  of,  11 79 
floating,  1 1 80 
hydatid  of,  1207 
hydronephrosis,  1185,  1188,  1223 
injuries  of,  11 83 
moveable,  11 80 
nephritis,  11 87 
pyelitis,  11 87 
pyelonephritis,     1189,    1187,     1188, 

1195,  1217.  1242 
sarcoma  of,  1206,  1180 
surgical,  1188,  1217 
tuberculous  disease  of,  1191,  1192 
tumours  of,  1205 
Killian's  tubes  for  air-passages,  915,  912 

oesophagoscope,  use  of,  879 
Kingsley's  splint  for  fracure  of  mandible, 

490 
Kinking  of  intestme,  1129,  1133 

of  ureter,  1180,  1181,  1185 
Knee-joint,  acute  arthritis  of,  649 
amputation  through,  1342 
ankylosis  of,  676 
contraction  of,  449 
dislocation  of,  633 
effusion  into,  640 
excision  of,  693,  662 
internal  derangement  of,  633 
subluxation  of,  633 
tuberculous  disease  of,  661 
Knock -knee,  445 

Kobelt's  tubes,  cysts  of,  1321,  224,  1295 
Koch's  postulates,  10,  9 

tuberculin,  16,  167,  657 
views  on  tuberculosis,  166 
Kocher's  method  of  treating  dislocation 
of  the  humerus,  621 
of    operating    for    removal    of 
tongue,  854 
operation     on     contracted     palmar 

fascia,  440 
per-trochanteric  fracture,  539 
'  Kopf -tetanus,'  128 
Kraske's  method  of  excision  of  rectum. 

1173 
treatment  for  erysipelas,  124 
Kronlein's  cerebral  topography,  758 
Kyphosis,  434,  595.  732,  841 

Labial  arteries,  compression  of,  290 
Labium,  abscess  of,  1304 

cysts  of,  1304 
Laboratory  diagnosis  of  gonorrhoea,  133 

of  syphilis,  144 
Labyrinthitis,  891 
Lacerated  wounds,  236 
Laceration  of  arteries,  298 

of  brain,  763,  767 

of  lung,  930 

of  recto-vaginal  septum,  1303 


Laceration  of  urethra,  125S 
Lachrymal  bone,  fracture  of,  486 
Lactic  acid  in  gastric  affections,  997,  ioo5 
in  mollities  ossium,  595 
in  tuberculous  disease  of  laryi^^. 
918 
Lacunar  abscess,  137,  1273 
Lambkin's  cream,  157 
Laminectomy,  711 

in  spinal  caries,  731 
in  spinal  diseases,  733 
Lane's  plates,  478 

Langenbeck's  operation  for  excision  of 
rectum,  ir72 
on  nasal  cavity,  839 
osteoplastic    section    of    upper 

jaw,  839 
uranoplasty,  865 
Laparotomy,    exploratory,    1008,    1022, 
1023,  1030,  1064,  1072,  1138 
for  abdominal  wounds,  977 
for  appendicitis  in  quiescent  period, 

1056 
for  ascites,  993 
for  cancer  of  intestine,  1030 
for  cancer  of  stomach,  looS 
for   fulminating   appendicitis,    1058 
for  intestinal  injuries,  1022,  979 
for  intestinal  obstruction,  11 34, 11 38 
for  intestinal  stenosis,  1028 
for  intussusception,  1x42 
for  kidney  tumours,  1208 
for  pancreatitis,  1082 
for  perforation   of  duodenal   ulcer, 
1020 
of  stomach  ulcer,  loor 
of  typhoid  ulcer,  X024 
for  perigastritis,  1002,  1009 
for  peritonitic  adhesions,  988 
for  peritonitis,  acute,  984,  987,  990 
chronic,  988 
tuberculous,  989 
for  rupture  of  bladder,  1213 
of  ectopic  gestation,  1319 
of  gall-bladder,  1072 
of  intestine,  1022 
of  liver,  1064 
of  spleen,  1084 
of  stomach,  998 
for  strangulated  hernia,  1126 
for  suppurative  appendicitis,  1059 
for  ulcer  of  duodenum,  1020 
for  ulcer  of  stomach,  1000,  looi 
for  wounds  of  intestine,  1022 
for  wounds  of  mesentery,  995 
for  wounds  of  rectum,  1149 
Lardaceous  disease,  74,  1085.     See  also 

Amyloid  disease 
Larrey's   amputation  at   shoulder-joint, 

1335 
Laryngeal  cartilages,  necrosis  of,  919 
dysphagia,  883 
paralysis,  918,  927 

from  aneurism,  320,  321,   322, 

388 
in  cancer  of  oesophagus,  882 
in  cut  throat,  901 
in  thyroid  tumours,  904 


INDEX 


1383 


Laryngeal  stenosis,  902,  917,  922,  927 

Laryngectomy,  919,  920 

Laryngitis,  acute  and  chronic,  91G,  922 

oedematous.   916,   922,   80,    81,    122, 
490,  846,  856,  871,  877,  901 
Laryngoscope,  use  of,  912 
Laryngotomy,  922,  913,  914,  917 
Laryngo-tracheotomy,  922 
Larynx,  diseases  of,  916-919 

acute    oedema    of,    916.     See    also 
CEdematous  laryngitis 

epithelioma  of,  918 

foreign  bodies  in,  913,  914,  922 

injuries  of,  916,  901 

intubation  of,  927 

papilloma  of,  918 

paralysis       of,      922.        See       also 
Laryngeal  paralysis 

syphilis  of,  917 

tuberculous  disease  of,  917 
Lateral  anastomosis  of  intestine,  1042 

curvature  of  spine,  429,  446 
in  hip  disease,  680 

implantation  of  intestine,  1043,  1031 

lithotomy,  1244 

sinus,    thrombosis   of,    895,    87,    90, 
761,  785 
pyasraia,  895,  349 
Lavage  of  stomach,  loio 

in  intestinal  obstruction,  1135 
in  stenosis  of  pylorus,  1009 
Leaking  aneurism,  313 
Leather-bottle  stomach,  1005 
Leather  splints,  474 
Leeches,  41 
Leg,  amputation  of,  methods  of,  1341 

fractures  of,  551 
Leiomyoma,  202 
Leiter's  tubes,  42 
Lembert's  intestinal  stitch,  974 
Lengthening  a  tendon,  method  of,  420 
Lennander's    method     of     opening    the 

abdomen,  971 
Leontiasis  ossea,  814,  202,  742 
Leprosy,  179,  676 
Lepto-meningitis,  778,  705,  781 
Leptothrix,  3 
Leucocytes,  enumeration  of,  50 

migration  of,  in  inflammation,  32 

phagocytic  action  of,  18,  34 

varieties  of,  51 
Leucocythaemia,  372,  370,  371 

splenectomy  for,  1085 
Leucocytosis,  52,  53,  69,  85,  1052,  1060, 

1066 
Leucopenia,  52,  54 
Leucoplakia,  847 

Ligament,  round,  affections  of,  1304 
Ligamentum  patellae,  bursa  beneath,  424 

rupture  of,  414 
Ligation  in  continuity  of  vessels,  32S 
Ligature  of  vessels,  328-343 

for  aneurism,  316,  321,  322,  323,  324, 
325 

for  hsemorrhage,  285,  295 
for  piles,  11 62 

gp.ngrene  following,  no,  330 

secondary  haemorrhage  after,  291, 330 


Ligatures,  materials  for,  286,  271 

changes  in,  287 

effects  of,  286 

preparation  of,  271,  286 
Linea  alba,  congenital  defects  of,  1088 

fatty  hernia  of,  iiii,  197 
Linear  craniectomy,  741 
Lingual  artery,  ligature  of,  332,  854,  856 
Lipoma,  195,  716 

arborescens,  665,  644 

diffuse,  197 

nasi,  826 

of  femoral  canal,  1107 

of  inguinal  canal,  1097 

of  intestine,  1028 

painful,  of  the  foot,  196 

parosteal,  196 

pericranial,  196 

retroperitoneal,  996 

subserous,  197 
'  Lipping  '  of  joints,  666,  663 
Lips,    affections    of   (Chapter    XXVII  ), 

794-805 
Lisfranc's  amputation,  1337 
Lister,   operation  for   fractured   patella, 

550 
Lister's  antiseptic  treatment  of  wounds, 
265 

bougies,  1264 

dressings,  274 

excision  of  wrist,  691 

modified  flap  and  circular  amputa- 
tion, 1330 

strong  mixture,  266 

supracondylar  amputation  of  thigh, 
1343 

tourniquet,  1344 
Liston's  long  splint,  538 
Lithiasis  (lithaemia),  1229,  1195,  1237 
Litholapaxy,  1240 
Lithotomy,  lateral,  1244 

perineal,  1243 

indications  for, 

suprapubic,  1243 
indications  for, 
Lithotrites,  1241 
Lithotrity,  contra-indications  to,  1244 

in  boys,  1244 

operation  of,  1240 
Littre's  hernia,  11 15 

operation  of  colostomy,  1036 
Liver,  abscess  of,  tropical,  1065,  1064,  62 

affections  of,  1062-1070 

amyloid  disease  of,  75 

embolus  in,  348 

tumours  of,  1069 
Local  anesthesia,  methods  of  inducing, 

1346 
Localization  in  csrebral  injuries,  769-771 
Locomotor  ataxy,  joints  in,  669 
Longitudinal  fractures,  468 
Loose  bodies  in  joints,  672 
Lordosis,  435 

in  hip  disease,  680 
Lorenz's   bloodless   method    of   treating 

congenital  dislocation  of  hip,  443 
Loreta's  operation  on  pylorus,  1009 
Lowenberg's  forceps,  842 


1244 


1244 


13^4 


A  MANUAL  OF  SURGERY 


Lov;er  jaw.     See  Jaw  and  Mandible 
Ludwig's  angina,  8i,  858,  916 
Lumbar  abscess,  723,  730,  1113 

colostomy,  1034,  1035 

hernia,  11 12 

incision  for  exposing  kidney,  1179 

nephrectomy,  1209 

puncture    for    diagnostic    purposes, 
760 

punctxire   for   treatment,    129,    763, 
767,  780 
Lung,  embolus  in,  34* 
Lungs,  actinomycosis  of,  182 

affections  of,  929  933 
Lupoid  ulcers,  402 
Lupus  action  of  erysipelas  on,  123 

erythematosus,  405 

of  palate,  869 

of  tongue,  849 

treatment  of,  by  Finsen  light,  404 
by  X  lays,  404 

vulgaris,  401 
Luschka's  tonsil,  840,  876 
Luxatio  erecta,  619 
Luxation  of  joints,  612 
Luy's  segregator,  11 78 
Lymph,  characters  of,  33 
Lymphadenitis,  acute.  364 

chronic,  366 

special  foims  of,  366 

syphilitic,  366,  150 

tuberculous,  367 
Lymphadenoma,  370,  207,  1085 
Lymphangeioplasty,  364,  968 
Lymphangiectasis,  360,  801,  846 
Lymphangioma,  360,  207,  996 

of  round  ligament,  1305 
Lymphangitis,    358,    78,    148,    359.    .397 

399,  846 
Lymphatic  glands,  affections  of,  365-372 
involvement  in  soft  sores,  141 
secondary  growths  in,  372,  959 
tumours  of,  370-372 
Lymphatic  leukaemia,  55,  56,  58,  372 

nsevus,  360 

oedema,  362,  961,  968 

vessels,  diseases  of,  358 
Lymphatics,    diseases    of    the    (Chapter 
XIV.),  358-372 

Lymphocytes,  51,  35,  44,  167 
in  chronic  inflammation,  44 
in    tuberculous    inflammation,    167, 
168 

Lymphocytosis,  55,  52 

Lyrnphorrhcea,  362,  361 

Lympho-sarcoma,  372,  191,  370,  371 
of  testis,  1290 
of  tonsil,  874 

Lysol,  267 

McBurney's  hook,  502 

method   of   opening   the   abdomen, 

971,  1036,  1056 
spot,  1051 
MacEwen    on   symptoms    of    abscess    of 

brain,  783 
MacEwen's  operation  for  hernia,  1103 

for  knock-knee  (osteotomy),  448 


l\racEwen's  treatment  of  aneurism,  318, 

321,  322,  325,  326 
Macintyre's  splint,  542,  551,  555 
Mackenzie's  guillotine,  873 
Macrocheilia,  801,  361 
Macrodactyly,  437 
Macroglossia,  361,  845 
Macrostoma,  800 
Magnesium    sulphate    in    treatment    of 

tetanus,  130 
Main-en-griflEe,  394 
Malar,  fracture  of,  486 
Malaria,  diagnosis  of,  56 
Malarial  spleen,  1085 
Malignancy,  characteristics  of,  187 
Malignant  adenoma,  214 
cysts  of  neck,  898,  900 
disease,  blood  in,  58 
diseases  of  scars,  257 
embolus,  190,  347 
endocarditis,  87.     See  also  Infective 

endocarditis 
epulis,  810,  819 
goitre,  910,  903 
oedema,  113 
papilloma,  212 
pustule,  131,  132 
sj'philis,  156 
tumours,  187 
;  ulcers,  850 

i  warts,  212 

!    Mallet -finger,  439 
Malposition  of  testis,  1279 

inflammation     of,      simulating 
strangulated  hernia,  1125 
Mamma.     See  Breast 
INIandible,  dislocation  of,  615 
excision  of,  821,  811 
injuries  of,  487,  615,  805 
tumours  of,  819 
Mandibular  clefts,  800 
Marjolin's  ulcer,  257 
Martin's  bandage,  95,  644 

proctoscope,  1147 
Massage,  47 

abdominal,  1026 

in  treatment  of  embolic  gangrene, 
105 
of  embolism,  348 
in  treatment  of  fractures,  476 
of  phlebitis,  349 
of  synovitis,  642 
of  prostate,  1247 
Mastitis,  acute,  946 
chronic,  948 
interstitial,  948 
Mast-cells,  51 
Mastoiditis,  891 
Mastoid  antrum,  suppuration  in,  891 

operations  on,  893 
Matas'  operation,  314 
Mattress  suture,  975 

Maxilla,  affections  of,  811 -819.     See  also 
Upper  jaw 
excision  of,  817 
fracture  of,  487 
Maxillary  sinus,  empyema  of.  Sir 
Meckel's  diverticulum,  1020,  980 


INDEX 


1385 


Meckel's  diverticulum,  strangulatioa  of 

intestine  by,  1131 
Median  hare-lip,  800 
cervical  fistula,  899 
nerve,  affections  of,  392 
operations  on,  393 
Mediastinitis,  septic,  901 
Medulla  oblongata,  injury  of,  771 

of    bone,     inflammation     of.      See 
Osteo-myelitis 
Medullary  cancer,  216 

plug,  472 
Megaloblasts,  55 
Megalocytes,  55 
Melaena,  277,  1161,  1019 
Melanin,  194 
Melanosis,  194 

Melanotic  sarcoma,  194,  1069 
Melon-seed  bodies,  417,  672,  655 
Membrana  tympani,  appearances  of,  885, 
886 
rupture  of,  888,  747 
Meningeal  hsemorrhage,  cerebral,  773 
spinal,  705 
tuberculosis     in     association     with 
tuberculous  testis,  1285 
Meningitis,  basal,  835 

cerebral  acute,  778,  752,  761,  784, 

895.  780 
chronic,  780 
spinal,  705,  724 
syphilitic,  781 
tuberculous,  781,  761,  1285 
Meningocele,  713,  738 
Meningococcus,  8 

Meningo-encephalitis,  780,  772,  778 
Meningo-encephalocele,  739 
Meningo-myelocele,  713 
Meniscitis,  634 
Menorrhagia,  1308 
Mercurialism,  158,  845 
Mercury,  treatment  of  syphilis  by,  156 
Mesenteric  glands,  affections  of,  995 

vesesls,    thrombosis   of,    995,    1020, 
1129 
Mesentery,  affections  of,  995 
Meso-appendix,  thrombosis  of  vessels  in, 

1050 
Mesognathion,  796 
Metacarpal  bones,  diseases  of,  579 
dislocations  of,  626 
fractures  of,  527 
removal  of  head  of,  in   ampu- 
tating, 1333 
Metacarpo-phalangeal  joint,  amputation 

at,  1333 
Metastases  in  mumps,  857 
Metastasis,  40 

Metatarsal,  first,  tubercle  of,  581 
Metatarsalgia  (Morton's  disease),  464 
Metchnikoff's  theory  of  immunity,  18 
Meteorism,  1127,  710,  1144 
Metrorrhagia,  1308 
Methylene-blue   test   of  renal   function, 

1178 
Michel's  clips,  235 
Microcephaly,  741 
Micrococci,  3 


Micrococcus  epidermidis  albus,  61 

melitensis,  8 

neoformans,  219 

prodigiosus,  195 

tetragenus,  62,  8 

ureae,  61,  1214 
Microcytes,  55 
Microsporon  Audouini,  ro 

furfur,  10 
Microstoma,  801 
Middeldorpf's  triangle,  503,  498 
Middle-ear  disease.     See  Otitis  media 
Middle  meningeal  artery,  wounds  of,  773 
Middle  turbinate  bone,  diseases  of,  834 
Mid-tarsal  joint,  amputation  at,  1338 
Miliary  tubercle,  168 

tuberculosis,  656,  725,  1285 
Miner's  elbow,  425 
Mirault's  operation  for  hare-lip,  798 
Mitosis  in  tumours,  211 
Mixed  infection,  62,  72 

parotid  tumour,  220 

thrombus,  345 
Modified   flap    and    circular   method    of 

amputation,  1330 
Moist  gangrene,  100 
Mollifies  ossium,  594 
Molluscum  contagiosum,  408,   ri 

fibrosum,  199 
Monartiqular  osteo-arthritis,  666 
Mononuclear  cells,  51 
Monoplegia  after  head  injuries,  769,  772 
Moore's  method  of  treating  aneurism,  318 
Morbus  coxse,  678 
Morgagni,  hydatid  of,  cysts  from,  1295. 

224 
Morris's  bitrochanteric  line,  535 
Morton's  disease.     See  Metatarsalgia 

fluid,  715 
Motor  aphasia,  769,  784 

area,  paralysis  of,  in  cerebral  com 
pression,  765 
topography  of,  770 
wounds  of,  769 

oculi  nerve,  affections  of,  381 
Mouse  cancer,  186 

Mouth,  affections  of  (Chapter  XXIX.), 
844-871 
of  floor  of,  856 
Moveable  kidney,  11 80 

spleen,  1084 
Moxa,  46 
Muco-pus,  70 
Mucous  colitis,  1025,  1054 

cysts  of  frontal  sinus,  756 
of  lips,  803 
of  mouth,  S56 

polypi  of  antrum  of  jaw,  813 

polypus  of  nose,  835 

tubercles,   150,   209,   802,   849,  917. 
1160,  1165 
treatment  of,  159 
Mulberry  calculus,  1236 
Multiple  abscess  of  liver,  1064 

fractures,  466 
Mummification,  100 
Mumps,  857 
Murexide  test,  1229 


I38& 


A  MANUAL  OF  SURGERY 


Murphy's  button,  1042 

Muscle,  congenital  induration  of,  427 

of  Treitz,  1089 
Muscles,   affections  of  (Chapter  XVII.), 
411-416 

changes  in,   after  injury  to  nerves, 

375 

inflammation  of,  414 

rupture  of,  412,  127 

tumours  of,  416 
Muscle-splitting,    method      of     opening 

abdomen,  971,  1036,  1056 
Muscular  torticollis,  427 
Musculo-spiral  nerve,  injury  of,  390,  970 

operation  on,  391 
Mydriasis,  382 
Myelitis,  spinal,  706,  724 
Myelocele,  713 
Myelocytes,  56 
Myeloid  sarcoma,  193,  598,  810,  820 

treatment  of,  607,  820 
Myeloma,  194 
Myeloplaxes,  193 
Mj'oma,  202,  1028 

Myomectomy  for  fibroids  of  uterus,  1309 
Myosarcoma,  193 
Myosis,  771 
Myositis,  414 

fibrosa,  415 

ossificans,  415,  416,  479,  675,  823 

parasitic,  415 

rheumatic,  415 

suppurative,  415 

sj'philitic,  415,  849 

traumatic,  415 

tuberculous,  413 
Myxoedema,  903,  597.  910 
Myxo-fibro-neiu^oma,  205 
Myxoma,  195,  733 

Naevo-lipoma,  355 
Ncevus,  354,  206,  312 

cavernous,  206 

lymphatic,  360 

of  lip,  803 

of  scalp,  737 

of  tongue,  850 

of  umbilicus,  980 

unius  lateris,  354 
Nails,  affections  of,  407 
Nasal  bones,  fracture  of,  486 

obstruction,  816,  829,  836,  838,  840 

polypi,  835-838,  813 

septum,  deviations  of,  829 
fracture  of,  486 

spurs,  829 
Naso-orbital  fissure,  796,  800 
Naso-pharyngeal  polypus,  837,  877 
Naso-pharynx,  examination  of.  828 

operations  on,  839 
Nastin  in  treatment  of  leprosy,  ^Pr 
Navel,  starting  of,  1109 
Neck,  abscess  in  glands  of.  366 

affections  of  (Chapter  XXXI.),  897. 
911 

collulitis  of,  80 

malignant  glands  "t  '>perations  on, 
855 


Neck  of  femur,  fractures  of,  531 
of  humerus,  fractures  of,  496 
of  radius  fractures  of,  517 
of  scapula,  fracture  of,  495 
tuberculous  glands  of,  368 
Necrosis,  acute,  568,  35 

after  amputation,  1332 
after  compound  fracture,  574 
central,  574 
'        fat,  1080 

quiet,  564,  673 
superficial,  566 
svphilitic,  586,  153 
tuberculous,    of   cranial  bones, 

742 
tubular,  574 
typhoid,  575 
of  bone,    568,    103,    114.    563.    S^o, 

569.  572 
of  jaw,  810 
of  ossicles  of  ear,  890 
of  palate,  870 
of  skull,  742 
of  temporal  bone,  890 
Needles,  wounds  by,  241 
Negri  bodies  in  hydrophobia,  131 
Nelaton's  line,  535,  444.  628 

operation  on  naso-pharynx,  839 
Nephrectomy,  for  abscess  of  kidney,  1 192 
for  calculous  pyonephrosis,  1205 
for  hydronephrosis,  1187 
for  injury  of  kidney,  1184 

of  ureter,  11 84 
for  tuberculous  disease,  1195 
for  tumours,  1206 
indications  for,  1208 
methods  of,  1208 
Nephritis,  1187,  1191 

surgical  treatment  of,  1187 
Nephrolithotomy,  1204 
Nephropex3^  1182 
Nephrorrhaphy,  11 82 
Nephrotomy,    1187,    1189,    1190,    1225, 

1266 
Nerve  anastomosis,  378,  386 
extraction,  381 
grafting,  378 

stretching,  381,  383,  395,  126 
suture,  377 
Nerves,  affections  of  (Chapter  XV.),  373- 
396 
of  special,  381-396 
bulbous  ends  of,  374.  i332.  205,  257 
degeneration  of,  374 
division  of,  374 
inflammation  of,  379 
injuries  of,  373.  748 
involvement  in  fractures,  483 
regeneration  of,  377 
rupture  of  374 
suture  of,  377 
tumours  of,  203-205 
See  also  the  special  nerves 
Nervous   phenomena   in    intestinal    ob- 
struction, 1 128 
traumatic  delirium,  263 
Neuralgia,  379.  312 
of  joints,  674 


INDEX 


1387 


Neuralgia  of  scalp,  791 

of  testis,  129S 

sciatic,  395 

trigeminal,  382 
Neurasthenia,  707,  716,  763 
Neurectomy,  380,  383 
Neurenteric    canal,    origin    of    tumours 

from,  716 
Neuritis,  acute  and  chronic,  379       , 

optic,  784,  785,  788 

peripheral,  joint  changes  in,  676 
Neuro-fibromatosis,  203,  733 
Neuroma,  203 

traumatic,  205,  374 
Neuropathic  arthritis,  669 
Neurotomy,  380,  383 
Nicoll's    operation    for    radical    cure    of 

femoral  hernia,  1 109 
Night  pains  in  bone  disease,  582,  586 
in  joint  disease,  655 

sweats,  74 
Nipple,  affections  of,  945 

retraction  of,  958 
Nitrous    oxide    gas,    method    of    using, 

1349 
Nocturnal  incontinence  of  urine,  1226 
Node,  periosteal,  576,  586,  742 

from  chronic  ulceration,  94 

syphilitic,  586,  150,  589 

tuberculous,  578 
Nodes,  Parrot's,  589 
Nodular  arterio-sclerosis,  303 
Noma,  115,  103 
Non-specific  pyogenic  infections,   59-90, 

12 
Non-tuberculated  leprosy,  180 
Non-union  of  fractures,  483 
Normal  blood,  57 

Nose,  affections  of  (Chapter  XXVIII.), 
825-843 

depression  of  bridge,  825 

examination  of,  828 

expansion  of  bridge,  S25 

foreign  bodies  in,  829 

malignant  disease  of,  837 

operations  for  dealing  with  disease 
of,  839 

ozaena,  831 

polypi  of,  835-838 

rhinitis,  830,  829 

septum  of,  deformities  of,  829 
Nystagmus,  891 

Oat-shaped  sarcoma,  192 
Oblique  facial  cleft,  798 

inguinal  hernia,  1092 
Obliterated  hypogastric  artery,  relation 

to  hernia,  1095 
Obliteration  of  appendix,  1047 

of  arteries,  307 
Obstructed  hernia,  11 14 
Obstruction,     intestinal     (Chapter 
XXXVI.),  1127-1145 
acute,  1129-1136,  1025,  1117 
artificial  anus  in  treatment  of, 

1 135 
causes  of,  1129 
diagnosis  of,  1142,  1082 


Obstruction,  acute,  method  of  examining 
a  case  of,  1142 
paralysis  of  bowel  in,  cause  of, 

1128,  1129 
phenomena  of,  11 32 
symptoms  of,  11 30 
treatment,  1134-1136 
chronic,  1136-1139 
causes  of,  11 36 
diagnosis  of,  1138 
symptoms  of,  1137 
treatment  of,  11 38 
nasal,  836,  838,  840 
of  vessels,  gangrene  from,  no 
to  flow  of  saliva,  858 
Obturator    artery,    relation    to    femoral 
hernia,  11 06 
dislocation  of  hip,  627,  631 
hernia,  11 13 
Obturators  for  cleft  palate,  868 
Occipital  artery,  compr.ession  of,  290 
ligature  of,  333 
lobe,  injuries  of,  769 
Occiput,  dislocation  of,  702 
Oculomotor  palsy,  770 
Odontoid  process,  fracture  of,  702 
Odontomata,  207,  813,  815,  819 
O'Dwyer's  intubation  tubes,  927 
CEdema,  acute  spreading,  765,  768 
anthrax,  132 
lymphatic,  362,  961,  968 
malignant,  1x3 
of  brain,  765,  768 
of  glottis,  916,  922,  80,  81,  122,  490, 

846,  856,  871,  879,  901,  913,  927 
of  scrotum,  1301 
Qisophageal  bougies,  882 
dysphagia,  883 
fistula,  903 
OEsophagocele,  878,  881 
CEsophagoscope,  879,  882 
CEsophagostomy,  882 
GEsophagotomy,  879,  882 
QEsophagus,  affections  of,  878 
diverticula  of,  878 
fistula  of,  878 
foreign  bodies  in,  878 
inflammation  of,  880 
spasm  of,  880 
stricture  of  fibrous,  880 

malignant,  881 
varix  of,  880 
Ogston's  operation  for  flat-foot,  461 
Oidium  albicans,  10,  844 
Oil  of  turpentine  in  frost-bite,  116 
Olecranon  bursa,  425,  640 

fracture  of,  513 
Oleo-balsams  in  treatment  of  gonorrhoea. 

135 
Olfactory  nerve,  affections  of,  381 
Omental  cords,  994,  1131 
grafts,  994 
hernia,  1090,  it  19 
Omentum,  affections  of,  994 
cancer  of,  995 

strangulation  of,  in  hernia,  11 17 
torsion  of,  981,  994,  1129 
Onychia,  405,  247 


A  MANUAL  OF  SURGERY 


Onychogryphosis,  406 
Oophorectomy  for  osteo-malacia,  595 

in  cancer  of  breast,  968 

in  hystero-epilepsy,  791 
Operating  theatre,  essentials  of,  268 
Operation  for  cerebral  tumour,  789 

foi  cancer  of  breast,  964 

for  cancer  of  tongue,  852-856 
Operation  for  tumours  of  tonsil,  874 

for  stricture  of  urethra,  1267-1271 
Operations,  abdominal,  remarks  on,  969 

during  shock,  262 

technique  of,  969-976 
Operative  surgery,  technique  of  (Chap- 
ter X.),  265-275 

treatment  of  fractures,  477 
Ophthalmia  neonatorum,  138 
Ophthalmoplegia  externa,  382 
Opisthotonos,  127 

Opium  in  intestinal  obstruction,  1143 
Oppler-Boas  bacillus,  997 
Opsonic  index,  25,  26,  167,  656,  989 

diagnostic  value  of,  26 
Opsonins,  24,  25,  26 
Optic  atrophy,  80,  788 

nerve  affections  of,  381 
rupture  of,  381 
syphilitic  affections  of,  381 

neuritis,  80,  381,  784,  785,  788 
Oral  sepsis,  importance  of,  76,  64,  808, 

1018,  1046 
Orbit,  penetrating  wounds  of,  80 
Orbital  aneurism,  324,  382 

cellulitis,  80,  381 
Orchitis,  acute,  1283,  857 

chronic,  1284,  1299 

syphilitic,  1287,  1299 

tuberculous,  1285,  1299 
Organ  of  Giraldes,  224,  1289 

of  Rosenmiiller,  224 
cysts  of,  1323 
Organic  stricture  of  urethra,  1261 
Organization  of  blood-clot,  healing  by, 

256 
Ormsby's  mask,  for  administering  ether, 

1352 
Orsudan  in  treatment  of  syphilis,  159 
Orthopnoea,  930,  940 
Os  calcis,  excision  of,  582 

fracture  of,  560 

tuberculosis  of,  580,  582 
Os  incisivum,  795,  797 

in  double  hare-lip,  799 
Os  magnum,  dislocation  of,  626 
Osseous  ankylosis,  449,  675 
Ossicles  of  ear,  necrosis  of,  890 
Osteitis,  563,  565,  566,  751 

deformans,  595,  434 

fibrosa,  609 

septic,  564 

syphilitic,  566 

tuberculous,  578,  566 

typhoid,  575 
Osteo-aneurism,  608 
Ostco-arthritis,  664,  671,  645 

of  hip,  669,  536 

of  spine,  732,  434 

of  temporo-maxillary  joint,  822,  669 


Osteo-arthritis,  varieties  of,  666 
Osteo-arthropathy,     hypertrophic     pui- 

monary,  434,  598 
Osteoblasts,  471,  563,  592 
Osteochondritis,  syphilitic,  589 
Osteoclasia,  486 
Osteoclasts,  565 
Osteocopic  pains,  150,  586 
Osteogenesis  imperfecta,  467,  594 
Osteoma,  200,  756 

of  antrum,  813 

of  lower  jaw,  819 

of  skull,  743 

of  spine,  733 

of  upper  jaw,  814 
Osteo-malacia,  594,  434,  466,  484 
Osteo-myelitis,  563,  566,  755 

acute,  septic,  568,  566,  574,  928 
in  compound  fractures,  480 
of  cranium,  742,  744 
of  spine,  717 

syphilitic,  588,  566 

tuberculous,  578,  566 
Osteo-periostitis,  chronic,  576 
Osteophytes,  647,  653,  666,  671 
Osteoplastic  section  of  upper  jaw,  839 
Osteo-porosis,  564,  563 
Osteo-psathyrosis,  466,  594 
Osteo-sarcoma,  598,  605 
Osteo-sclerosis,  565,  563 
Osteotome,  448 
Osteotomy,  Adams's,  677 

cuneiform,  450,  677 

for  knock-knee,  448 

MacEwen's,  448 

subtrochanteric  (Gant),  677,  445 
Otitis  media,  888,  61,  776,  781,  841 
abscess  of  brain  in,  782 
thrombosis  of  lateral  sinus  in, 
895 
Otomycosis,  10 
Otorrhoea,  chronic,  889,  782 

complications  of,  890-896 
Ovarian  cysts,  132 1 

complications  of,  1324 

malignant,  1321 

torsion  of,  1324,  981,  1129,  ii34 

dermoids,  1323,  221 

hydrocele,  1323 
Ovaries,   removal  of,   in   hysterectomy, 

1310 
Ovaritis,  complicating  appendicitis,  1050 
Ovariotomy,  1325 
Ovary  in  sac  of  hernia,  109 1 

tumours  of,  1327 
Oxalate  of  lime  calculi,  1236,  1198 

deposits  in  urine,  1230 
Oxaluria,  1230,  1237 
Oxyuris  vermiculai'is,  1150 
Ozsena,  831 

Pachydermatocele,  205,  7j8 

Pachymeningitis,  777 

Paget's  disease  of  nipple,  945, 11,  958 
'  quiet  necrosis,'  564,  673 
recurrent  fibroid,  192,  957 

Pain  in  burns,  117 

in  gangrene,  99,  103,  105,  107 


INDEX 


1389 


Pain  in  inflammation,  37 

in  intestinal  obstruction,  1130 
in  Pott's  disease,  719 
in  vesical  calculi,  1238 
Painful  lipoma  of  foot,  196 
Painful  scars,  257 
stump,  1332 

subcutaneous  nodule,  203 
Painless  hematuria,  1221 
Palate,  affections  of,  862-871 
cleft,  862-869 
diseases  of,  869 
Palatine  route  for  operations  on  nasal 

growths,  839 
Palmar  abscess,  248 

arch,  hsemorrhage  from,  295 
fascia,  contraction  of,  439 
ganglion,  compound,  418 
Palsy  (crutch),  478 

infantile,  451,  733 
Panaritium.     See  Paronychia 
Pancreas,  affections  of,  1080-1084 
carcinoma  of,  1083 
cysts  of,  1082 
in  diabetes,  1235 

risks  of  wounds  of,  and  operations 
on,  1080 
Pancreatic  calculi,  1081 

ferments,   treatment   of  cancer  by, 

219 
juice,  danger  of  leak  of,  1080 
Pancreatitis,  acute,  1081 

chronic,  1082 
Panhysterectomy,  1311,  1314 
Panophthalmitis  after  orbital  cellulitis. 

80,  138 
Panostitis,  acute,  568 
Pan-sinusitis,  833 
Papillary  synovitis,  644 
Papillomata,  208 
malignant,  212 
of  bladder,  1221 
of  breast,  951,  957 
of  intestine,  1028 
of  kidney,  1206 
of  larynx,  918 
of  lip,  803 
of  nipple,  946 
of  rectum,  1168 
of  scalp,  737 
of  tongue,  850 
Paracentesis  abdominis,  993 
Paradidymis,  1290 
.  Paraffin  cancer,  1302 

use  of,  for  cure  of  deformed  nose, 
825 
Paralysis  after  injury  to  brain,  765 
Erb-Duchenne,  389 
infantile,  733,  451 
of  intestine,  1117,  985,  1128 
of  larynx,  918,  320,  321,  322,  388, 

882,  901,  922,  927 
of  serratus  magnus,  389,  437 
of  sphincter  vesicae,  1226 
Paralytic     talipes.     See     Varieties     of 
talipes 
torticollis,  427 
Paraphimosis,  1274,  1275 


Paraplegia  In  spinal  caries,  724,  731 

in  spinal  injuries,  708,  696,  698,  699, 

700,  703,  705,  706,  711.  712 
bedsores  in,  112,  701 
gravitation,  705 
Parasites,  4 
cancer,  185 

examination  of  blood  for,  56 
Parasitic,  organisms,  4 
cysts,  226 
emboli,  347 
myositis,  415 
theory  of  tumours,  185 
Parathyroids,  911 

Parenchymatous  glossitis,  acute,  846 
goitre,  904 
inflammation,  40 
Parieto-occipital  fissure,  758 
Parker's  tracheotomy-tube,  924 
Paronychia,  247 
Paroophoron  cysts,  1322,  224 
Parosteal  lipoma.  196 
Parotid  tumours,  859 

mixed,  220 
Parotitis,  epidemic,  857 

suppurative,  858 
Parovarian  cysts,  1323,  1321,  224 

treatment  of,  1326 
Paroxysmal  haemoglobinuria,  1231,  109 
Parrot's  nodes,  589 
Passable  stricture  of  urethra,  treatment 

of,  1267 
Passive  hyperemia,  46 
immunity,  17 

incontinence  of  urine,  1226 
Paste,  Unna's,  95 
Pasteur's  treatment  of  hydrophobia,  131 

vaccine  for  anthrax,  133 
Patella,  dislocations  of,  632 
fractures  of,  547 
operations  on,  549 
Patellar,  bursa,  enlargement  of,  423,  640 

tap,  640 
Patheticus  nerve,  affections  of,  382 
Pathogenic  bacteria,  4 

organisms,  4 
Pathological  contractions  of  scars,  256 

dislocations,  611 
Paul's  tube,  1033 

Peau  d'orange  in  cancer  of  breast.  960 
Pelvic  cellulitis,  1214,  1216,  1220 
Pelvirectal  abscess,  1152 
Pelvis,  deformity  of,  in  rickets,  592 
fractures  of,  528-531 

injury     to    bladder    in,     1213, 

529 
to  urethra  in,  1258,  529 
Pemphigus,  162 
Penetrating  wounds,  238 

of  abdominal  walls,    976,981, 

995 
of  arteries,  300 
of  brain,  yyt 
of  joints,  610 
of  liver,  1063 
of  lung,  931 
of  spine,  696 
of  testis.  1281 


1390 


A  MANUAL  OF  SURGERY 


Penile,  fistula,  137 

Penis,  affections  of,  12  74-1278 

amputation  of.  1277 

balanitis,  1276 

chancre  of,  145 

epithelioma  of,  1276 

fistulffi  of,  1273 

herpes,  1276 

paraphimosis,  1275 

phimosis,  1274 

plastic   operations   on,    1257,    1258, 
1273 

warts  of,  1276 
Peptic   ulcer    after    gastro-enterostomy, 

1004 
Perforating  ulcer  of  duodenurn,  1018,  118 

of  foot,  400,  672 
Perforation  of  appendix,  1047 

of  bowel,  1023,  981,  983,  113.7,  1139 

of  colon,  in  chronic  obstruction,  1024 

of  duodenal  ulcer,  1018,  1054 

of  palate,  870 

of  typhoid  ulcer  of  intestine,  1023 

of  ulcer  of  stomach,  1000,  1054 
Peri-adenitis  in  soft  sore,  141 

in  tuberculous  glands,  368 
Peri-arteritis,  302 
Pericecal  abscess,  1062 
Pericardial  effusions,  939 
Pericarditis,  suppurative,  939 
Perichondritis  of  larynx,  acute,  919,  916, 
914 
chronic,  919 
Pericranial  gumma,  587 

lipoma,  196 
Pericranitis,  742 
Perigastritis,  999,  1002 
Perineal  abscess,  1262,  1272 

cystotomy,  1216,  1218 

fistula,  1262,  1271,  1273 

lithotomy,  1243 

operation  for  malformation  of  rec- 
tum, 1 147 

prostatectomy,  1255,  1172 

section,  1270 
Perinephric    abscess,    726,    1050,    1184. 
1186,  1193 

haemorrhage,  11 83 
Perinephritis,  1192,  1195 
Perineum,  operation  for  ruptured,  1306 
Perineuritis,  379 
Peri-onychia,  405 
Periosteal  nodes,  576,  586 

sarcoma,  605 
Periostitis,  566,  565 

acute,  566,  565,  743 

albuminosa,  571 

chronic,  565,  576 

suppurative,  568,  564 

sj-philitic,  565,  929 

tuberculous,  565,  577 

typhoid,  575 
Peripheral  neuritis,  108 
Periphlebitis,  348,  121 
Periproctitis,  gangrenous,  1153 
Perirectal  suppuration,  1149,  1153,  1170 
Peristalsis  in  intestinal  obstruction,  11 28. 
1137,  1145 


Perisynovial  gummata,  663 
Perithelial  sarcoma,  221 
Perithelioma,  221 

.  Peritoneal  adhesions,   strangulation  by, 
1131 
bands,  strangulation  by,  1131 
pouches  and  slits,  1131 
Peritonism,  973 

Peritonitis,  980-990,  979,  60,  1065,  ro68, 
1213,  1216 
acute  diffuse,  982,  1021,  1049,  1052, 

1071,  1075,  1118,  1139 
acute  localized,  986 
aseptic,  981,  1081,  1 129 
chronic  simple,  987,  994,  1138 
following  appendicitis,  1049,  1052 
gonorrheal,  140,  989 
pneumococcal,  989 
septic,  977,  979,  981,  982,  998,  1049, 

1109,  1124,  1129,  1164 
tuberculous,  980,  988,  994,  996 
Peritonsillar  abscess,  871 
Perityphlitis,  1043 
Peri-urethral  abscess,  1271,  1259 
Permanent  callus,  472 
Permanganate  of  potash,  267 
Pernicious  anaemia,  55,  77 
Pernio,  401 

Peroneal  artery,  ligature  of,  343 
Peronei  tendons,  tenotomy  of,  420 
Peroxide  of  hydrogen,  267 
Perrin's    (Maurice)    subastragaloid    am- 
putation, 1339 
Per-trochanteric  fracture,  539 
Pes  cavus,  452,  461 
Petechiae,  276 

in  septic  conditions,  83,  85 
Petrissage,  47 
Petticoated  tube,  1219 
Pfeiffer's  reaction,  22 
Phagedena,  147,  114,  103 
Phagocytosis,  18 

Metchnikoff's  theory  of,  18 
Phalanges,  amputation  of,  1333 
dislocation  of,  626 
fracture  of,  527 
Phantom  tumour,  974 
Pharjmgeal  dysphagia,  883 
fistula,  921 
stenosis,  876 
tonsil,  846 
Pharyngitis,  varieties  of,  875 
Pharyngotomy,  subhyoid,  919 

transhyoid,  920,  877 
Pharynx,  affections  of,  875 
Phelps'  box,  727 

operation  for  talipes,  457 
Phimosis,  1226,  1274 

as  a  cause  of  hernia,  1088 

in  association  with  cancer  of  penis. 

1274,  1276 
retention  of  urine  from,  1227 
Phlebitis,  348,  353 
infective,  348,  87 
septic,  349 
Phleboliths,  345,  352 
Phlebotomy,  356 
Phlegmasia  alba  dolens,  346 


INDEX 


^391 


Phlegmonous  gastritis.  998 

inflammation,  40 
Phloridzin  test  for  estimation  of  renal 

function,  1179 
Phosphates  in  urine,  1230 
Phosphatic  calculi,  1198,  1236,  1250 
Phosphaturia,  1230 
Phosphorus  necrosis  of  jaw,  810 
Phrenic  nerve,  injury  of,  389 
Picric  acid  in  treatment  of  buras,  i  j  8 
Pigeon-breast,  591 
'  Pig-skin  '  in  cancer  of  breast,  960 
Piles,  1 157.     See  also  haemorrhoids 
Pipe-stem  motions,  1167,  11 70 
Pirogofi's  amputation,  1340 
Pityriasis  rubra,  10 
Plantar  arch,  haemorrhage  from,  296 

fascia,  division  of,  457 
Plantaris  tendon,  rupture  of,  414 
Plaques  mucjueuses,  874 
Plasma-cells,  44 
Plaster  of  Paris  jackets,  728 

splints,  475 
Plastic  arteritis,  302 

inflammation,  40 
Pleura,  affections  of,  929,  930 

drainage  of,  935 
Pleurosthotonos,  127 
Plexiform  angioma,  207 

neuroma,  204 
Pneumatocele  capitis,  755 
Pneumectomy,  938 
Pneumocele,  933 
Pneumococcal  arthritis,  651 

empyema,  934,  935 

peritonitis,  989 
Pneumococcus,  60,   8,   84,  87,   571,   645, 
777,  934.  935.  981.  990 

capsules  of,  2 
Pneumogastric  nerve,  affections  of,  388 
Pneumomycosis,  10 

Pneumonia,  diagnosis  from  appendicitis, 
105 

hypostatic,  478 

leucocytosis  in,  53 

septic,  in  fracture  of  jaw,  488 

after  excisison  of  tongue,  855 
after  injury  to  lung,  931 
after  tracheotomy,  927 
from  foreign  body  in  bronchus, 

915 
in  cut  throat,  901 
in  wound  of  lung,  931 
Pneumothorax,  930 
Pneumotomy,  937 
Podagra,  650 
Poikilocytosis,  55 
Points  douloureux,  380,  382 
Poisoned  wounds,  245 
Polio-myelitis,  anterior,  733 
Politzer's  method  of  inflating  middle  ear, 

886 
Polyarticular  osteo-arthritis,  667 
Polydactylism,  437 
Polymastia,  944 

Polymorphism  of  syphilides,  149 
Polymorphonuclear  leucocytes,  5 1 
Polynuclear  leucocytes,  51,  34.  64 


Polyorchism,  1279 
Polypus,  mucous,  833 
of  antrum,  811,  813 
of  ear,  890 
of  frontal  sinus,  756 
of  naso-pharynx,  837,  877 
of  nose,  835 

of  rectum,  1168,  209,  1150,  ir6o 
of  umbilicus,  980 
of  urethra,  1260 
of  uterus,  1307 
Polyvalent  sera,  28 
Pond  fracture  of  skull,  75c, 
Pons  Varolii,  injury  of,  7/1 
Popliteal  aneurism,  327 

artery,  ligature  of,  340  . 
bursas,  affections  of,  424 
nerves,  injury  of,  396 
Poroplastic  splints,  474 
Post-anal  dimple,  716 
Posterior  cervical  nerves,  operation  on, 
428 
gastro-enterostomy,  ioi5 
rhinoscopy,  828 

tibial  artery,  compression  of,  290 
ligature  of,  341 
Post-mortem  wounds,  247 
Post -nasal  plug,  843 
Pott's  disease,  7^-7.  434.  676 
fracture,  556 
puffy  tumour,  778 
Pouches  of  peritoneum,  strangulation  of 

intestines  by,  1131 
Poultices,  43 
Power  (D'Arcy),  treatment  of  aneurism. 

318 
Precipitins,  21 

Pregnancy,  extra-uterine,  1317 
lordosis  in,  435 
piles  in,  11 58 

varicose  veins  in,  1304,  350 
Preliminary  colostomy,  11 72,  ii73 

tracheotomy,  855,  922,  924 
Preparation    of    patient    for    abdominal 

operations,  969 
Prepuce,  deformities  of,  1257 
Pressure  diverticula  of  oesophagus,  878 
Pressure   in   treatment    of   hiemorrhage, 
283 
of  disease  of  joints,  642,  644 
of  inflammation,  46 
of  ulcers,  95 
Priapism.,  704,  706,  710,  1252 
Prickle  cells  in  epitheliomata,  214 
Primary  arterial  hasmorrhage,  288 
nerve  suture,  377 
sore,  145 

of  anus,  1 165 
of  finger,  147 
of  lips,  801 
of  nipple,  846 
of  tongue,  849 
of  tonsil,  874 
of  urethra,  146 
tuberculosis  of  kidney,  1193 
union  of  wounds,  253 
Probang,  879 
Proctectomy,  1171-1176 


1392 


A  MANUAL  OF  SURGERY 


Proctitis,  1 149 

gonorrhoeal,  138,  1167 
Proctoclysis,  83,  279,  985,  972 
Proctoscope,  1147 
Profeta's  law,  161 
Prolapse  of  anus,  11 63 

of  lung,  933 

of  rectum,  11 60,  11 63 

of  uterus,  1306 
Properitoneal  hernia,  1095 
Proptosis.     See  Exophthalmos 
Prostate,  affections  of,  1245-1256 

abscess  of,  1245,  1272,  1273 

calculi  of,  1247 

cancer  of,  1255 

hemorrhage  from,  1232 

inflammation  of,  1245 

senile    enlargement    of,    1248-1256, 
1216 

tuberculosis  of,  1247 
Prostatectomy,  perineal,  1255 

suprapubic,  1254 
Prostatic  pouch,  1250 

urethra,  forcible  dilatation  of,  1247 
in  enlarged  prostate,  1249 
Prostatitis,  1245,  138 

chronic,  1246 
Prostatorrhoea,  1246,  135 
Protopathic  sensation,  375 
Protozoa,  11 
Provisonal  callus,  471 
Pruritus,  1150,  1157 
Psammomata,  221,  733,  786 
Psathyrosis  idiopathic,  594 
Pseud-arthrosis,  422,  483,  613 

after  excision  of  joints,  689 
Pseud-elephantiasis,  94 
Pseudo-hypertrophic  paralysis,  435 
Pseudo-neuroma,  203 
Pseudo-paralj'sis,  syphilitic,  589 
Psoas  abscess,  723,  174,  682,  730,  1107 
treatment  of,  730 

bursa,  affections  of,  425 
Psoriasis  linguse,  847 

syphilitic;  151 
Psorosperms,  ix 
Ptomains,  5 
Ptosis,  382,  782 

Pubic  dislocation  of  hip,  627,  631 
Pudic  artery,  haemorrhage  from,  296 

ligature  of,  338 
Puerperal  peritonitis,  981 
Pulled  elbow,  625 

abscess,  937 
Pulmonary  decortication,  937 

embolus,  346,  347 

haemorrhage,  933 
Pulpy   degeneration    of   synovial   mem- 
brane, 652 
Pulsating  empyema,  934 

exophthalmos,  324 

goitre,  323 

sarcoma  of  bone,  190,  312,  606,  608 

tumours  of  bone,  608 
of  scalp,  736 
Pulse  in  aneuiisms,  311,  321,  322 

in  cerebral  compression,  765 
concussion,  762 


Piilse  in  hemorrhage,  277 
in  shock,  259 
in  peritonitis,  983 
Punctured   fracture    of    skull,  749,   751, 
754 
wounds,  238 

of  chest,  931 
of  heart,  938 
of  intestie,  1022 
of  lung,  931 
of  testis,  1281 
Pupils  in  anesthesia,  1350,  1353 
in  cerebral  compression,  765 

concussion,  762 
in  spinal  injuries  (cervical),  705 
Purpura,  Henoch's,  1141 
Pus  corpuscles,  32 

in  acid  urine  in  pyelitis,  11 89 
in  acute  abscess,  70,  65 
in  chronic  abscess,  172 
laudable,  66 
tuberculous,  172 
varieties  of,  70 
Pustular  acne,  60 
Pustule,  malignant,  132 
Pyaemia,  87,  60,  122,  123,  346,  570,  782 
895,  1064,  1084 
in  diseases  of  bones,  570,  572 
in  joint  diseases,  822 
lateral  sinus,  895,  346 
Pyemic  abscess,  88,  1064,  1084,  1191 

synovitis,  651 
Pyelitis,  11 87,  11 88 
Pyelo-nephritis,   1187,  1188,  1189,  1195, 

1217,  1220,  1242,  X252,  1262,  1266 
Pylephlebitis,  88,  348,  1050,  1052,  1064 
Pylorectomy,  1008,  1014 
Pyloroplasty',  1009,  1014 
Pylorus,  stenosis  of,  1007,  1008 

congenital  hj'pertrophy  of,  1009 
Pyogenic  bacteria,  59 
infections,  59 

of  kidney  and  ureters,  11 87 
membrane,  66 
Pyonephrosis,    1186,    1188,    1190,    1216. 

1251,  1262 
Pyo-pneumothorax,  subphrenic,  991 
Pyorrhoea  alveolaris,  76,  807,  1018,  1046 
Pyosalpinx,  1315,  987,  990,  62 
Pyosepticemia,  88 
Pyrexia,  38 
Pyuria,  1232,  1191,  1261 

in  tuberculous  kidney,  1193 
prostate,  1247 

Quiescent  interval  in  appendicitis,  1052 

operation  in,  1056 
'  Quiet  necrosis,'  564,  673 
Quilled  suture,  234 
Quinine  in  liver  abscess,  1068 
Quinsy,  871 

Rabies,  130 

Rachitic  tibia  and  fibula,  450 

Racquet  method  of  amputation,  1329 

at  hip-joint,  1345 
Radial  artery,  compression  of,  290 
ligature  of,  336 


INDEX 


'393 


Radiant  heat,  46,  415,  668 
Radical  cure  of  haemorrhoids,  1161 

of    hernia,     1099,    1107,     mo, 
1112 
recurrence  after,  1105 
of  hydrocele,  1293 
of  varicocele,  1297 
Radicular  odontome,  207 
Radiography.     See    Rontgen    rays    and 

X  rays 
Radium   bromide   in   the   treatment    of 
cancer,,  219,  968 
in  the  treatment  of  malignant 
•  stricture  of  oesophagus,  883 
in  the  treatment  of  rodent  ulcer, 
410 
Radius,  congenital  absence  of,  437 
dislocations  of,  624 
excision  of  head  of,  624 
fractures  of,  514,  518 
separation  of  lower  epiphysis,  522 
subluxation  of  head  of,  625 
Radius  and  ulna,  dislocation  of,  622 

fractures  of,  522 
Railway  spine,  707 
Ranula,  856 
Rapid   dilatation   of   stricture    urethrae, 

1267 
Rarefaction  of  bone,  563,  564 
Rashes  of  syphilis,  149 
Ray  fungus,  181 

Raynaud's  disease,  109,  103,  676, 
hasmoglobinuria  in,  1232 
Reaction  from  concussion,  762 
from  shock,  259 
of  degeneration,  375 
Reactionary  fever,  262 
hemorrhage,  291 
Recklinghausen's  disease,  205 
Rectal  examination  in  appendicitis,  1052, 
1055 
in    diseases    of    bladder,    12 10, 
1223 
of  prostate,  1252 
in  tuberculous  disease  of  ureter, 
1194 
Rectal  feeding,  972 

suppuration,  1150 
Rectopexy,  1165 
Rectovaginal     septum,     laceration     of, 

1303 
Rectovesical  fistulae,  1170,  1166,  1219 
in  cancer  of  bladder,  1224 
of  rectum,  11 71 
Rectum,        affections        of        (Chapter 
XXXVII.),  1146-1176 
cancer  of,  11 69- 11 76 
colostomy  in  cancel  of,  11 72,  11 75, 

1176 
congenital  malformations  of,  1147 
excision  of,  11 71 -11 76 
foreign  bodies  in,  1 149 
inflammation  of,  1149 
injuries  of,  529,  1149,  12 19 
methods  of  examining,  11 46 
polypus  of,  209,  1 150,  1 160 
prolapse,  1160,  1163 
stricture  of,  1150,  1166 


Rectum,  suppuration  in  connection  with, 
1150 
syphilis  of,  1165,  1166 
treatment  of  cancer  of,  1171-1176 
tuberculous  disease  of,  1165 
tumours  of,  1168 
Rectus    abdominis   muscle,    injuries    of, 

976,  979 
Recurrence  after  radical  cure  of  hernia, 

1105 
Recurrent  appendicitis,  1053 
dislocations,  633 
fibroid,  192,  957 
hffimorrhage,  291 
laryngeal  nerve,  paralysis  of,  901 
Red  corpuscles  in  inflammation,  33 
nucleated,  355 
thrombus,  345 
Redness  in  inflammation,  36 
Redressment  modelant,  457 
Reduction  en  masse  of  a  hernia,   1120, 
1121 
of  a  dislocation,  613,  614 
of  a  fracture,  474 
Reef-knot,  286,  329 
Referred  pain  in  hip  disease,  683,  37 
in  spinal  caries,  719,  37,  38 
in  renal  calculus,  37 
Regeneration  of  nerves,  377 
Reid's  base-line,  757 

line  of  fissure  of  Sylvius,  758 
Relapsing  appendicitis,  1053 

fever,  56 
Renal   artery,   ligature   of,    for   urinary 
fistula,  1205 
calculus,  1 195-1205 
colic,  1197,  1054,  1183,  1196,  1203 
functional    activity,    estimation    of, 

1178 
hcematuria,  123 1 
Rendle's  mask  for  A.C.E.,  1352 
Repair  after  fractures,  471-473,  480 

after  inflammation,  35 
Resection.     See  Excision 
Residual  abscess,  725,  174 

urine,  1227,  1250,  1261 
Resilient  stricture  of  urethra,  1261 
Respiration,  artificial,  940 

cessation  of,  in  general  anaesthesia, 

1354 
obstruction  of,  in  general  anassthesia, 
1354 
Rest  in  treatment  of  inflammation,  41, 

42.  45 
Retained  testis,  1279,  1097 

malignant  disease  of.  1280 
removal  of,  1280 
Retention  cysts,  951,  226 
of  testis,  1279,  1097 
of  urine,  1227.  1245,  1252,  1262.  1269 
Retina,  embolus  in.  347 
RetracHon  of  head,  779,  784.  894 
Retrograde     dilatation     of     oesophageal 

stricture,  883 
Retroperitoneal  abscess,  990,  102 1,  1197 
lipoma,  996 
sarcoma,  996 
Retropharyngeal  abscess,  877,  721,  916 

88 


1394 


A  MANUAL  OF  SURGERY 


Retro-sternal  goitre,  904 

Reverdin's  method  of  skin-grafting,  97 

Revolver  wounds,  244 

Rhabdomyoma,  203 

Rhagades,  162 

Rheumatic  gout,  664 

myositis,  415 

spondylitis,  427,  732 

synovitis,  649 
Rheumatism,   diagnosis  from  aneurism, 
312 

gonorrhoeal,  of  spine,  732 
Rheumatoid    arthritis,     664.     See    also 

Osteo-arthritis 
Rhinitis,  829 

atrophic,  832 

gonorrhoeal,  138 

sicca,  831 

syphilitic,  162 
Rhinophyma,  826 
Rhinoplasty,  827 
Rhinoscopy,  828 

Rhomboid  muscles,  paralysis  of,  437,  389 
Rib,  cervical,  429 
Ribbert's  theorv  of  tumour  formation, 

187 
Ribs,  fracture  of,  490 

osteo-myelitis  of,  928 

syphilitic  disease  of,  928 

tuberculous  disease  of,  722,  929 

tumours  of,  929 
Richter's  hernia,  1115,  1118,  1126 
Rickets,  589-593,  466,  1085 

adolescent,  593 

coxa  vara  from,  444 

femur  in,  446 

genu  valgum  from,  445 

genu  varum  from,  448 

green -stick  fractures  in,  467 

hasmorrhagic,  593 

of  spine,  429,  590 

of  tibia  and  fibula,  450 
Rickety  rosary,  591 
Rider's  bone,  202,  416 
Riedel's  lobe  of  liver,  1063 
Rigg's  disease  (pyorrhoea  alveolaris),  807 
Rigors,  69 

in  infective  thrombosis  of  cerebral 
sinuses,  782 

in  lateral  sinus  pyaemia,  895 

in  urethral  fever,  1266 
Ringworm,  10 

Rinne's  tuning-fork  test,  885 
Risus  sardonicus,  127 
Robson's  (Mayo)  decalcified  bone  bobbin, 

1042 
Rodent  ulcer,  408 
Rogers  on  liver  abscess,  1067 
Rolandic  line,  757 
Rolando,  fissure  of,  757 
Rontgen  (X)  rays,  in  diagnosis  of  aneur- 
isms, 320 
of  fractures,  470 
of  gastric  diseases,  997 
of  renal  calculi,  11 98 
of  subphrenic  abscess,  992 
of  vesicle  calculi,  1238 
in  diseases  of  bone,  577.  579 


Rontgen  (X)  rays,  in  diseases  of  frontal 
sinus,  754 
of  joints,  656 
in  sarcoma  of  bone,  605 
of  upper  jaw  (antrum),  816 
in  treatment  of  cancer,  968 
of  lupus,  404 
of  rodent  ulcer,  410 
Rose's   operation   for   removal   of   Gas- 

serian  ganglion,  385 
Rouge's  operation  for  nasal  diseases,  839 
Roughton's  splint,  642 
Round-cell  sarcoma,  191 
of  breast,  957 
of  tonsils,  874 
Round  ligaments,  affections  of,  1304 
fibro-myoma  of,  1305 
hydrocele  of,  1304 
tumours  of,  1305 
shoulders,  434 
Roux's  operation  for  femoral  hernia,  1108 

of  gastro-enterostomy,  1018 
Rubber  gloves,  use  of,  270 
Rupia,  152 

Rupture.     See  Hernia 
Rupture  of  aneurism,  313,  726 
of  arteries,  298,  307 
of  bladder,  1213,  529 
ol  crucial  ligaments,  635 
of  gall-bladder,  981,  1071 
of  intestine,  982,  1021 
of  kidney,  11 83 
of  liver,  1063 
of  muscles,  412,  127 
of  nerves,  373 
of  ovarian  cyst,  1325 
of  recto-vaginal  septum,  1303 
of  rectus  abdominis,  979 
of  sheath  of  muscle,  411 
of  spleen,  1084 
of  stomach,  982,  997 
of  tendons,  412 
of  thoracic  duct,  35S 
of  tubal  gestation,  1318 
of  tympanic  membrane,  888 
of  ureter,  11 84 
of  urethra,  1258,  529 
of  vas  deferens,  1282 

Saccharomyces,  10 
Sacculated  aneurism,  310 
Sacculi  of  bladder,  1216,  1262 

rupture  of,  121 3,  1262 
Sac  of  a  hernia,  description  of,  1089 

in  strangulation,  11 17 
Sacral  anus,  11 74 

tumours,  congenital,  716 
Sacro-iliac  disease,  687,  726 
Sacrum,  fractures  of,  530 
Saline  solution  in  septicasmia,  83,  86 
in  shock,  261 
in  peritonitis,  985 
use  of,  in  abdominal  operations, 

970,  971 
use  of,  in  hasmorrhage,  278 
Salivary  calculus,  858 
fistula,  861 
glands,  affections  of,  857 


INDEX 


1395 


Salivary  glands,  cysts  of,  900 

Salivation  ia  mercurialism,  158 

Salmon  patches  of  cornea,  164 

Salpingitis,  140 

Salpiago-oophorectomy,  double,  13 11 

Salter's  swing,  264,  470 

Salvarsan  ('  606  '),  159 

Sanitas,  267 

Saphena,  varix  of,  350,  1107 

Sapraemia,  84 

Saprophytes,  4 

Sarcinae,  3 

Sarcocele,  cystic,  of  testis,  icSg 

syphilitic,  1287 

tuberculous,  1285 
Sarco-lipoma,  197 
Sarcoma,  189 

after  fibroids  of  uterus,  1308 

after  fractures,  473 

alveolar,  194 

congenital,    of    kidney,    1206,    193, 
1180 

curative  action  of  erj-sipelas  on,  123 

endosteal,  605 

melanotic,  194,  1069 

myeloid,  193,  810,  820 

of  antrum,  813 

of  appendix,  1062 

of  bladder,  1222 

of  bone,  598,  466,  473,  595,  605 

of  brain,  786 

of  breast,  957,  963 

of  cranium,  737,  743 

of  dura  mater,  737,  743 

of  gum,  810 

of  intestiae,  1028 

of  jaws,  820,  813,  814 

of  kidney,  1206,  1180 

of  liver,  1069 

of  lymphatic  glands,  372,  191 

of  muscles,  416 

of  naso-pharynx,  837 

of  nose,  835,  837 

of  orbit,  324 

of  ovary,  1327 

of  palate,  870 

of  pancreas,  1084 

of  parotid,  860 

of  rectum,  11 68 

of  sacrmn,  716 

of  scalp,  737,  738 

of  skuU,  756 

of  spiae,  733 

of  testis,  1290 

of  thyroid,  910 

of  tonsil,  874 

of  uterus,  1312 

periosteal,  605 

pulsating,  190,  312 

retroperitoneal,  996 

secondary,  of  bone,  607 

treatment  of,  195 
Satellite  chancre,  141 
Saucer  fracture  of  skull,  750 
Sayre's  apparatus  for  talipes,  456 

spinal  jacket,  434 

treatment  of  fracture  of  clavicle,  494 
Scab,  healing  under  a,  255 


'  Scabbard  '  trachea  in  goitre,  904 

Scalds,  116 

Scalp,  cellulitis  of,  79 

diseases  of  (Chapter  XXV.),  735-756 

injuries  of,  735 

tumours  of,  736 
Scaphoid,  fracture  of,  527 
Scapula,  congenital  elevation  of,  436 

dislocation  of  angle,  437 

fractures  of,  495,  527 

winged,  437 
Scars,  256 

keloid,  257 

malignant  disease  of,  257 

painful,  257 

pathological  conditions  of,  256 

ulceration  of,  256 
Schede's  operation  of  thoracoplasty,  936 
Schimmelbusch's  low-pressure  steriliser, 

267 
Schizomycetes,  i 
Schlatter's  disease,  552 
Schleich's     method     of    inducing     local 

anaesthesia,  1347,  1135,  908 
Schlosser's  treatment  for  tic -douloureux, 

383 
Schwartze's  operation  for  mastoid  dis- 
ease, 893 
Sciatic  artery,  aneurism  of,  327 
haemorrhage  from,  296' 
ligature  of,  338 

dislocation  of  hip,  627,  629 

hernia,  1087 

nerve,  operation  on,  395 
Sciatica,  395 
Scirrhous  ulcer,  960 
ScLrrhus,  215,  958 

of  breast,  958„962 

of  pancreas,  1083 

of  prostate,  1255 

of  pylorus,  1005 
'  Scissor  '  deformity  of  hip-joint,  676 
Sclavo's  serum,  133 
Sclerosis  of  bone,  563,  565,  587 
Sclerotitis,  gonorrhoeal,  139 
Scolices,  227,  1068 
Scoliosis,  429,  426,  430,  433 
Scott's  dressing,  45 
Scrofuloderma,  98 
Scrotal   tumours,    general   diagnosis   of, 

1299 
Scrotum,  cellulitis  of,  1301 

eczema  of,  1301 

epithelioma  of,  1302 

erysipelas  of,  1301,  122 

fistula  of,  1273,  1301 

oedema  of,  1301 
Scurvy,  hematuria  in,  1231 

infantile,  484,  593 

rickets,  593 
Sebaceous  adenoma,  40S,  738 

cysts,  407,  738,  899 
of  neck,  899 
of  nipple,  946 
of  scalp,  738 

glands,  cancer  of  (rodent  ulcer),  408 

horn,  407,  1276 
Second  intention,  healing  by.  253 


1396 


A  MANUAL  OF  SURGERY 


Secondary  anamia,  57 

growths  in  glands,  372 

haemorrhage,  291,  330 

nerve  suture,  378 

sarcoma  of  bone,  607 

syphilis,  148 

union  of  wounds,  253 
Sedillot's  amputation  of  foot,  1341 
Segregation  of  urine,  11 78 
Semicircular  canals,  disease  of,  891 
Semilunar    cartilage,    displacement    of, 

633.  674 
Semimembranous  bursa,  enlargement  of, 
424 

tendon,  tenotomy  of,  420 
Senile  atrophy  of  bone,  740 

enlargement  of  prostate,  1248-1256 

gangrene,  106,  103,  306 

sensation,  varieties  of,  375 
Sensory  nerve,  results  of  section  of,  376 
'Sentinel '  pile,  1156 
Separation,  line  cf,  in  gangrene,  loi 
Sepsis,  81 

oral,  808 
Septic  arthritis,  645 

gangrene,  100 

intoxication,  82 

meningitis,  778 

osteo-myelitis.     See  Osteo-myelitis 

peritonitis.     See  Peritonitis 

phlebitis,  349 

pneumonia,  488,  855,  901,  915,  927, 
931 

thrombosis  of  lateral  sinus,  895,  87, 
90,  761,  785 

traumatic  fever,  84,  901 

wounds,  236 
Septicaemia,  84-86,  59,  60,  247 

blood  in,  85 
Septum  nasi,  fracture  of,  486 

lateral  deviation  of,  829 
ulcer  of,  842 
Sequestra,  661 

separation  of,  564 
Sequestration  dermoids,  222 
Sequestrotomy,  574 
Sequestrum,  99,  811 

signs  of,  564 
Sera,  antitoxic,  28 

polyvalent,  28 

use  of,  28,  29 
Serotherapy,  42 
Serous  cysts,  225,  900,  951,  1207 

synovitis,  643 
Serratus  magnus,  paralysis  of,  389,  437 
Serum,  antistreptococcic,  28 

antitetanic,  133 

disease,  29 

in  inflammation,  42 
Setons,  46 

Seventh  nerve,  affections  of,  385,  891 
Sheath  of  muscle,  rupture  of,  411 
Sheaths  of  tendons,  disease  of,  416 
Sheffield-Tallerman  bath,  46 
Shock,  258-262 

adrenalin  in,  261 
anaesthesia  during,  262 
from  amputation,  1331 


Shock  in  abdominal  injuries,  978,  1021 

in  burns,  117 

in  catheterism,  1265 

in  contusion  of  testis,  12  81 

in  intestinal  obstruction,  1128,  1130 

in  perforated  gastric  ulcer,  looi 

operations  during,  262 

pathology  of,  260 

prevention  of,  262 

use  of  saline  solution  in,  261 
Short-circuiting  operations  on  intestine, 

1031 
Shortening  a  tendon,  method  of,  421 

of  round  ligaments  of  uterus,  1305 
Shoulder -joint,  acute  arthritis  of,  648 

amputation  through,  1335 

ankylosis  of,  676 

dislocations  of,  618 

effusion  into,  639 

excision  of,  659,  689 

tuberculosis  of,  659 
Shoulders,  round,  434 
Side-chain  theory  of  Ehrlich,  20 
Sigmoid  colostomy,  1034 
Sigmoidoscope,  1147 
Signe  de  Dance,  1141 
Silk,  271 
Silver   filigree   in   treatment    of    hernia, 

1112 
Simple  fractures,  467 

naevus,  206 

tumours,  187 
Sinus,  72 
Sinuses  of  nose,  affections  of,  833 

of    skull,    infective    thrombosis    of, 
781,  761,  895 
Site  of  election  for  amputation  of  leg, 

1341 
'  606,'  159 

Sixth  nerve,  injuries  of,  385 
Skiagraphy.     See  X  rays  and  Rontgen 

rays 
Skin,  preparation  of,  for  operations,  272 

surgical  diseases  of,  397-410 
Skin-grafting,  97 
Skull,  affections  of,  735-756 
fractures  of,  744-754 
base  of,  745 
compound,  751,  745 
depressed,  749 
fissured,  744 
punctured,  749 
treatment,  752 
gunshot  injuries  of,  751 
in  osteitis  deformans,  595 
Slough,  99 

Sloughing  of  amputation  flaps,  1332 
of  appendix,  1047 
of  tendons  of  fingers,  417 
Smith's  method   of  reducing  dislocated 
shoulder,  622 
(Henry)  operation  for  piles,  1161 
(Stephen),  amputation,  1342 
Smoker's  patch,  848 
'  Snail-track'  ulcers  of  tonsil,  150,  874 
Snake-bites,  246. 
Snap -finger,  430 
Snuffles  in  syphilis,  162 


INDEX 


1397 


Soamin  in  syphilis,  159 
Sobenheim's  serum  ki  anthrax,  133 
Soft  chancre,  140 

fibromata,  199 
Softening,  yellow,  of  brain,  768 
Sordes,  263 
Sore,  primary,  145,  801 

soft,  140 
Sounding  the  urinary  bladder,   method 

of,  1238,  1210 
Southey's  trocars,  993 
Spasm  of  intestine,  1129,  1134 

of  oesophagus,  880 
Spasmodic  stricture  of  urethra,  1266 
stump,  1332 
torticollis,  427 
Spastic  talipes,  451 
Specific  infective  diseases,  120-183,  12 
Speculum,  nasal,  828 
Spence's   amputation   at   shoulder-joint, 

1335 
Spermatic  cord,  haematocele  of,  1282 
hydrocele  of,  1295 
torsion  of,  1280 
Spermatocele,  1295 
Sphacelus,  99 

Sphenoidal  sinus,  disease  of,  834 
Spheroidal-celled  cancer,  214,  858 
Sphincter  vesioe,  paralysis  of,  1226 
Spina  bifida,  713,  451,  676,  716,  795 
occulta,  716 

ventosa.     See    Tuberculous    dacty- 
litis 
Spinal  abscess,  721 

Spinal  accessory  nerve,  affections,  388 
operations  on,  388,  428 
anesthesia,  1347,  log 
caries,  717-731,  429,  434,  877 
concussion,  704,  707,  708 
cord,  diseases  of,  704,  733 
hsemorrhages  into,  705 
injuries  of,  704 
pressure  on,   in  Pott's  disease, 

724,  731 
total  transverse  lesion  of,  709 
tumours  of,  733 
haemorrhage,  705 
m.embranes,  tumours  of,  733 
meningitis,  705,  724 
myelitis,  706,  724 
nerves,  affections  of,  389-396 
neurasthenia,  707 
splints,  433,  435 
Spindle-celled  sarcomata,  192 
Spine,  deformities  of,  429-436 

diseases  of  (Chapter  XXIV.),  713-734 
congenital     malformations     of, 

713 
gonorrhoeal  rheumatism  of,  732 
osteitis  deformans,  595 
osteo-arthritis,  732,  434 
osteo-myelitis,  717 
rheumatic  spondylitis,  732 
rickets  of,  590,  429 
spinal    caries    (Pott's    disease), 

717 
syphilit'c  disease  of,  731 
tumour?  of,  733.  725 


Spine,  injuries  of  (Chapter  XXIII.),  695- 
712 
bladder,  effects  on,  1213 
dislocations,  702 
fracture-dislocation,  699 
fractures,  697 
sprains,  695 
wounds,  696 
Spiral  fractures,  467 
Spirilla,  3 
Spirillum  Obermeyeri,  56 

of  relapsing  fever,  8,  4 
Spirochaeta,  142,  8 
Splay-foot.     See  Flat-foot 
Spleen,  affection^  of,  1084-1086 

amyloid  disease  of,  76,  1085 

embolus  in,  348 

torsion  of,  981,  1129 
Splenectomy,  1085 
Splenic  anaemia,  1085 

fever,  131 
Spleno-medullary  leucocythaemia,  56,  58, 

1085 
Splenomegaly,  1085 
Splenopexy,  1084 

Splint-pressure  causing  gangrene,  iii 
Splints,  uses  of,  474 
Spondylitis  deformans,  434,  732 

rheumatic,  427,  732 
Spondylolisthesis,  435 
Spongy  gums,  806 

in  mercurialism,  158 
Spontaneous  cure  of  aneurism,  312 

fracture,  466,  594,  605 
Spore  formation,  2,  i 
Spores,  characters  of,  2 
Sprains  of  joints,  610 

of  muscles,  411 

of  spine,  695 

of  wrist,  527 
Spreading  gangrene,  acute,  113 

oedema  of  brain,  768,  765 
Sprengel's  shoulder,  436 
Spring-finger,  439 
Spur  in  artificial  anus,  1126 

in  colostomy,  1034,  1037,  1038 

of  nose,  829 
Spurious  valgus.     See  Flat-foot 
Squamous  epithelioma,  212 
Squint,  in  paralysis  of  sixth  nerve,  3S5 

in  paralysis  of  third  nerve,  382 

in   thrombosis   of   cavernous   sinus. 
782 
Stabs,  238,  1022 
Stacke's  operation  for  mastoid  disease, 

894 
Stains  for  bacteria,  8 
Staphylococcus  pyogenes,   59,  4,   5.   62. 

77,  85,  87,  398,  570,  777.  1188,  1214 
Staphylorrhaphy,  868 
Starch  bandages,  475 
Starting  pains  in  joint  disease,  655,  6Sr 
Stasis,  31,  34 
Statical  scoliosis,  429 
Static  knock-knee,  445 
Status  lymphaticus.  911,  1355 
Stave  of  thumb  fracture,  538 
Stay-knot.  287,  329 


•398 


A  MANUAL  OF  SURCU.RY 


Stenosis  after  duodenal  ulcer,  1020 
after  ulcer  of  stomach,  1003 
of  intestine,  1027,  1126,  1129,  1136 
of  larynx,  902,  922,  927 
of  pylorus,  1007,  1008 
of  trachea,  902 
Stenson's  duct,  wounds  of,  861 
Sterile  abscess,  1065 
Sterilization  of  wounds,  232 
Sterilizers,  267 
Sternal  end  of   clavicle,   dislocation   of, 

617 
Sterno-mastoid  in  torticollis,  426 

congenital  induration  of,  427,  898 
tenotomy  cf,  428 
Stercoraceous     vomiting,     11 18,     1128, 

1130,  1145 
Stercoral  ulcers,  1139,  1167 
Sternum,  diseases  of,  928 

fractures  of,  492 
Stewart's    treatment    of   aneurism,    318, 

321,  322,  325 
Sthenic  fevsr,  39 

treatment  of,  43 
Still's  disease  of  joints,  664,  667 
Stings  of  insects,  245 
Stitch  suppuration,  82,  973 
Stitches,  deep,  233 

of  coaptation,  233 
Stokes-Gritti  amputation  of  thighs,  1343 
Stomach,  affections  of,  996-1010 
anatomy  of,  996 
cancer  of,  997,  1005 
dilatation  of,  1007,  1008 

acute,  loio 
hour-glass,  1003 
operations  on,  loio 
rupture  of,  982,  997 
ulcer  of,  990,  997,  999,  1009 
haemorrhage  in,  999,  1000 
perforation  of,  1000,  1054 
Stomatitis,  844 

mercurial,  845 
Stone.     See  Calculus 
Stools  in  pancreatis,  1082 
Stovaine,  uses  of,  1347 
Strabismus,  382,  385 
Strains.     See  Sprains 

juxta-epiphyseal,  469 
Strangulated  external  hernia,  1115-1126 
complications  after  opera- 
tion for,  1 1 24 
complications    after    taxis 

for,  1 120 
gangrene  of  bowel  in,  1116, 
1118,    1120,    1123,    1124, 
1125 
operative      treatment     of, 

1121-1126 
pathological  effects  of,  1116 
prognosis  of,  11 19 
sequelae  of,  1126 
signs    and    symptoms    of, 

1117 
taxis  in,  1119 
treatment    of   intestine    in 

operations  for,  11 22 
umbilical  hernia,  980 


Strangulation  of  intestine  by  bands,  1131. 
1129 

of  piles,  1 1 60 

internal,  11 29 

acute,  of  testis,  1280 
Strangury,  1197,  1216 
Strepto-bacillus,  3 
Streptococci,  3 

Streptococcus  pyogenes,  60,  3,  8,  11,  77, 
84,  87,  114,   120,   195,  571.  645,  777, 
934.  935.  981,  1046,  1188 
Streptothrix,  10,  8 
Stricture  of  appendix  vermiformis,  1047 

of  bile-duct,  1079 

of  intestine,  1026,  1136 

of  oesophagus,  880,  881 

of  pylorus,  1008 

of  rectum,  11 50,  11 66 

of  urethra,   1216,   1227,   1258,   1260, 

134 
'  Strong  mixture,'  232,  260 
Strongylus  gigas,  11 88 
'  Strumous  lip,'  801 
Strumpell-Marie's  spondylitis  deformans, 

732 
Strychnine-poisoning,  128 
Stumps,  amputation  of,  1332 

affections  of,  1332 
Styloid  process  of  ulna,  fracture  of,  514 
Styptics,  284  . 
Subaponeurotic  abscess,  736 

hematoma,  735 
Subarachnoid    space,    drainage    of,    in 

meningitis,  780 
Subastragaloid  amputation,  1339 

dislocation,  637 
Subclavian  artery,  aneurism  of,  325 
compression  of,  289,  325 
ligature  of,  325,  326,  333,  321, 
322 
Subclavicular    dislocation    of    shoulder, 

620 
Subcoracoid  dislocation  of  shoulder,  620 
Subcranial  abscess,  777,  744,   75 1»  784. 
894 
haemorrhage,  773 
inflammation,  777 
Subcutaneous  gumma,  155 
infusion,  985 
tenotomy,  419 
whitlow,  248 
Subcuticular  stitch,  234 

whitlow,  248 
Subdeltoid  bursa,   enlargement   of,   639, 

425 
Subdiaphragmatic  abscess,  990 
Subglenoid  dislocation  of  shoulder,  619 
Subhepatic  abscess,  990 
Subphyoid  pharyngotomy,  919 
Sublingual  abscess,  856 

gland,  affections  of,  858 
Subluxation  of  head  of  radius,  625 

of  joints,  613 

of  knee,  633 
Submammary  abscess,  947 
Submaxillary  cellulitis,  858,  916 

gland,  affections  of,  858 
tumours  of,  861 


INDEX 


1399 


Submucous  abscess  of  rectum,  1x50 
fibroid,  1307 

resection  of  septum  of  nose,  829 
Subpericranial  abscess,  736 

hematoma,  231,  736 
Subperiosteal  abscess,  569,  572 
gummata,  586 

hemorrhages  in  scurvy  rickets,  594 
whitlow,  248 
Subphrenic    abscess,    990,     1002,     1019, 
1049,  1077,  1081 
pyopneumothorax,  991  . 
Subpsoas  abscess,  682 
Subserous  fibroids,  1307 

lipoma,  197 
Subspinous  dislocation  of  shoulder,  620 
'  Substance  sensibilatrice,'  23 
Subtrochanteric  osteotomy,  445,  677 
Subungual  exostosis,  201 
Suicidal  wounds,  244 
Superior  longitudinal  sinus,    injury   of, 
773 
thrombosis  of,  782 
Superior  maxilla,  affections  of,  811,  814 
excision  of,  817 
fracture  of,  487 
tumours  of,  814 
Suppression  of  urine,  1266 
Suppuration,  62,  34,  35,  59 
in  pericardium,  939 
leucocytosis  in,  58 
of  aneurisms,  313 
of  parotid  gland,  858 
of  frontal  sinus,  755 
of  maxillary  antrum,  811 
of  tuberculous  glands,  367 
lesults  of,  74 
without  organisms,  62 
Suppurative  nephritis,  1187 
Supraclavicular   gland,    enlargement   of, 

in  cancer  of  stomach,  1007 
Supracondyloid    amputation  .  of    thigh, 
1342 
fracture  of  femur,  544 
of  humerus,  504 
Supracoracoid   dislocation    of   humerus, 

620 
Supramalleolar  amputation,  1341 
Supramammary  abscess,  947 
Supra-orbital  nerve,  operations  on,  383 
Suprapubic  aspiration  of  bladder,   1253, 
1270 
cystotomy,  1220,  1224 
lithotomj',  1243 
prostatectomy,  1254 
puncture  for  enlarged  prostate,  1253 
Supravaginal  h3^sterectomy,  1309 
Surgical  emphysema,  930,  486,  901 
kidney,  12 17 

neck  of  humerus,  fracture  of,  497 
of  scapula,  fracture  of,  496 
Susceptibility,  14 
Suture  of  arteries,  300 
Sutures,  232 

of  nerves,  377 
of  tendons,  413 
intestinal,  973-976 
preparation  of,  271 


Swabs,  271 
Sweep's  cancer,  1302 
Sylvester's  method  of  artificial  respira- 
tion, 940 
Sylvian  point,  758 
S^'lvius,  fissure  of,  758 
Syme's  amputation,  1339 
horseshoe  splint,  560 
operation  for  epithelioma  of  lip,  805 
for  epithelioma  of  tongue,  853 
for  external  urethrotomy,  1268 
staff,  1268 

treatment  of  chronic  ulcers,  95 
Symond's  tube  for  oesophageal  stricture, 

882 
Sympathetic  nerve,    affections   of,    396, 
203 
excision  of  cervical,  396,  910 
in  shock,  action  cf,  260 
irritation     of,     in     innominate 
aneurism,  321 
Symptomatic  gangrene,  103,  104 

traumatic  fever,  262 
Syncope  in  shock,  259 
Syncytioma  maligna,  13 14 
SjTidactylism,  438 
Synechise,  151 
Syndesmotomy,  457 
Synostosis,  675 

Synovial  membrane,  piilpy  degeneration 
of,  652 
sheaths,  suppuration  in,  248 
villi  (fringes),  644 
Synovitis,  acute,  641,  639,  822 
chronic,  643 
gonorrhceal,  652,  139 
papillary,  644 
pyaemic,  651 
rheumatic,  649 
serous,  643 
syphilitic,  645,  663 
typhoid,  651 
tuberculous.     See  Joints 
Syphilides,  149 
Syphilis,  142-164 

abortive  treatment  of,  156 

arylarsonates  in,  158 

congenital     (inherited),     160,     802, 

1085 
laboratory,  diagnosis  of,  144 
malignant,  156 
secondary,  148 
spirochete  of,  142 
tertiary,  153 
treatment  of,  156 
Syphihtic  affections  of  anus,  1165 
of  arteries,  305,  153 
of  bone,  565.  45o,  566,  586 
of  breast,  930 
of  bursse,  423 
of  calvarium,  5S7,  743 
of  cornea,  164 
of  cranium,  743 
of  epididymis,  12S7,  153 
of  epiphyses,  589 
of  eye,  151,  164 
of  hair,  150 
of  intestine,    1027 


I400 


A  MANUAL  OF  SURGERY 


Syphilitic  affections  of  jaw,  8io 

of  joints,  663,  645 

of  larynx,  917 

of  lips,  801 

of  liver,  1069 

of  lymphatic  glands,    147,    150, 
366 

of  meninges,  781 

of  mucous  membranes,  149 

of  muscles.  415 

of  nipple,  946 

of  nose,  835 

of  optic  sheath,  381 

of  palate,  869,  870 

of  pharynx,  876 

of  periosteum,  586 

of  rectum,  1165,  ii65 

of  ribs,  928 

of  skin,  149 

of  skull,  586 

of  spine,  731 

of  sternum,  928 

of  teeth,  163 

of  testis,  1287 

of  tibia  and  fibula,  450 

of  tongue,  847,  849 

of  tonsil,  875 
alopecia,  150 
chondro-arthritis,  663 
endarteritis,  305,  153 
epiphysitis,  589 
iritis,  151 
keratitis,  164 
pseudo-paralysis,  589 
psoriasis,  151 
sarcocele,  1287 
stomatitis,  150,  845 
stricture  of  rectum,  11 66 
synovitis,  645,  663 
.    ulcers,  155,  98,  152,  850 
Svringo-myelia,  joint  affections  in,  672, 

676 
Syringo-myelocele,  225,  713 

Tabes  dorsalis,  spontaneous  fracture  in, 
466 
joint  affections  in,  669,  676 

mesenterica,  996,  367 
Taenia  echinococcus,  226,  347 
Tagliacozzian  operation,  827 
Tahpes,  450,  795 

calcaneus,  451,  454 

decubitus,  451,  452 

equino-varus,  452,  453 

equinus,  451,  452,  416 

paralytic,  714 

tenoplasty  in  paralytic,  421 

treatment  of,  456 

valgus,  451,  455 

varieties  of,  451 

varus,  451,  453 
Talma's    operation    of    epiplopexy    for 

ascites,  993 
Tapotement,  47 

Tapping  a  hydrocele,  method  of,  1293 
Tarsectomy,  457 

Tarso-metatarsal  joints,  amputation  at, 
1337 


Tarsus,  amputation  through,  1338 

tuberculous  disease  of,  580 
Taxis,  1 1 14,  1 1 19 

Taylor's  brace,  729  > 

Teale's  amputation  of  leg,  1330,  1341 
Technique  of  operative  siurgerv   (Chap- 
ter X.),  265-275 
Teeth,  extraction  of,  805 

in  congenital  syphilis,  163 

tumours   in    connection   with,    207, 
819 

See  also  Odontomata 
Tegmen  tympani,  necrosis  of,  890 
Temporal  artery,  compression  of,  290 
ligature  of,  333 

bone,  necrosis  of,  890 
Temporo-maxillary    joint,    diseases    of 
822 
dislocation  at,  615 
osteo-arthritis  of,  822,  669 
subluxation  of,  617 
Temporo-sphenoidal    lobe,     abscess    of, 
786 

injuries  of,  770 
Tendo  Achillis,   affections  of  bursa  be 
neath,  425,  640 
operation    on,    in    talipes    cal- 
caneus, 458 
right  angle  contraction  of,  461 

rupture  of,  413 

tenotomy  of,  420,  457,  462,  636,  637. 
638 
Tendons,  adhesion  of,  414 

displacement  of,  411 

of  fingers,  division  of,  414 

operations  on,  413,  419 

rupture  of,  412 

sloughing  of,  of  fingers,  414 

suture  of,  413 
Tendon  sheaths,  diseases  of,  416 

ganglion,  418 

suppurative,  417,  248 

tenosynovitis,  416 

tuberculous,  417 
Tenesmus,  1149,  1150,  1168 

in  fissure-in-ano,  1156 

in  cancer  of  rectum,  11 70 

in  cystitis,  12 16 

in  intussusception,  1141 

in  tumours  of  rectum,  11 68 

in  vesical  calculus,  1238 

in  volvulus,  1 132 

in  uterine  fibroids,  1308 
Tenoplasty,  421,  734 
Teno-synovitis,  416,  417,  248 
Tenotomy,  419,  734 

of  biceps  cruris,  420 

of  peronei,  420 

of  semimembranosu?,  420 

of  semitendinosus,  420 

of  sterno-mastoid,  428 

of  tendo  Achillis,  457,  636,  637,  638 

of  tibialis  anticus,  420 

of  tibialis  posticu<^,  420 
Teratoma,  221,  716 
Tertiary  syphilis,  153.     See  also  Gumma 

ulcers,  98 
Testicular  sensation,  loss  of,  1290 


INDEX 


1401 


Testis,    affections     of    (Chapter    XLI.), 
1279-1302 

atrophy  of,  1298 

carcinoma  of,  1290 

congenital  affections  of,  1279,  1280 

epididymitis,  1283,  1285,  1287 

fi-bro-cystic  disease,  1289,  224 

hernia,  1288 

injuries  of,  1281 

innocent  tumours  of,  1289 

malposition  of,  1280 

neuralgia  of,  1298 

orchitis,  1283,  1285,  1287 

retention  of,  1279,  1097,  1125 

sarcoma  of,  1290 

syphilis  of,  1287,  1299 

torsion  of,  1280,  1125 

tuberculous  disease  of,  1285,  1299 

wounds  of,  1 28 1 
Test-meal,  use  of,  997,  1006 
Tetanus,  125 

bacillus  of,  125 

hydrophobicus,  128 

paralyticus,  128 

neonatorum,  980 

toxins  of,  126 
Tetracocci,  3 
Thecal  whitlow,  248 
Thermo-penetration,  46 
Thiersch's  method  of  nerve  extraction, 
381 
of  skin-grafting,  119 
Thigh,  amputation  of,  1342 

Stokes-Gritti  amputation  of,  1343 

supracondylar  amputation  of,  1342 
Thiosinamin,  257 
Third  nerve,  affections  of,  381 
Thomas's  hip-splint,  537,  538,  684,  728 

knee-splint,  661 

operation  on  breast,  955 

wrench,  457,  461 
Thoma-Zeiss  hsemocytometer,  49 
Thompson's  lithotrite,  1241 
Thoracic  aorta,  aneurism  of,  320 

duct,  rupture  of,  358 
Thorax,  in  scoliosis,  430 

punctured  wounds  of,  932 
Thread-worms,  1150 
Thrombo-angiitis  obliterans,  108 
Thrombosis,  344,  31 

arterial,  100,  298,  307 

gangrene  from,  100 
.  of  cavernou.T.  sinus,  755,  835 

of  cerebral  sinuses,  781 

of    femoral    vein    in    appendicitis, 
1050 

of  haemorrhoids,  1158 

of  lateral  sinus,  761,  785,  895 

of  mesenteric    vessels,     995,     1020, 
1129 

of  superior  longitudinal  sinus,  782 

of  vessels  in  meso-appendix,  1050 

venous,  344,  348,  352 
Thrombus,  87 

changes  in,  281 

characters  of,  345 
Thrush,  10,  844 
Thudichum's  speculum,  828 


Thumb,  amputation  of,  1334 

dislocation  of,  626 
Thyro-glossal  cyst,  898,  850,  857,  910 

duct,  anatomy  of,  898 
Thyroid  accessory,  910 

body,  affections  of,  903-911 

cancer  of  bone,  737,  907,  607 

cartilage,  injuries  of,  916 

cysts  .^f,  900,  906 

extract,  in  cancer  of  breast,  968 

goitre,  903,  899 

dissemination  of,  906 
operations  on,  907 

inflammation  of,  910 

tumours  of,  910,  922 

vessels,  ligature  of,  334 
Thyroidectomy,  partial,  907,  909 
Thyroiditis,  acute,  910 
Thyro-iodine,  907 
Thyrotomy,  919,  920 
Tibia,  fractxire  of,  551 

and  fibula,  fracture  of,  552 

lower  epiphysis,  separation  of,  559 

rachitic,  450 

syphilitic  affections  of,  450 
Tibial  arteries,  compression  of,  290 
ligature  of,  341 

nerves,  affections  of,  396 
Tibialis  anticus,  tenotomy  of,  420 

posticus,  tenotomy  of,  420 
Tic-douloureux,  382 

facial,  387 
Tinnitus,  891 

Tissue  tension,  Ribbert's  theory  of,  187 
Toenail,  ingrowing,  406 
Toes,  amputation  of,  1337 

deformities  of,  462 
Tongue,  affections  of,  845-856 

cancer  of,  850-856 

operations  on,  852-856 
Tongue-tie,  845 
Tonsil,  abdominal,  1043 
Tonsillitis,  871 
Tonsillotomy,  873 
Tonsils,  affections  of,  871 
Tophi,  650 

Topography,  cranio-cerebral,  757 
Torsion  in  treatment  of  haemorrhage,  285 

of  omentum,  994,  11 29 

of  ovarian  cyst,  98r,  1129,  1134,  1324 

of  testicle,  1280,  1125 

of  spleen,  1129 
Torticollis,  426 

Tour-de-maitre  in  passing  bougies,  1264 
Tommiquets  in  amputating,  1331,  1344 

in  arresting  haemorrhage,  290 
Toxaemia,  13,  59,  82,  982,  1216,  1118 
Toxins,  5,  6 
Toxophore,  20 
Trachea,  foreign  bodies  in,  914,  922 

stenosis  of,  9,  202,  902 

wounds  of,  901 
•  Tracheal  tug '  in  aneurisms  of  aorta, 

320,  322 
Tracheotomy,   922,  902,  914,   915,  917, 
919,  920,  124,  940 

preliminary,  922,  924,  855 

tubes,  924 


I402 


A  MANUAL  OF  SURGERY 


Traction  diverticula  of  oesophagus,  878 
Transfixion  method  of  amputating,  1329 
Transfusion  for  haemorrhage,  278 
Transhyoid  pharyngotomy,  920 
Transillumination  of  antrum,  812,  816 
Tramsverse  colon,  colostomy  of,  1034 
Trans-sacral  proctectomy,  11 72 
Traumatic  aneurism,  298,  324 
arteritis,  302 
arthritis,  664 
cephalhydrocele,  737,  744 
delirirun,  263 
dermatitis,  272 
dermoid  cys+s,  226 
dislocations,  611 
epilepsy,  744,  771,  791 
fever,  262,  470 
flat-foot,  459 
gangrene,  no,  100,  103 
genu  valgum,  446 
insanity,  792 
myositis,  415 

ossificans,  416 
neurasthenia,  707 
neuroma,  205,  374 
osteomyelitis,  574 
periostitis,  566 
ulcers,  848 
Travelling  acetabulum,  678 
Trendelenburg's    operation    for    ectopia 
vesicae,  12 12 
for  vairicose  veins,  353,  96 
position,  970 
trachea  tampon,  924,  855 
Trephining,  operation  of,  759 
for  abscess  of  brain,  785 
for  fracture  of  skull,  753 
for  intrameningeal  haemorrhage,  776 
for  lateral  sinus  thrombosis,  895 
for  middle   meningeal  hemorrhage, 

775 
for  tuberculous  meningitis,  781 
for  tumours  of  brain,  785 
Treponema  pallida,  142 
Trichina  spiralis,  226,  415 
Trichophyton,  10 
Trigeminal  neuralgia,  382 
Triple  displacement  of  knee-joint,   449, 
661 
phosphate  calculi,  1236 
phosphates  in  urine,  1230 
Trismus,  126,  128,  823 
Trochanter,  fracture  of,  539 
Trophic  changes   after  division   of  sen- 
sory nerves,  376 
Tropical  abscess  of  liver,  1065 
Trunk  neuroma,  203 
Trusses,  femoral,  1107 
hinged-cup,  11 14 
inguinal,  1099 
umbilical,  11 10 
wool,  1099 
Tr\'panosomes,  11 
T-shaped  fractures,  508,  544 
Tubal  gestation,  i3r7 

rupture  of,  1318 
treatment  of,  1319 
Tubby's  painful  lipoma,  196 


Tubercle  bacillus.     See  imder  Bacillus 
'  miliary,  168 
!    Tuberculated  leprosy,  179 
Tuberculin,  74,  167,'  175,  368,  405,  657, 
989,  1194 
in   tuberctilous   disease   of  bladder, 

1220 
in  tuberculous  diseaise  of  prostate, 
1247 
Tuberculonr^^ces,  11 
Tuberculosis,  164-177 

acute  miliary,  174,  656,  1085,  1192 
pathological  diagnosis  of,  167 
treatment  of,  174 
Tuberculous  abscess,  172,  368,  657,  678, 
721,  725.  783.  1151 
treatment  of,  176,  730 
coxitis,  678 
dactylitis,  579 

disease    of    appendix    vermiformis, 
1062 
of  arteries,  305 
of  astragalus,  580,  582 
of  atlas  and  axis,  725 
of  bladder,  1220 
of  bone,    577.    565.    566,    576, 

578 
of  brain,  781,  786 
of  bre?st,  950 
of  bursae,  423 
of  caecum,  1027,  1062 
of  cranium,  742 
of  elbow,  659 
of  epididj'mis,  1285 
of  epiphyses,  582,  469 
of  hip-joint,  678 
of  intestine,  1026 
of  jaw,  810 

of  joints,  652,  645,  585 
of  kidney,  1191,  1192 
of  larynx,  917 
of  lung,  929,  937 
of  lymphatic  glands,  367,  841 
of  lymphatic  vessels,  359 
of  mastoid,  892 
of  meninges  of  brain,  761,  781 
of  mesenteric  glands,  996 
of  muscles,  415 
of  OS  calcis,  580,  582 
of  palate,  869 
of  peritoneum,    980,    988,    994, 

996 
of  phalanges,  579 
of  prostate,  1247 
of  rectum,  1165 
of  ribs,  722,  929 
of  sacro-iliac  joint,  687 
of  shoulder,  659 
of  skin,  401 
of  spine,  434,  717,  877 
of  sternum,  929 
of  tarsus,  580 

of  temporo-maxillary  joint,  823 
of  testis,  1285 
of  tongue,  849 
of  vas  deferens,  1285,  1286 
of  vesiculae  seminales,  130X 
of  wrist,  660 


INDEX 


1403 


Tuberculous  endarteritis,  305 

epiphysitis,  582,  653 

ischio-rectal  abscess,  1151 

lupus,  401 

meningitis,  761,  781 

sarcocele,  1285 

sequestra,  578,  565 

tenosynovitis,  418,  417 

tumour  of  cascum,  1027,  1062 

ulcers,  173,  405,  1026,  1027 
Tuber  ischii,  fracture  of,  530 
Tuberosity  of  humerus,  fracture  of,  501 
Tubes,  Fallopian,  diseases  of,  13 15 
Tubular  necrosis,  574 
Tubiilo-dermoids,  223 
Tumours,  184-221 

benign,  187 

congenital  sacral,  716 

fatty.     See  Lipoma 

malignant,  187 

of  adrenals,  1207 

of  antrum,  813 

of  bladder,  122 1 

of  bone,  598-609 

of  brain,  785,  786 

of  breast,  952 

of  connective-tissue  origin,  189-207 

of  cranium,  743 

of  endothelial  origin,  219-221 

of  epithelial  origin,  207-219 

of  frontal  sinus,  756 

of  gums,  809,  810 

of  intestine,  1028 

of  kidney,  1205 

of  larynx,  918 

of  lip,  803 

of  liver,  1069 

of  lymphatic  glands,  370 

of  mandible,  819 

of  maxilla,  814 

of  mesentery,  996 

of  muscle,  416 

of  nipple,  946 

of  nose,  835-839 

of  oesophagus,  881 

of  ovary,  1327 

of  palate,  870 

of  parotid,  859 

of  penis,  1276 

of  pharynx,  877 

of  prostate,  1248,  1255 

of  pylorus,  1007 

of  rectum,  11 68 

of  ribs,  929 

of  round  ligament,  1305 

of  scalp,  736 

of  scrotum,  1299 

of  spinal  cord,  733 

of  spine,  725,  733 

of  spleen,  1085 

of  sternum,  929 

of  stomach,  1005,  1007 

of  submaxillary  gland,  861 

of  testis,  1284 

of  thyroid,  903 

of  tongue,  850 

of  tonsil,  874 

of  upper  jaw,  814 


Tumours  of  urethra,  1260 

of  uterus,  1307 

of  vulva,  1304 

pathogenesis  of,  185 

phantom,  979 

Pott's  puffy,  778 

theories  of  origin  of,  185 
Tunica  albuginea,  hydrocele  of,  1295 

vaginalis,  haematocele  of,  1281 
hydrocele  of,  1291 
Tuning-fork  ear  tests,  885 
Tympanic  cavity,  inflation  of,  885 

membrane,  appearances  of,  885,  i 
rupture  of,  888 
Typhoid  bacillus.     See  under  Bacilli 

carriers,  62 

disease  of  joints,  651 

fever,  1054 

osteitis,  575 

state,  39 

ulcer,  perforation  of,  1023,  1027 

Ulcer,  rodent,  408 

Ulceration  (Chapter  V.),  91 -98,  35 

aneemic,  10 1 

duodenal,  in  bums,  118,  1018 

dysenteric,  1027,  1149 

of  bladder,  1216,  1220 

of  palate,  869 

of  rectum,  1165 

of  scars,  257 

of  tongue,  848 

of  umbilicus,  980 
Ulcerative  colitis,  1026 

endocarditis,  60,  84 
Ulcerous  tuberculous  peritonitis,  988 
Ulcers,  callous,  93 

due  to  bacterial  infection,  91,  92 

dyspeptic,  848 

eczematous,  94,  96 

epitheliomatous,  212 

gummatous,  154 

healing,  96 

indolent,  93 

irritable,  94,  96 

lupoid,  402,  98 

malignant,  98,  91,  850 

Marjolin's,  257 

of  bladder,  1216,  1220 

of  duodenum,  990,  1018 

of  intestine  (tuberculous),    1023, 
1026,  1027 

of  palate,  869 

of  pharynx,  876,  877 

of  stomach,  990,  997.  999    1009 

of  tongue,  848 

perforating,  of  foot,  400 

phagedenic,  147 

scirrhous,  960 

snail-track,  150 

stercoral,  1029,  1139,  1167 

syphilitic,  98 

traumatic,  91,  92 

tuberculous,  173.  405 

typhoid   1023, 1027 

varicose,  94,  352 

varieties  ot,  921.  98 
Ulcus  I  nolle,  140 


I404 


A  MANUAL  OF  SURGERY 


Ulcus  serpens,  29 
Ulna,  dislocation  of,  623 

fracture  of,  513 
Ulnar  artery,  compression  of,  290 
ligature  of,  336 
nerve,  injury  of,  393 
operation  on,  394 
paralysis  of,  393 
Ultramicroscope,  144 
Umbilical  faecal  fistula,  980,  988 
hernia,  980,  1109 
urinary  fistula,  1213,  1257 
Umbilicus,  affections  of,  980 
Undescended  testis,  1279,  1097 
inflammation  of,  11 25 
malignant  disease  of,  1280 
Ungual  whitlow,  405 
Union  of  fractures,  471,  480 
Unna's  treatment  of  ulcers,  95 
Unreduced  dislocations,  613,  615 
Ununited  fractures,  483 
Upper  extremity,  deformities  of,  436 
fractures  of,  492 
jaw.     See  Maxilla 
Uraemia,  1206,  1252,  1266 
Uranoplasty,  865 

Urate  of  ammonium  calculus,  1236 
Urates,  amorphous,  1229 
Ureter,  removal  of,  in  nephrectomy,  1184 
Ureter  oplasty,  11 87 

Ureters,    calculus    impacted    in,     1197, 
1185,  1196,  1198,  1205 
catheterization  of,  1177 
kinking  of,  1181,  1185 
removal  of  calculus  in,  1205 
rupture  of,  11 84 

transplantation  into  rectum.    1225, 
1212 
Urethra,  affections  of,  1257-1278 

calculus  impacted  in,  1259,  1227 
changes  of,  in  enlarged  prostate,  1249 
congenital  malformations  of,  1257 
dilatation  of,  in  females,  1245 
epithelioma  of,  1260 
false  passages  of,  1265 
foreign  bodies  in,  1259 
haemorrhage  from,  1258,  1260 
poljrpoid  tumours  of,  1260 
rupture  of,  1258 

stricture  of,  1260,  1216,  1227,  1258 
complications  of,  1271 
pathological  effects  of,  1262 
treatment  of,  1267-1274 
varieties  of,  1261 
Urethral  chancre,  146,  12  61 
fever,  1265 
hsematuria,  1231 
Urethritis,  1259,  i34>  I35 

posterior,  134 
Urethroscope,  137 
Urethrotome,  1268 
Urethrotomy,  external,  1268 

internal,  1267 
Uric  acid  and  urates,  1228 

calculus,  1 198,  1236 
Urinary  fever,  1265 

fistula,  980,  1184,  1196,  1205,  1213, 
1225,  1255,  1257,  1259,  1271,  1273 


Urinary  segregator,  Luy's,  1178 
Urine,  abnormal  conditions  of,  1228 

extravasation  of,  1272,  1228,  iz^8, 
1262 
treatment  of,  1273 

incontinence  of,  1226 

in  cystitis,  1216,  1217 

pus  in,  1232 

residual,  1227,  1250,  1261 

retention  of,  1227,  1252,  1262,  1269 

segregation  of,  11 78 

suppression  of,  1266 
Uterus,  carcinoma  of,  1312 

deciduoma  malignum,  1314 

displacements  of,  1305 

fibroids  of,  1307 

prolapse  of,  1306 

sarcoma  of,  13 12 

syncytioma  maligna,  13 14 

tumours  of,  1307 
Uvula,  elongation  of,  870 

Vaccination,   16 
Vaccines,  27,  16,  26 

treatment  Isy,   27,   48,   74,   86,   398, 
652 
Vaginal  hernia,  1093 
hydrocele,  1291 
hysterectomy,  1313,  1306 
Vaginitis,  1304 

in  gonorrhoea,  1304,  140 
Vagus,  nerve  affections  of,  388 
Valsava's    method    of   inflating    middle 

ear,  886 
Vapour-baths,  mercurial,  157 
Varicocele,  1296,  1097 

in  carcinoma  of  kidney,  1207 
Varicose  aneurism,  302,  737 
eczema,  352 
ulcer,  352,  94 
veins,  350,  352 
Varix,  350,  880,  1107,  1303 
aneurismal,  301,  324,  350 
of  oesophagus,  880 
of  saphena  vein,  350,1107 
of  vulva,  1303 
Vas  deferens,  rupture  of,  1282     . 

tuberculous    disease    of,    1286, 
1287 
Vater,   ampulla  of,   stone  impacted  at, 

1077,  io8r 
Vein  stones,  345,  352 
Veins,  entrance  of  air  into,  293 

laceration  of,  in  fractures,  483 
surgery  of  (Chapter  XIII.),  344-357 
varicose,  350 
Venereal  warts,  209 
Venesection,  356,  43 
Venous  haemorrhage,  276,  293 
nsevus,  354 
sinuses,  thrombosis  of,  781 

wounds  of,  773 
thrombosis,  344,  352 
Ventral  hernia,  iiii,  971,  1061 
Vermiform     appendix.     See     Appendix 

vermiformis 
Verruca.     See  warts,  401 
necrogenica,  246,  401 


INDEX 


1405 


Vertebral  artery,  haemorrhage  from,  295 

ligature  of,  334,  322 
Vertigo,  891 
Vesical  calculus,  1236-1245 

choice  of  operatioa  for,   1244 
hematuria,  123 1 
Vesiculse  seminales,  affections  of,  1301 
Vesicular  mole,  13 15 
Vesiculitis,  1301,138 
Vibrio  cholerae  Asiatics,  4,  8,  22 
Vibrion  septique,  113 
Vibrios,  4 

Vicious  circle  after  gastro-enterostomy, 
1016 
union  of  fractures,  485-560 
Villi,  synovial,  644 
Villous  tumour  of  bladder,  122 1 
Virchow's  theory  of  origin  of  tumours, 

186 
Volkmann's  ischaemic  contraction,  479 

sliding  rest  for  extension,  538 
Volvulus,  1132,  1129,  981,  1120 

treatment  of,  1136 
Vomiting  after  concussion,  762 
after  shock,  259 
anesthetic,  1354 
biliary,    after    gastro  -  enterostomy, 

1018 
cerebral,  788 

faecal,  1118,  1128,  1137,  1144,  1145 
in  intestinal  obstruction,  1130,  1128, 

1137,  1144,  1145 
in  moveable  kidney,  1181 
in  peritonitis.  983 
in  strangulated  hernia,  11 18 
after  operation  for,  11 24 
after  taxis,  1121 
regurgitant,       after       gastro-enter- 
ostomy, 1018 
in  intestinal  obstruction,  1128 
Von  Bechterews  spondylitis  deformans, 

732 
Von   Hacker's  method   of  gastro-enter- 
ostomy, 1016 
Von  Pirquet's  skin  reaction,  167 
Vulva,  affections  of,  1303 
injuries  of,  1303 
varix  of,  1303 
Vulvitis,  1304,  140,  1 2 14 

cystitis  in,  12 14 

Vulvo- vaginitis,  12 14,  140 

cystitis  in,  1 2 14 

Wagner's   osteoplastic  resection    of   the 

skull,  760 
Wagstaffe's  fracture,  552 
Wallerian  degeneration,  37^ 
Walsham's  operation  for  talipes  calcaneus, 

458 
Wardrop's  operation  for  aneurism,  317 
Warts,  401.     See  also  Papilloma 

anatomical,  246 

gonorrhoeal,  137 

Hutchinson's,  849 

malignant,  212 

on  lip,  803 

umbilical,  980 

venereal,  1276,  209 


Warty  growths  on  tongue,  malignant,  850 
Wassermann's  reaction,  27,   144 
Water-glass  bandage,  475 
Wax,  Horsley's,  760 

in  ear,  887 
Webbed  fingers,  438 
Weber's  test,  885 
Weight  extension  in  fractures,  537 

in  spinal  caries,  727 
Weir  Mitchell  .treatment,  1032 
Whalebone  bougie,  1264 
Wheelhouse's    operation   for   impassable 
stricture,  1269 

staff,  1269 
Whip-lash  bougie,  1264 
Whitehead's    operation    for    cancer    of 
tongue,  852 
for  piles,  1162 

varnish,  854 
White-leg,  345 
White  swelling,  652 

thrombus,  345 
Whitlow,  247,  405 
Widal's  reaction,  22,  27 
Winged  scapula,  437 
Witzel's  method  for  gastrostomy,  1013 
Wolfe's  method  of  skin-grafting,  98 
Wolffian    body,    origin    of    tumouxs     of 

testis  in,  1289 
Wolfler's  intestinal  suture,  975 
Woody  angina,  80 
Woolsorter's  disease,  132 
Wool  truss,  1099 
Wound  phagedena,  114,  103 
Wounds  (Chapter  IX.),  230-264 

abdominal.  976 

antiseptic  treatment  of,  265 

arterio-venous,  301,  736 

aseptic  treatment  of,  267 

by  needles,  241 

contused,  236 

dissection,  247 

fish-hook,  241 

gimshot,  242-245 

healing  of,  249 

incised,  232 

lacerated,  236 

of  abdominal  walls,  976 

of  air -passages,  goo 

of  arteries,  298,  300 

of  bladder,  12 13 

of  brachial  plexus,  389 

of  brain,  771,  767 

of  bursae,  422 

of  gall-bladder,  1071 

of  heart,  938 

of  internal  carotid  artery,  775 

of  intestine,  1020,  1021,  1022 

of  joints,  610 

of  kidney,  11 83 

of  larynx,  901 

of  liver,  1063 

of  lung,  929 

of  mesentery,  995 

of  middle  meningeal  artery,  773 

of  nerves,  373.  374 

of  omentum,  994 

of  pancreas,  1081 


1406 


A   MANUAL  OF  SURGERY 


Wounds  of  recto-vaginal  septum,  1149 
of  rectum,  1149,  12 19 
of  scalp,  735 
of  scrotum,  1301 
of  spine,  696 
of  spleen,  1084 
of  Stenson's  duct,  861 
of  stomach,  997 
of  testis,  1 28 1 
of  throat,  900 
of  tongue,  846 
of  trachea,  901 
of  mreter,  11 84 
of  urethra,  1258 
of  veins,  293,  301 
of  venous  sinuses  of  head,  773 
of  vulva,  1303 
open,  231 
poisoned,  245 
post-mortem,  247 
pimctured,  238 
repair  of,  249 
revolver,  244 
suicidal,  244 
treatment  of  abdominal,  977 

of  contused,  235 

of  gunshot,  244 

of  incised,  232-236 

of  lacerated.     See  Contused 
wounds 

of  poisoned,  244 
Wrist-drop,  391 
Wrist-joint,  acute  arthritis  of,  648 


Wrist-joint,  amputation  at,  1334 

ankylosis  of,  676 

dislocation  of,  625 

effusion  into,  640 

excision  of,  660,  691 

tuberculous  disease  of,  660 
Wiy-neck.     See  Torticollis 
Wyeth's  method  of  controlling  haemor- 
rhage in  amputation  at  hip-joint,  1344 

Xanthine,  1237 

X  rays  in  diagnosis  of  aneurism,  320 
of  bone  diseases,  577,  579 
of  disease  of  joints,  656 
of  fractures,  470 
of  gastric  affections,  997 
of  renal  calculus,  1198 
of  sarcoma  of  bone,  605 
of  subphrenic  abscess,  992 
of  vesical  calculus,  1238 
in  treatment  of  cancer,  968,  218 
of  lupus,  404 
of  rodent  ulcer,  410 

Y-ligament  of  hip-joint,  importance  of, 
627 

Z -operation  on  tendons,  421 
Ziehl-Nielsen  method  of  staining  bacilli,  8 
Zinc  ions,  treatment  by,  410 
Zoogloea,  346,  87,  2 
Zygoma,  fractiure  of,  487 


THE    END 


Bailliere.,   TTttdall  and  Cox,  8,  Henj-ieiia  Street,  Coveni  Garden 


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